Should surgeons take a break after an intraoperative death? Attitude survey and outcome evaluation

Objectives To investigate attitudes of cardiac surgeons and anaesthetists towards working immediately after an intraoperative death and to establish whether an intraoperative death affects the outcome of subsequent surgery. Design Questionnaire on attitudes to working after an intraoperative death and matched cohort study. Setting UK adult cardiac surgery centres and regional cardiothoracic surgical centre. Participants 371 consultant cardiac surgeons and anaesthetists in the United Kingdom were asked to complete a questionnaire, and seven surgeons from one centre who continued to operate after intraoperative death. Main outcome measures Outcome for 233 patients operated on by a surgeon who had experienced an intraoperative death within the preceding 48 hours compared with outcome of 932 matched controls. Hospital mortality and length of stay as a surrogate for hospital morbidity. Results The questionnaire response rate was 76%. Around a quarter of surgeons and anaesthetists thought they should stop work after an intraoperative death and most wanted guidelines on this subject. Overall, there was no increased mortality in patients operated on in the 48 hours after an intraoperative death. However, mortality was higher if the preceding intraoperative death was in an emergency or high risk case. Survivors operated on within 48 hours after an intraoperative death had longer stay in intensive care (odds ratio 1.64, 95% confidence interval 1.08 to 2.52, P = 0.02) and longer stay in hospital (relative change 1.15, 1.03 to 1.24, P = 0.02). Conclusion Mortality is not increased in operations performed in the immediate aftermath of an intraoperative death, but survivors have longer stays in intensive care and on the hospital ward

EuroSCORE II dagger

To update the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk model. A dedicated website collected prospective risk and outcome data on 22 381 consecutive patients undergoing major cardiac surgery in 154 hospitals in 43 countries over a 12-week period (May-July 2010). Completeness and accuracy were validated during data collection using mandatory field entry, error and range checks and after data collection using summary feedback confirmation by responsible officers and multiple logic checks. Information was obtained on existing EuroSCORE risk factors and additional factors proven to influence risk from research conducted since the original model. The primary outcome was mortality at the base hospital. Secondary outcomes were mortality at 30 and 90 days. The data set was divided into a developmental subset for logistic regression modelling and a validation subset for model testing. A logistic risk model (EuroSCORE II) was then constructed and tested. Compared with the original 1995 EuroSCORE database (in brackets), the mean age was up at 64.7 (62.5) with 31% females (28%). More patients had New York Heart Association class IV, extracardiac arteriopathy, renal and pulmonary dysfunction. Overall mortality was 3.9% (4.6%). When applied to the current data, the old risk models overpredicted mortality (actual: 3.9%; additive predicted: 5.8%; logistic predicted: 7.57%). EuroSCORE II was well calibrated on testing in the validation data subset of 5553 patients (actual mortality: 4.18%; predicted: 3.95%). Very good discrimination was maintained with an area under the receiver operating characteristic curve of 0.8095. Cardiac surgical mortality has significantly reduced in the last 15 years despite older and sicker patients. EuroSCORE II is better calibrated than the original model yet preserves powerful discrimination. It is proposed for the future assessment of cardiac surgical risk