Publications by authors named "Robert Slight"

19 Publications

  • Page 1 of 1

Support for Healthcare Professionals After Surgical Patient Safety Incidents: A Qualitative Descriptive Study in 5 Teaching Hospitals.

J Patient Saf 2021 Apr 13. Epub 2021 Apr 13.

From the *School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom †Singleton Hospital ‡Swansea Medical School, Swansea University, Swansea, Wales §Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne ∥Department of Sociology, Durham University, Durham ¶Newcastle upon Tyne Hospitals, NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.

Objective: Patient safety incidents can have a profound effect on healthcare professionals, with some experiencing emotional and psychological distress. This study explored the support medical and nonmedical operating room staff received after being involved in a surgical patient safety incident(s) in 5 UK teaching hospitals.

Methods: An invitation letter and information sheet were e-mailed to all medical and nonmedical operating room staff (N = 927) across the 5 sites. Semistructured interviews were arranged with a range of different healthcare professionals working in operating rooms across a wide variety of surgical specialities. Interviews were audio recorded, transcribed verbatim, and analyzed using an inductive thematic approach.

Results: We conducted 45 interviews with medical and nonmedical operating room staff, who emphasized the importance of receiving personalized support soon after the incident. Operating room staff described how the first "go to" people were their peers and reported feeling comforted when their peers empathized with their own experience(s). Other participants found it very difficult to seek support, perceiving it as a sign of weakness. Although family members played an important role in supporting second victims, some participants felt unable to discuss the incident with them, fearing that they might not understand.

Conclusions: There should be clear support structures in place for operating room staff who have been involved in surgical incidents. Health organizations need to offer timely support to frontline staff after these incidents. Senior clinicians should be proactive in offering support to junior colleagues and empathize with their own experiences, thus shifting the competitive culture to one of openness and support.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PTS.0000000000000844DOI Listing
April 2021

Preventing sepsis; how can artificial intelligence inform the clinical decision-making process? A systematic review.

Int J Med Inform 2021 Apr 10;150:104457. Epub 2021 Apr 10.

School of Pharmacy, Newcastle University, King George VI Building, Newcastle upon Tyne, NE1 7RU, UK. Electronic address:

Background And Objectives: Sepsis is a life-threatening condition that is associated with increased mortality. Artificial intelligence tools can inform clinical decision making by flagging patients at risk of developing infection and subsequent sepsis. This systematic review aims to identify the optimal set of predictors used to train machine learning algorithms to predict the likelihood of an infection and subsequent sepsis.

Methods: This systematic review was registered in PROSPERO database (CRD42020158685). We conducted a systematic literature review across 3 large databases: Medline, Cumulative Index of Nursing and Allied Health Literature, and Embase. Quantitative primary research studies that focused on sepsis prediction associated with bacterial infection in adults in all care settings were eligible for inclusion.

Results: Seventeen articles met our inclusion criteria. We identified 194 predictors that were used to train machine learning algorithms, with 13 predictors used on average across all included studies. The most prevalent predictors included age, gender, smoking, alcohol intake, heart rate, blood pressure, lactate level, cardiovascular disease, endocrine disease, cancer, chronic kidney disease (eGFR<60 mL/min), white blood cell count, liver dysfunction, surgical approach (open or minimally invasive), and pre-operative haematocrit < 30 %. All included studies used artificial intelligence techniques, with average sensitivity 75.7 ± 17.88, and average specificity 63.08 ± 22.01.

Conclusion: The type of predictors influenced the predictive power and predictive timeframe of the developed machine learning algorithm. Predicting the likelihood of sepsis through artificial intelligence can help concentrate finite resources to those patients who are most at risk. Future studies should focus on developing more sensitive and specific algorithms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijmedinf.2021.104457DOI Listing
April 2021

Learning from safety incidents in high-reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare.

Int J Qual Health Care 2021 Mar;33(1)

School of Pharmacy, Newcastle University, King George VI Building, Newcastle Upon Tyne, Tyne and Wear NE1 7RU, UK.

Objective: A high-reliability organization (HRO) is an organization that has sustained almost error-free performance, despite operating in hazardous conditions where the consequences of errors could be catastrophic. A number of tools and initiatives have been used within HROs to learn from safety incidents, some of which have the potential to be adapted and used in healthcare. We conducted a systematic review to identify any learning tools deemed to be effective that could be adapted and used by multidisciplinary teams in healthcare following a patient safety incident.

