The use of sleep aids among Emergency Medicine residents: a web based survey

BACKGROUND: Sleepiness is a significant problem among residents due to chronic sleep deprivation. Recent studies have highlighted medical errors due to resident sleep deprivation. We hypothesized residents routinely use pharmacologic sleep aids to manage their sleep deprivation and reduce sleepiness. METHODS: A web-based survey of US allopathic Emergency Medicine (EM) residents was conducted during September 2004. All EM residency program directors were asked to invite their residents to participate. E-mail with reminders was used to solicit participation. Direct questions about use of alcohol and medications to facilitate sleep, and questions requesting details of sleep aids were included. RESULTS: Of 3,971 EM residents, 602 (16%) replied to the survey. Respondents were 71% male, 78% white, and mean (SD) age was 30 (4) years, which is similar to the entire EM resident population reported by the ACGME. There were 32% 1st year, 32% 2nd year, 28% 3rd year, and 8% 4th year residents. The Epworth Sleepiness Scale (ESS) showed 38% of residents were excessively sleepy (ESS 11–16) and 7% were severely sleepy (ESS>16). 46% (95 CI 42%–50%) regularly used alcohol, antihistamines, sleep adjuncts, benzodiazepines, or muscle relaxants to help them fall or stay asleep. Study limitations include low response and self-report. CONCLUSION: Even with a low response rate, sleep aid use among EM residents may be common. How this affects performance, well-being, and health remains unknown

A Review of the Literature on Pulmonary Artery Balloon Counterpulsation and a Successful Application of Concomitant Balloon Counterpulsation

The intraaortic balloon pump is the most common method of left ventricular support in use today. Various types of ventricular assist devices and centrifugal pumps are also used at many institutions for both single and biventricular support. Balloon pump technology can also be used to support the right ventricle, as we were able to recently demonstrate in a successful application of concomitant aortic and pulmonary artery balloon counterpulsation

Embolic Activity During In Vivo Cardiopulmonary Bypass

Neurologic injury after cardiac surgery is principally associated with emboli. Although much work has focused on surgical sources of emboli, less attention has been focused on emboli associated with the heart–lung machine. We tested whether emboli are associated with discrete processes during cardiopulmonary bypass (CPB). One hundred patients undergoing cardiothoracic surgery were enrolled between April 2008 and May 2011 at a single medical center. During each surgical procedure, emboli were counted in three CPB locations: the venous side (Channel 1), before the arterial line filter (Channel 2), and after the arterial line filter (Channel 3). We used prespecified event markers to identify perfusionist interventions. Identical circuits were used on all patients. Of the 100 patients enrolled, 62 underwent isolated coronary artery bypass grafting (CABG), 17 underwent isolated valve operations, and 21 underwent CABG plus valve. Median counts across Channels 1, 2, and 3 were 69,853, 3,017, and 1,251, respectively. The greatest contributor to emboli in Channels 1, 2, and 3, respectively, were achieving the calculated CPB flow, opening of the electronic arterial line clamp, and introducing a hemofilter. The circuit technology was efficient in reducing total emboli counts from Channels 1–2 irrespective of the size of the emboli. Nearly 71% of all emboli 30–100 mm in size were removed from the circuit between Channels 2 and 3. No significant association was found between emboli counts and S100B release. Emboli occur frequently during CPB and are predominantly associated with the initiation of bypass, operation of the electronic arterial line clamp, and the initiation of a hemofilter. Continued work to reduce the occurrence of emboli is warranted

Circulatory Support for Repair of Cerebral Aneurysms Using Heparin-Bonded Bypass Circuits and Low-Dose Heparin

Modern advances in neurosurgical technique and improvements in cardiopulmonary bypass technology have facilitated a renewed interest in the ligation of giant cerebral aneurysms utilizing deep hypothermia and low-flow conditions. The widespread introduction of biocompatible heparin-bonded bypass circuits presents perfusionists with the opportunity to curtail sharply the need for heparin and protamine in these patients. We briefly discuss the merits of this procedure and describe our clinical experience

Variation in arterial inflow temperature: a regional quality improvement project.

