Journal and News Scan

The Workforce on Evidence-Based Surgery has created an expert consensus statement on the management of resuscitation in patients who arrest after cardiac surgery.

The STS believes that if a patient arrests after cardiac surgery and external cardiac massage is not providing adequate perfusion with a systolic over 60mmHg, then am emergency resternotomy should always be performed in under 5 minutes to prevent irreversible brain injury.

This is not easy to achieve and this document provides comprehensive advice regarding rapidly reversible causes of arrests to avoid a resternotomy, how to organize your teams to achieve a good outcome and how to train your teams to provide the best outcomes possible.  The STS provides a one page poster as a summary of this advice.

This document is currently out for consultation and we want your advice and opinions. Please click on this link to provide your ideas and feedback.

http://www.sts.org/Expert-Consensus-for-the-Resuscitation-of-Patients-who-Arrest-After-Cardiac-Surgery

We would like to know :

Do you like the presented STS protocol ?

Do you agree that in VF arrest, you should proceed to deliver 3 shocks prior to external massage ?

Do you agree that epinephrine and atropine should not be a routine part of the algorithm ?

Do you agree that for a patient who arrests and external massage is not generating an adequate perfusion pressure, that this person needs an urgent resternotomy once all rapidly reversible causes have been excluded ?

We have paired up with the APACVS who has created a charity to provide training in this protocol. Training will be provided by a network of trained and experienced physicians assistants and senior nurse practitioners. www.csu-als.org

Do you have any ideas or suggestions for the national training program that they will be leading ? 

Thank you very much for your interest. Please do get in contact if you have any questions.

Joeldunning@doctors.org.uk

Chairman of the STS workforce on resuscitation in arrest after cardiac surgery

sfirestone@sts.org

Lead systematic reviewer for the STS evidence based workforce.

This is a very interesting study. The authors tried to find if the weekend effect would affect the outcomes of both elective surgery and urgent surgery (cardiac and non-cardiac surgery). This retrospective study enrolled more than 300K patients undergoing surgery including CABG. The authors compared the in-hospital mortality and major complications for weekday versus weekend surgery using multivariable logistic regression analysis. Results showed that weekend elective and urgent surgery were associated with higher risk of death and major complications compared to the week day surgery (p<0.001).

Can we suggest surgeons avoid the elective (non-emergency) cardiac surgery on weekends based on this study? 

Anomalous aortic origin of a coronary artery (AAOCA) has been associated with myocardial ischemia and sudden death. There are several controversies regarding the indications and efficacy of surgery. This report analyzes the experience of one center whose institutional approach has been to recommend surgical treatment for all patients identified with AAOCA between the ages of 10 and 30 years, with  a more selective approach based upon symptoms and other factors for patients under the age of 10 or over  the age of 30. In all, 115 patients have undergone  surgical repair of AAOCA. The results demonstrate that AAOCA surgery can be performed safely and is effective in relieving symptoms of myocardial ischemia. For the first time, an association between AAOCA and myocardial bridges is reported.

The entire issue is dedicated to thrombosis and makes a compulsory read for cardiovascular and thoracic hospitalists. Of patricular relevance to the thoracic surgeon are the translational articles on system analysis (page 1348) and the table on oral anticoagulants on page 1410.