Impact of preoperative right-ventricular function and platelet transfusion on outcome after lung transplantation

Objective: Lung transplantation has become an established treatment option for end-stage pulmonary diseases. However, outcome depends on preoperative condition and co-morbidity. Furthermore, perioperative blood-product use is known to be associated with worse outcome even in transplant surgery. We investigated the impact of poor preoperative right-ventricular function and blood-product use on outcome after lung transplantation. Methods: The medical records of 169 lung-transplant recipients from 1996 to 2006 were examined. Duration of hospital stay, hours on mechanical ventilation, duration of stay in the intensive care unit, perioperative complications, death during hospital stay, and long-term survival were recorded. These outcome parameters were analyzed regarding coherence with right-ventricular function and the perioperative administration of crystalloids, colloids, allogeneic red blood cells, fresh frozen plasma, and platelets. Results: Patients with poor preoperative right-ventricular function had a significant increase in postoperative hours on ventilation (p=0.005), intensive care stay (p=0.003), and in-hospital death (p=0.012). The hours on ventilation increased also with high intra-operative fluid administration (p=0.026). Blood-product use was associated with prolonged mechanical ventilation and intensive care stay. After multivariate analysis, transfusion of platelets (p=0.022) was an independent prognostic factor for in-hospital death. Hours of mechanical ventilation was the only independent prognostic factor for long-term mortality (p=0.014). Conclusions: Perioperative transfusion of platelets is an independent prognostic factor for perioperative mortality. Furthermore, the study indicated that poor preoperative right-ventricular function might worsen perioperatively after lung transplantation. Therefore, pre-transplant treatment of pulmonary hypertension to protract right-ventricular failure and a restrictive use of allogeneic blood products may be options to improve outcom

Bottom-up feedback to improve clinical teaching: validation of the Swiss System for Evaluation of Teaching Qualities (SwissSETQ).

AIMS OF THE STUDY Clinical teaching is essential in preparing trainees for independent practice. To improve teaching quality, clinical teachers should be provided with meaningful and reliable feedback from trainees (bottom-up feedback) based on up-to-date educational concepts. For this purpose, we designed a web-based instrument, "Swiss System for Evaluation of Teaching Qualities" (SwissSETQ), building on a well-established tool (SETQsmart) and expanding it with current graduate medical education concepts. This study aimed to validate the new instrument in the field of anaesthesiology training. METHODS Based on SETQsmart, we developed an online instrument (primarily including 34 items) with generic items to be used in all clinical disciplines. We integrated the recent educational frameworks of CanMEDS 2015 (Canadian Medical Educational Directives for Specialists), and of entrustable professional activities (EPAs). Newly included themes were "Interprofessionalism", "Patient centredness", "Patient safety", "Continuous professional development', and "Entrustment decisions". We ensured content validity by iterative discussion rounds between medical education specialists and clinical supervisors. Two think-aloud rounds with residents investigated the response process. Subsequently, the instrument was pilot-tested in the anaesthesia departments of four major teaching hospitals in Switzerland, involving 220 trainees and 120 faculty. We assessed the instrument's internal structure (to determine the factorial composition) using exploratory factor analysis, internal statistical consistency (by Cronbach's alpha as an estimate of reliability, regarding alpha >0.7 as acceptable, >0.8 as good, >0.9 as excellent), and inter-rater reliability (using generalisability theory in order to assess the minimum number of ratings necessary for a valid feedback to one single supervisor). RESULTS Based on 185 complete ratings for 101 faculty, exploratory factor analysis revealed four factors explaining 72.3% of the variance (individual instruction 33.8%, evaluation of trainee performance 20.9%, teaching professionalism 12.8%; entrustment decisions 4.7%). Cronbach's alpha for the total score was 0.964. After factor analysis, we removed one item to arrive at 33 items for the final instrument. Generalisability studies yielded a minimum of five to six individual ratings to provide reliable feedback to one supervisor. DISCUSSION The SwissSETQ possesses high content validity and an "excellent" internal structure for integrating up-to-date graduate medical education concepts. Thereby, the tool allows reliable bottom-up feedback by trainees to support clinical teachers in improving their teaching. Transfer to disciplines other than anaesthesiology needs to be further explored