Methods: This review followed the Preferred Reporting Items for Systematic Reviews and MetaAnalyses for Protocols reporting guidelines and was registered with the PROSPERO (CRD42017071528). A search of databases was carried out in January 2021, from the date of their commencement. We conducted a search on electronic databases such as Web of Science, Science Direct, MEDLINE in Process Jan 1950-present, EMBASE Jan 1974-present, CINAHL 1982-present, PsycINFO 1967-present, Scopus and Google Scholar. We also searched the grey literature including reports from government agencies, relevant doctoral dissertations and conference proceedings. A customized data extraction form was used to capture pertinent information from included studies and Critical Appraisal Skills Programme tool to appraise on their quality.

Results: A total of 5921 articles were identified, with 964 duplicate articles removed and 4932 excluded at the title (4055), abstract (510) and full-text (367) stages. Twenty-five articles were included in the review. Learning tools identified included debriefing, simulation, crew resource management and reporting systems to disseminate safety messages. Debriefing involved deconstructing incidents using reflective questions, whilst simulation training involved asking staff to relive the event again by performing the task(s) in a role-play scenario. Crew resource management is a set of training procedures that focus on communication, leadership and decision-making. Sophisticated incident-reporting systems provide valuable information on hazards and were widely recommended as a way of disseminating key safety messages following safety incidents. These learning tools were found to have a positive impact on learning if conducted soon after the incident with efficient facilitation.

Conclusion: Healthcare organizations should find ways to adapt to the learning tools or initiatives used in HROs following safety incidents. It is challenging to recommend any specific one as all learning tools have shown considerable promise. However, the way these tools or initiatives are implemented is critical, and so further work is needed to explore how to successfully embed them into healthcare organizations so that everyone at every level of the organization embraces them.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/intqhc/mzab046DOI Listing
March 2021

Designing the Optimal Digital Health Intervention for Patients' Use Before and After Elective Orthopedic Surgery: Qualitative Study.

J Med Internet Res 2021 Mar 8;23(3):e25885. Epub 2021 Mar 8.

School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom.

Background: Health behavior changes made by patients during the perioperative period can impact the outcomes and success of elective surgeries. However, there remains a limited understanding of how best to support patients during this time, particularly through the use of digital health interventions. Recognizing and understanding the potential unmet needs of elective orthopedic surgery patients is central to motivating healthier behavior change, improving recovery, and optimizing overall surgical success in the short and long term.

Objective: The aim of this study is to explore patient perspectives on technology features that would help support them to change their lifestyle behaviors during the pre- and postoperative periods, and that could potentially maintain long-term healthy lifestyles following recovery.

Methods: Semistructured interviews with pre- and postoperative elective orthopedic patients were conducted between May and June 2020 using telephone and video call-based software. Patient perspectives on the use of digital technologies to complement current surgical care and support with lifestyle behavior changes were discussed. Interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data, with QSR NVivo software (version 12) facilitating data management. Ethical approval was obtained from the National Health Service Health Research Authority.

Results: A total of 18 participants were interviewed. Four themes were developed from the data regarding the design and functionality of digital technologies to best support the perioperative journey. These center around an intervention's ability to incorporate interactive, user-centered features; direct a descriptive and structured recovery; enable customizable, patient-controlled settings; and deliver both general and specific surgical advice in a timely manner. Interventions that are initiated preoperatively and continued postoperatively were perceived as beneficial. Interventions designed with personalized milestones were found to better guide patients through a structured recovery. Individualized tailoring of preparatory and recovery information was desired by patients with previously high levels of physical activity before surgery. The use of personalized progression-based exercises further encouraged physical recovery; game-like rewards and incentives were regarded as motivational for making and sustaining health behavior change. In-built video calling and messaging features offered connectivity with peers and clinicians for supported care delivery.

Conclusions: Specific intervention design and functionality features can provide better, structured support for elective orthopedic patients across the entire surgical journey and beyond. This study provides much-needed evidence relating to the optimal design and timing of digital interventions for elective orthopedic surgical patients. Findings from this study suggest a desire for personalized perioperative care, in turn, supporting patients to make health behavior changes to optimize surgical success. These findings should be used to influence future co-design projects to enable the design and implementation of patient-focused, tailored, and targeted digital health technologies within modern health care settings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/25885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985803PMC
March 2021

Digital Support for Patients Undergoing Bariatric Surgery: Narrative Review of the Roles and Challenges of Online Forums.