Peer-reviewed evidence (Class IIa, Level B) suggests that arterial blood temperature should be limited to 37 degrees C during cardiopulmonary bypass. We implemented a regional quality improvement initiative to reduce regional variability in our performance around this recommendation at four northern New England medical centers between January 2006 and June 2010. Cardiovascular perfusionists at four medical centers collaborated by conference calls regarding blood temperature management. Evidence from the recommendations were reviewed at each center, and strategies to prevent hyperthermia and to improve performance on this quality measure were discussed. Centers submitted data concerning highest arterial blood temperatures among all isolated coronary artery bypass grafting procedures between 2006 through June 2010. Scope and focus of local practice changes were at the discretion of each center. The timing of each center\u27s quality improvement initiatives was recorded, and adherence to thresholds of 37 degrees C and 37.5 degrees C were analyzed. Data were collected prospectively through our regional perfusion registry. Data were available for 4909 procedures (1645 before interventions, 3264 after interventions). Prior to the quality improvement interventions, 90% of procedures had elevated arterial line temperatures (37 degrees C or more), and afterwards it was 69% (p \u3c .001) for an absolute difference of 21%. Prior to the intervention, 53% of procedures had temperatures beyond a threshold of 37.5 degrees C versus 19% subsequent to interventions, for an absolute difference of 34% (p \u3c .001). This regional effort to reduce patient exposure to elevated arterial line temperatures resulted in a significant sustained reduction in high arterial outflow temperatures at three of the four centers. A regional registry provides a means for assessing performance against evidence-based recommendations, and evaluating short and long-term success of quality improvement initiatives

Lowest core body temperature and adverse outcomes associated with coronary artery bypass surgery.

To examine the effect of lowest core body temperature on adverse outcomes associated with coronary artery bypass graft (CABG) surgery, data were collected on 7134 isolated CABG procedures carried out in New England from 1997 to 2000. Excluded from the analysis were patients with pump times \u3c 60 and \u3e 120 min and those operated upon using continuous warm cardioplegia. Data for lowest core temperature were divided into quartiles for analysis ( \u3c 31.4 degrees C, 31.5-33.1 degrees C, 33.2-34.3 degrees C, and 2 34.4 degrees C). Patients with lower core body temperature on cardiopulmonary bypass (CPB) had higher in-hospital mortality rates. Crude mortality rates were 2.9% in the \u3c or = 31.4 degrees C group, 2.1% in the 31.5-33.1 degrees C group, 1.3% in the 33.2-34.3 degrees C group and 1.2% in the \u3e or = 34.4 degrees C group. The trend toward higher mortality as core temperature decreased was statistically significant (P(trend) \u3c 0.001). Adjustment for differences in patient and disease characteristics did not significantly change the results and the test of trend remained significant (p \u3c 0.001). Rates of perioperative stroke were somewhat lower in the colder groups. Rates in the two colder groups were 0.9% compared with 1.6% and 1.4% in the warmer groups (P(trend) = 0.082). This remained a marginal but significant trend after adjustment for possible confounding factors (p = 0.044). Low core body temperatures on CPB are associated with higher rates of in-hospital mortality among isolated CABG patients. Rates of intra- or postoperative use of an intra-aortic balloon pump are also higher with lower core temperatures. We concluded that temperature management strategy during CABG surgery has an important effect on patient outcomes

Cardiopulmonary bypass recommendations in adults: the northern New England experience.

Using a regional cardiopulmonary bypass (CPB) registry, we compared the practice of CPB at eight northern New England institutions to recently published recommendations. We examined CPB practice among 3597 adult patients undergoing isolated coronary artery bypass grafting surgery from January 2004 to June 2005. Registry variables were used to compare regional CPB practice to recommendations on topics of neurologic protection (pH management, avoidance of hyperthermia, minimizing return of pericardial suction blood, aortic assessment, arterial line filtration), maintenance of euglycemia, reduction of hemodilution, and attenuation of the inflammatory response. We report overall regional practice (regional minimum, maximum). All centers used alpha-stat pH management and arterial line filters. Avoidance of hyperthermia (temperature \u3c 37degrees C) was achieved during 23.4% of procedures (regional minimum, 1.5%; maximum, 83.2%). Minimizing return of pericardial suction blood was achieved in 23.7% of cases (0.7%, 93.6%). Aortic assessment was performed during 45.7% of procedures (1.3%, 98.9%). Maintenance of euglycemia (\u3c 200 mg/dL) was accomplished in 82.7% (57.1%, 97.9%) of cases. Hemodilution (hematocrit \u3c 23% on CPB) was lower for men 32.4% (20.6%, 52.3%) than women 77.9% (64.7% 88.9%). Men were less likely to receive red blood cell transfusions in the operating room (11.0%; 1.8%, 20.9%) than women (54.6%; 30.1%, 70.6%). In an effort to attenuate the inflammatory response, surface coated circuits were used in 83.3% of procedures (8.8%, 100%). During this time, gaps existed between regional CPB practice and recently published recommendations. We continue to prospectively measure CPB practice relating to these recommendations to monitor and improve the care provided to our patients