Established and potential predictors of blood loss during lung transplant surgery

Lung transplantation is an established therapeutic procedure for end stage lung diseases. Its success may be impaired by perioperative complications. Intraoperative blood loss and the resulting blood transfusion are among the most common complications. The various factors contributing to increased blood loss during lung transplantation are only scarcely investigated and not yet completely understood. This is in sharp contrast to other surgical fields, as in orthopedic surgery, liver transplantation and cardiac surgery the contributors to blood loss are well identified. This narrative review article aims to highlight the acknowledged factors influencing blood loss in lung transplantation (such as double vs. single lung transplant) and to discuss potential factors that may be of interest for further research or helpful to develop strategies targeting risk factors in order to minimize blood loss during lung transplantation and finally improve patient outcome

A mobile application to facilitate implementation of programmatic assessment in anaesthesia training

Background: Programmatic assessment is a concept to support learning through continuously providing information about learner progress to trainees and supervisors. Central to the concept are multiple low-stakes workplace-based assessments and meaningful feedback opportunities. Mobile technology may facilitate frequent and concise workplace-based assessments and trigger meaningful feedback. We designed a mobile application (app) for real-time use at the workplace utilising the concept of entrustable professional activities. As the primary outcome, we analysed completion times and as the secondary outcome the quality of documented learning goals. Methods: The prEPAred app requests trainees and supervisors to rate level of supervision of a professional activity directly after completion. Subsequently, ratings are compared, and supervisors may provide feedback via the app. We tested the app in five anaesthesiology departments at major teaching hospitals, analysing completion times, agreement on ratings, and quality of documented learning goals. Results: We recorded 1518 assessments from 159 trainees and 89 supervisors. Median time for level of supervision rating was 56 (inter-quartile range: 39-85) s for trainees and 17 (11-30) s for supervisors. Learning goals via the app were documented in 767 cases (50.5%). Median feedback time was 2 min, 31 s (confidence interval [CI]: 1 min, 20 s to 5 min, 20 s). In 443 (29%) cases, a specific learning goal was documented. A post hoc analysis revealed that the odds of documenting learning goals increased if trainees rated the level of supervision higher than their supervisors (odds ratio 1.39; CI: 1.03-1.87). Conclusions: The prEPAred mobile app enabled frequent and concise documentation of workplace-based assessments. Disagreement in level of supervision rating stimulated documentation of specific learning goals indicating more meaningful feedback. Thus, the tool could advance workplace-based assessments towards programmatic assessment. Keywords: anaesthesiology; entrustable professional activities; mobile application; postgraduate medical education; programmatic assessment; workplace-based assessmen

Impact of cytokine release on ventricular function after hepatic reperfusion: a prospective observational echocardiographic study with tissue Doppler imaging

BACKGROUND Postreperfusion syndrome and haemodynamic instability are predictors for poor outcome after liver transplantation. Cytokine release has been claimed to be responsible for postreperfusion syndrome. However, the underlying pathophysiologic mechanism is not clarified. The aim of this prospective observational study was to correlate cardiac performance (measured by transoesophageal echocardiography (TEE), Doppler and Tissue Doppler Imaging (TDI)) to plasmatic cytokines: IL-6, IL-8, CXCL1, TGF-β and CD40L at 5 different time points during liver transplantation. METHODS Seventeen consecutive patients scheduled for orthotopic liver transplantation, age 18 to 75 years without contraindication for transoesophageal echocardiography were included. Patients were monitored with TEE and TDI. Systolic and diastolic cardiac function, MAP, MPAP, CVP, PCWP, CO and blood samples for cytokine assays were recorded or collected after induction, 15 min after vena cava inferior clamping, 2 to 5 min after reperfusion, 60 min after reperfusion and at the end of surgery. RESULTS Mean arterial pressure and catecholamine requirements remained unchanged, MPAP, CVP and CO increased, SVR decreased after unclamping. Postreperfusion syndrome did not develop. The haemodynamic parameters and the variations of TEE parameters were consistent with the volume load changes during clamping and declamping and did not reveal systolic or diastolic cardiac dysfunction. All cytokines, except TGF-β, increased. CONCLUSION These findings suggest, that significant cytokine release during liver transplantation is not necessarily coincident with haemodynamic instability and impaired cardiac function. TRIAL REGISTRATION ClinicalTrials.gov: NCT00547924