JMIR Perioper Med 2020 Jul 15;3(2):e17230. Epub 2020 Jul 15.

School of Pharmacy, Institute of Population Health Sciences, Newcastle University, Newcastle Upon Tyne, United Kingdom.

Background: The internet has become an important medium within health care, giving patients the opportunity to search for information, guidance, and support to manage their health and well-being needs. Online forums and internet-based platforms appear to have changed the way many patients undergoing bariatric surgery view and engage with their health, before and after weight loss surgery. Given that significant health improvements result from sustained weight loss, ensuring patient adherence to recommended preoperative and postoperative guidance is critical for bariatric surgery success. In a patient cohort with high information needs preoperatively, and notoriously high attrition rates postoperatively, online forums may present an underutilized method of support.

Objective: The aim of this study was to conduct a narrative review focusing on the developing roles that online forums can play for patients with bariatric conditions preoperatively and postoperatively.

Methods: A literature search was conducted in October-November 2019 across 5 electronic databases: Scopus, EMBASE, PsycINFO, CINAHL, and MEDLINE. Qualitative or mixed methods studies were included if they evaluated patients undergoing bariatric surgery (or bariatric surgery health care professionals) engaging with, using, or analyzing online discussion forums or social media platforms. Using thematic analysis, themes were developed from coding patterns within the data to identify the roles and challenges of online forums for patients undergoing bariatric surgery.

Results: A total of 8 studies were included in this review, with 5 themes emerging around (1) managing expectations of a new life; (2) decision making and signposting; (3) supporting information seeking; (4) facilitating connectedness: peer-to-peer social and emotional support; and (5) enabling accessibility and connectivity with health care professionals.

Conclusions: Online forums could offer one solution to improving postoperative success by supporting and motivating patients. Future research should consider how best to design and moderate online forums for maximal effectiveness and the sharing of accurate information. The surgical multidisciplinary team may consider recommendations of online peer-support networks to complement care for patients throughout their surgical journey.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/17230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709839PMC
July 2020

Digital and Mobile Technologies to Promote Physical Health Behavior Change and Provide Psychological Support for Patients Undergoing Elective Surgery: Meta-Ethnography and Systematic Review.

JMIR Mhealth Uhealth 2020 12 1;8(12):e19237. Epub 2020 Dec 1.

School of Pharmacy, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.

Background: Digital technology has influenced many aspects of modern living, including health care. In the context of elective surgeries, there is a strong association between preoperative physical and psychological preparedness, and improved postoperative outcomes. Health behavior changes made in the pre- and postoperative periods can be fundamental in determining the outcomes and success of elective surgeries. Understanding the potential unmet needs of patients undergoing elective surgery is central to motivating health behavior change. Integrating digital and mobile health technologies within the elective surgical pathway could be a strategy to remotely deliver this support to patients.

Objective: This meta-ethnographic systematic review explores digital interventions supporting patients undergoing elective surgery with health behavior changes, specifically physical activity, weight loss, dietary intake, and psychological support.

Methods: A literature search was conducted in October 2019 across 6 electronic databases (International Prospective Register of Systematic Reviews [PROSPERO]: CRD42020157813). Qualitative studies were included if they evaluated the use of digital technologies supporting behavior change in adult patients undergoing elective surgery during the pre- or postoperative period. Study quality was assessed using the Critical Appraisal Skills Programme tool. A meta-ethnographic approach was used to synthesize existing qualitative data, using the 7 phases of meta-ethnography by Noblit and Hare. Using this approach, along with reciprocal translation, enabled the development of 4 themes from the data.

Results: A total of 18 studies were included covering bariatric (n=2, 11%), cancer (n=13, 72%), and orthopedic (n=3, 17%) surgeries. The 4 overarching themes appear to be key in understanding and determining the effectiveness of digital and mobile interventions to support surgical patients. To successfully motivate health behavior change, technologies should provide motivation and support, enable patient engagement, facilitate peer networking, and meet individualized patient needs. Self-regulatory features such as goal setting heightened patient motivation. The personalization of difficulty levels in virtual reality-based rehabilitation was positively received. Internet-based cognitive behavioral therapy reduced depression and distress in patients undergoing cancer surgery. Peer networking provided emotional support beyond that of patient-provider relationships, improving quality of life and care satisfaction. Patients expressed the desire for digital interventions to be individually tailored according to their physical and psychological needs, before and after surgery.

Conclusions: These findings have the potential to influence the future design of patient-centered digital and mobile health technologies and demonstrate a multipurpose role for digital technologies in the elective surgical pathway by motivating health behavior change and offering psychological support. Through the synthesis of patient suggestions, we highlight areas for digital technology optimization and emphasize the importance of content tailored to suit individual patients and surgical procedures. There is a significant rationale for involving patients in the cocreation of digital health technologies to enhance engagement, better support behavior change, and improve surgical outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/19237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738263PMC
December 2020

Prolonged air leak after IPC insertion: An unusual complication.

Respir Med Case Rep 2020 16;31:101257. Epub 2020 Oct 16.

Department of Respiratory Medicine, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Trust, Freeman Road, High Heaton, Newcastle Upon Tyne, NE7 7DN, United Kingdom.

Indwelling pleural catheters [IPC] have an important role in the management of malignant pleural effusions. We report the development of a significant air leak following IPC insertion with resultant extensive subcutaneous emphysema. The air leak developed, presumably, as a result of visceral pleural disruption, which occurred at the time of vacuum drainage of pleural fluid after IPC placement and not due to lung injury during insertion. The patient required insertion of a large bore intercostal drain connected to low-pressure negative suction. He was eventually discharged home with the aid of an ambulatory system. Although commonly seen in the surgical setting, we believe emergency and respiratory physicians should be aware of the risk of such a complication, and the challenges in its management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.rmcr.2020.101257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7578547PMC
October 2020

Relationship between labour force satisfaction, wages and retention within the UK National Health Service: a systematic review of the literature.

BMJ Open 2020 07 21;10(7):e034919. Epub 2020 Jul 21.

School of Pharmacy, Newcastle University, Newcastle upon Tyne, England, UK

Objectives: A systematic review was undertaken to understand the nature of the relationship between the UK National Health Service (NHS) labour force and satisfaction, retention and wages.

Design: Narrative systematic review.

Data Sources: The literature was searched using seven databases in January 2020: MEDLINE (1996-present), the Cumulative Index to Nursing and Allied Health Literature (CINAHL via EBSCO) (1984-present), Embase (1996-present), PsycINFO (1987-present), ProQuest (1996-present), Scopus (all years) and Cochrane library (all years). We used medical subject headings and key words relating to 'retention', 'satisfaction' and 'wages'.

Eligibility Criteria For Selecting Studies: Primary research studies or reviews that focused on the following relationships within the NHS workforce: wages and job satisfaction, job satisfaction and retention or wages and retention.

Data Extraction And Synthesis: Two independent reviewers screened all titles, abstracts and full texts, with arbitration by a third reviewer.

Results: 27 803 articles were identified and after removing duplicates (n=17 156), articles were removed at the title (n=10 421), abstract (n=150) and full-text (n=45) stages. A total of 31 full-text articles were included. They identified three broad themes, low job satisfaction impacting negatively on job retention, poor pay impacting negatively on staff satisfaction and the limitations of increasing pay as a means of improving staff retention. Several factors affected these relationships, including the environment, discrimination, flexibility, autonomy, training and staffing levels.

Conclusions: This review highlighted how multiple factors influence NHS labour force retention. Pay was found to influence satisfaction, which in turn affected retention. An increase in wages alone is unlikely to be sufficient to ameliorate the concerns of NHS workers. More research is needed to identify the role of autonomy on retention. A system leadership approach underpinned by data is required to implement bespoke job satisfaction improvement strategies to improve retention and achieve the goals of the NHS Long Term Plan.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2019-034919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375434PMC
July 2020

The value of teachable moments in surgical patient care and the supportive role of digital technologies.

Perioper Med (Lond) 2020 4;9. Epub 2020 Feb 4.

1School of Pharmacy, Newcastle University, King George VI Building, Newcastle upon Tyne, NE1 7RU UK.

Evidence strongly supports improved outcomes following surgery when patients are more physically active, have better dietary intake, or are generally fitter prior to surgery. Having an operation is a major life event for patients, and many are not educated around what they can do as individuals to aid a speedier and more successful recovery following their operation. What if there was a time point before surgery where clinicians could inspire patients to adjust their lifestyles for the better, in order to see fewer complications after surgery? This is where the concept of teachable moments comes into play. This commentary explores the concept of teachable moments and their value in surgical patient care and discusses the potentially under-utilized opportunities on hand to the surgical multidisciplinary team to remotely support patients using digital health technologies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13741-019-0133-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6998815PMC
February 2020

Resource implications of robotic thoracic surgery: what are the wider issues?