Preoperative clonidine blunts hyperadrenergic and hyperdynamic responses to prolonged tourniquet pressure during general anesthesia

Although the mechanism of tourniquet-induced hypertension is still unclear, plasma norepinephrine concentrations continuously increase in parallel to arterial blood pressure during tourniquet inflation. Clonidine attenuates hyperadrenergic and hyperdynamic responses. We investigated the effects of clonidine on prolonged tourniquet inflation. Twenty-nine patients scheduled for elective orthopedic surgery were randomly assigned to receive IV clonidine (3 microg/kg; n = 14) or placebo (n = 15) before tourniquet inflation of the lower limbs under general anesthesia in a double-blinded manner. Arterial blood pressure, heart rate, epinephrine, and norepinephrine plasma concentrations were measured before tourniquet inflation, 60 min after tourniquet inflation, just before tourniquet deflation, and 20 min after tourniquet deflation. Mean arterial blood pressure and norepinephrine plasma-concentrations were significantly lower in the Clonidine group compared with Control after 60 min tourniquet inflation (P = 0.016; P = 0.006). Immediately before deflation of the tourniquet, the difference for mean arterial pressure between groups was even more pronounced (P = 0.005). Twenty minutes after deflation mean arterial blood pressure in the Control group was still increased and significantly higher compared with the Clonidine group (P = 0.002). In conclusion, preoperative IV clonidine blunts hyperadrenergic and hyperdynamic responses resulting from prolonged tourniquet inflation under general anesthesia in ASA class I--II patients. IMPLICATIONS: Tourniquet inflation is associated with a continuous increase in arterial blood pressure and sympathetic outflow. This study shows that IV clonidine effectively blunts increases of both arterial blood pressure and plasma norepinephrine concentrations

Agreement between trainees and supervisors on first-year entrustable professional activities for anaesthesia training

Background Entrustable professional activities (EPAs) are commonly developed by senior clinicians and education experts. However, if postgraduate training is conceptualised as an educational alliance, the perspective of trainees should be included. This raises the question as to whether the views of trainees and supervisors on entrustability of specific EPAs differ, which we aimed to explore. Methods A working group, including all stakeholders, selected and drafted 16 EPAs with the potential for unsupervised practice within the first year of training. For each EPA, first-year trainees, advanced trainees, and supervisors decided whether it should be possible to attain trust for unsupervised practice by the end of the first year of anaesthesiology training (i.e. whether the respective EPA qualified as a ‘first-year EPA’). Results We surveyed 23 first-year trainees, 47 advanced trainees, and 51 supervisors (overall response rate: 68%). All groups fully agreed upon seven EPAs as ‘first-year EPAs’ and on four EPAs that should not be entrusted within the first year. For all five remaining EPAs, a significantly higher proportion of first-year trainees thought these should be entrusted as first-year EPAs compared with advanced trainees and supervisors. We found no differences between advanced trainees and supervisors. Conclusions The views of first-year trainees, advanced trainees, and supervisors showed high agreement. Differing views of young trainees disappeared after the first year. This finding provides a fruitful basis to involve trainees in negotiations of autonomy