Ann Cardiothorac Surg 2019 Mar;8(2):250-254

Freeman Hospital, Newcastle Upon Tyne, UK.

The benefits of minimally invasive thoracic surgery are well documented when compared to the use of standard thoracotomy. Much controversy exists, however, regarding the resource implications when using robot-assisted thoracic surgery (RATS), especially when compared to video-assisted thoracoscopic surgery (VATS). Much of the costs attributed to a particular approach center around the frequency and severity of the complications that may arise. Little exists in the literature to appropriately compare and contrast the complication rate following either of the minimally invasive approaches. There is a suggestion that many conventional open surgeons are more readily persuaded to adopt a minimally invasive approach through the use of the robotic platform, therefore reducing the complication-related costs of standard thoracotomy by an increase in minimally invasive resection rates. Further gains may be made in the ability to perform more complex minimally invasive procedures via a RATS approach without recourse to open conversion when compared to VATS. As opportunities and competition increase in the commercial market place, it is reasonable to assume costs will fall and further savings will be made.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/acs.2018.11.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6462561PMC
March 2019

Sequential robotic-assisted lung resection with a subxiphoid utility incision.

Asian Cardiovasc Thorac Ann 2018 Jun 9;26(5):404-406. Epub 2018 May 9.

2 Bart's Health NHS Trust, London, UK.

For the past two years, the authors have used a subxiphoid utility incision for robot-assisted lobectomies. This approach prevents unnecessary rib pressure, offers a good angle of approach to the hilum, and allows specimen retrieval with minimal resistance. Robot-assisted lung resection is an established technique that facilitates postoperative recovery by minimizing operative trauma and postoperative pain. We believe the subxiphoid utility incision further enhances recovery and facilitates early repeat surgery. We present two cases of staged sequential robot-assisted anatomical lung resection using the same subxiphoid utility incision on each occasion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0218492318776890DOI Listing
June 2018

Does the number of wires used to close a sternotomy have an impact on deep sternal wound infection?

Interact Cardiovasc Thorac Surg 2012 Aug 18;15(2):219-22. Epub 2012 May 18.

Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK.

Objectives: We studied the influence of the number of sternotomy mechanical fixation points on deep sternal wound infection (DSWI).

Methods: Between September 2007 and February 2011, 2672 patients underwent a standard peri-sternal wire closure following a median sternotomy for a first-time cardiac surgery. Data were collected during the study period.

Results: The mean age of the patients was 66 ± 11 and 1978 (74.0%) were male. The mean body mass index (BMI) was 28.9 ± 9.3 and the median of the logistic EuroSCORE was 3.14, with a range of 0.88-54.1. Postoperatively, 40 (1.5%) patients developed DSWI after 14 ± 6 days, of whom 39 (92.5%) had positive deep sternal wound specimen cultures, predominantly Staphylococci (62.5%). The risk of DSWI was significantly increased in patients in whom eight or fewer paired points of sternal wire fixation were used when compared with patients in whom nine or more paired points of fixation were used (P = 0.002). Preoperative myocardial infarction (P = 0.001), elevated BMI (P = 0.046), bilateral internal mammary artery harvest (P < 0.0001), postoperative hypoxia (P < 0.0001), sepsis (P = 0.019) and postoperative inotrope use (P = 0.007) significantly increased the risk of DSWI.

Conclusions: DSWI is associated with hypoxia, ischaemia, sepsis and mechanical sternal instability. DSWI may be prevented by using nine or more paired fixation points when closing with standard peri-sternal wires.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/icvts/ivs200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3397758PMC
August 2012

Oxygen delivery and hemoglobin concentration in cardiac surgery: when do we have enough?

Artif Organs 2008 Dec;32(12):949-55

The Royal Infirmary of Edinburgh, Scotland, UK.

For many years it has been assumed that patients undergoing cardiac surgery utilizing cardiopulmonary bypass accumulate an "oxygen debt" that requires a higher postoperative hemoglobin concentration for its reversal. Much of this evidence has now been discredited due to mathematical error with recent research suggesting critical levels of oxygen delivery are lower than previously thought. This article aims to explore the relationship between observed and critical oxygen delivery with an estimation of the minimal hemoglobin required. This was a single-center observational study. Nineteen adult elective cardiac surgery patients were recruited to participate with four subsequently excluded. Observed measurements of oxygen delivery were recorded and compared with calculated "critical" values adjusted for temperature. The hemoglobin value that represented critical oxygen delivery was compared with the observed value to identify any "hemoglobin reserve." At no perioperative time point did observed oxygen delivery or critical hemoglobin concentration significantly approach its corresponding critical value. Current transfusion practice in noncritically ill cardiac surgery patients may be considered excessive if systemic oxygen requirement is the sole parameter considered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/j.1525-1594.2008.00685.xDOI Listing
December 2008

What factors should we consider in deciding when to transfuse patients undergoing elective cardiac surgery?

Transfus Med Rev 2009 Jan;23(1):42-54

The Royal Infirmary of Edinburgh, Scotland, United Kingdom.

Blood transfusion remains one of the commonest interventions carried out upon individuals undergoing cardiac surgery. Despite this, the scientific rationale on which to base this decision is limited. Currently, hemoglobin concentration is often used as the sole guide as to when a transfusion may be required. A fall in hemoglobin concentration is often assumed to be associated with a similar drop in red cell volume. A review was undertaken of all the relevant peer-reviewed literature to determine what factors we should consider when deciding to transfuse elective cardiac surgery patients. The large fluid load associated with cardiac surgery, primarily from the cardiopulmonary bypass circuit, may have a significant dilutional effect. In such a scenario, several interlinked protective mechanisms may ensure that tissue oxygenation is maintained, including a reduction in blood viscosity, a decrease in systemic afterload, and an increase in cardiac output. Furthermore, oxygen requirements during the initial perioperative phase are reduced because of the effect of general anesthesia and hypothermia during cardiopulmonary bypass. When deciding to transfuse, consideration should be given to red cell volume, circulatory status, and oxygen requirement. It is possible that such an all-encompassing approach would reduce the incidence of unnecessary, and potentially counterproductive, red cell transfusion in cardiac surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.tmrv.2008.09.004DOI Listing
January 2009

A comparison of activated coagulation time-based techniques for anticoagulation during cardiac surgery with cardiopulmonary bypass.

J Cardiothorac Vasc Anesth 2008 Feb 7;22(1):47-52. Epub 2007 Nov 7.

The Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom.

Objective: The inadequacy of heparinization during cardiopulmonary bypass (CPB) can lead to hemostatic activation with increases in postoperative blood loss and blood product requirements after cardiac surgery. Because activated coagulation time (ACT) measurements may not be accurate during CPB, the use of a heparin management system (HMS) has been advocated. This study compared the efficacy of a modified ACT-based system versus an HMS (Hepcon; Medtronic Inc, Minneapolis, MN) for CPB anticoagulation.

Design: Randomized controlled trial.

Setting: Regional cardiac surgery center.

Participants: Adult elective cardiac surgical patients.

Interventions: Patients allocated to the HMS group (HC) received individualized heparin doses as indicated by the Hepcon system. Patients in the modified ACT group (C) received a standard weight-based heparin bolus with further doses as dictated by the ACT (Max-ACT, Helena Labs, Sunderland, UK). In addition, group C received supplemental heparin, independent of the ACT, as dictated by the volume of crystalloid added to the extracorporeal circuit. Outcome measures examined were hemostatic activation, postoperative chest tube loss, and blood product requirements.

Results: This study showed no significant difference in efficacy between the modified ACT and HMS heparinization strategies. Although the HC group received significantly greater amounts of heparin, this did not reduce hemostatic activation, postoperative blood loss, or transfusion requirements.

Conclusion: ACT-based heparinization was found to be as efficacious as the Hepcon HMS system.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.jvca.2007.07.011DOI Listing
February 2008

The effect of gain in total body water on haemoglobin concentration and body weight following cardiac surgery.

Heart Lung Circ 2006 Aug 8;15(4):256-60. Epub 2006 Jun 8.

Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Little France Crescent, Old Dalkeith Road, Edinburgh, Scotland EH16 4SU, United Kingdom.

Background: Haemodilution contributes to a low post-operative haemoglobin concentration in cardiac surgery patients. An assessment of the degree of haemodilution could contribute to the avoidance of red cell transfusion when such an act is based simply on a haemoglobin "transfusion trigger". We have recorded post-operative change in total body water along with body weight to assess the impact of haemodilution on haemoglobin concentration.

Methods: Total body water, measured by bio-electrical impedance analysis, haemoglobin and body weight were measured pre-operatively and on the 1st, 3rd, 5th and 10th post-operative days. The percentage peri-operative change in all three variables was used to examine the paired associations.

Results: Total body water and body weight underwent a fall from day 1, with both variables significantly associated up until day 10. Haemoglobin rose steadily from day 1 to 10. This rise was associated with falling total body water and body weight until day 5, but not from day 5 to 10.

Conclusion: Following cardiac surgery, an individual's fluid state should be considered in determining a patient's need for red cell transfusion. Monitoring body weight provides a simple estimate. Such an approach may reduce the incidence of unnecessary, and potentially counterproductive, transfusion in cardiac surgery patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hlc.2006.03.013DOI Listing
August 2006

Perioperative red cell, plasma, and blood volume change in patients undergoing cardiac surgery.

Transfusion 2006 Mar;46(3):392-7

Department of Cardiothoracic Surgery, The Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, Scotland, United Kingdom.

Background: Current blood prescription in cardiac surgery is based largely on hemoglobin (Hb) concentration. Hb may not provide a reliable guide to the patient's red cell (RBC) volume (RCV) during cardiac surgery as a consequence of the high fluid loads infused. This study provides estimates of the perioperative changes in RCV, plasma volume (PV), and blood volume (BV) with a view to developing a more accurate way of assessing a patient's need for transfusion.

Study Design And Methods: Thirty adult elective cardiac surgery patients were recruited to the study. The preoperative RCV was calculated by use of a standard nomogram. Losses and gains in RCV at several time points were added or subtracted from the baseline value. Estimates of PV and BV were derived from patient hematocrit level and RCV for each time point.

Results: The greatest perioperative loss of RCV occurred during cardiopulmonary bypass (CPB); however, half of this loss was returned to the patient at the end of CPB. A net gain of RCV occurred during the period of intensive care management. PV and BV showed two distinct peaks, immediately after CPB and at 16 hours after intensive therapy unit return.

Conclusions: PV and BV expansion are significant factors that may lead to a Hb value that is misleadingly low in that it overestimates the decrease in RCV. This effect could lead to unnecessary transfusion if the RBC transfusion threshold is based only on Hb concentration.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/j.1537-2995.2006.00734.xDOI Listing
March 2006

Cor-triatriatum sinister presenting in the adult as mitral stenosis: an analysis of factors which may be relevant in late presentation.

Heart Lung Circ 2005 Mar 18;14(1):8-12. Epub 2004 Dec 18.

Department of Cardiothoracic Surgery, The Royal Infirmary of Edinburgh, Little France, Edinburgh, Scotland EH16 4SU, UK.

Background: Cor-triatriatum sinister is a rare congenital heart defect resulting from the division of the left atrium by a fibro-muscular membrane. It is usual for patients to present in infancy and early childhood, although some cases remain undetected until adult life. As a consequence of trans-membrane flow obstruction, the clinical features often mimic mitral stenosis. At present, the reasons for late presentation are poorly understood.

Methods: A complete review of all cases of cor-triatriatum sinister published in the English literature from 1966 to date as mitral stenosis was performed. Statistical analysis was carried out to determine associations between measurements reflecting the communicating membrane fenestration area, the presence of several clinical variables and patient age at initial presentation.

Results: Both pulmonary capillary wedge pressure and mean pressure gradient were significantly higher in younger adults. In addition, the incidence of atrial fibrillation and mitral regurgitation was found to rise with advancing age.

Conclusions: Cor-triatriatum sinister remains an uncommon form of congenital heart disease although it is being diagnosed with increasing frequency in adults due to improvements in diagnostic imaging. This diagnosis should be considered in all patients presenting with signs or symptoms of mitral stenosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hlc.2004.10.003DOI Listing
March 2005

Spontaneous coronary artery dissection: a report of two cases occurring during menstruation.

N Z Med J 2003 Sep 12;116(1181):U585. Epub 2003 Sep 12.

Department of Cardiothoracic Surgery, The Royal Infirmary of Edinburgh, Edinburgh, Scotland.

View Article and Find Full Text PDF

Download full-text PDF

Source
September 2003