Surgical incidents and their impact on operating theatre staff: qualitative study.

BACKGROUND: Surgical incidents can have significant effects on both patients and health professionals, including emotional distress and depression. The aim of this study was to explore the personal and professional impacts of surgical incidents on operating theatre staff. METHODS: Face-to-face semistructured interviews were conducted with a range of different healthcare professionals working in operating theatres, including surgeons and anaesthetists, operating department practitioners, and theatre nurses, and across different surgical specialties at five different hospitals. All interviews were audio recorded, transcribed verbatim, and analysed using an inductive thematic approach, which involved reading and re-reading the transcripts, assigning preliminary codes, and searching for patterns and themes within the codes, with the aid of NVivo 12 software. These emerging themes were discussed with the wider research team to gain their input. RESULTS: Some 45 interviews were conducted, generally lasting between 30 and 75 min. Three overarching themes emerged: personal and professional impact; impact of the investigation process; and positive consequences or impact. Participants recalled experiencing negative emotions following surgical incidents that depended on the severity of the incident, patient outcomes, and the support that staff received. A culture of blame, inadequate support, and lack of a clear and transparent investigative process appeared to worsen impact. CONCLUSION: The study indicated that more support is needed for operating theatre staff involved in surgical incidents. Greater transparency and better information during the investigation of such incidents for staff are still needed.

Digital technology to support lifestyle and health behaviour changes in surgical patients: systematic review.

BACKGROUND: Digital technologies (such as smartphone applications, activity trackers, and e-learning platforms) have supported patients with long-term conditions to change their lifestyle health behaviours. The aim of this study was to examine the effectiveness of digital technologies in supporting patients undergoing elective surgery to change their health behaviours. METHODS: A systematic review was conducted of articles reporting a digital intervention supporting behaviour change in adult patients who underwent elective bariatric, oncological or orthopaedic surgery. MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Scopus were searched from inception to March 2019 for quantitative intervention studies with a specific focus on physical activity, dietary intake, and weight loss in patients before and after surgery (PROSPERO: CRD42019127972). The Joanna Briggs Institute critical appraisal checklist was used to assess study quality. RESULTS: Of 3021 citations screened, 17 studies were included comprising 4923 surgical patients; these included experimental (pre-post design, feasibility studies, and RCTs) and observational studies. Three factors were identified as effective for supporting health behaviour change in elective surgical populations: digital technology delivery, implementation, and theoretical underpinning. Six of eight studies that referred to behaviour change theories observed significant improvements in health behaviour relating to reduced weight regain, and improved lifestyle choices for physical activity and diet. Meta-analysis was not possible because of heterogeneous outcome measures. CONCLUSION: Digital technologies may effectively support behavioural change in patients undergoing elective surgery.

Systematic review of psychological, emotional and behavioural impacts of surgical incidents on operating theatre staff.

BACKGROUND: Adverse surgical incidents affect both patients and health professionals. This study sought to explore the effect of surgical incidents on operating theatre staff and their subsequent behaviours. METHODS: Eligible studies were primary research or reviews that focused on the effect of incidents on operating theatre staff in primary, secondary or tertiary care settings. MEDLINE, Embase, CINALH and PsycINFO were searched. A data extraction form was used to capture pertinent information from included studies and the Critical Appraisal Skills Programme (CASP) tool to appraise their quality. PRISMA-P reporting guidelines were followed and the review is registered with PROSPERO. RESULTS: A total of 3918 articles were identified, with 667 duplicates removed and 3230 excluded at the title, abstract and full-text stages. Of 21 included articles, eight focused on the impact of surgical incidents on surgeons and anaesthetists. Only two involved theatre nurses and theatre technicians. Five key themes emerged: the emotional impact on health professionals, organization culture and support, individual coping strategies, learning from surgical complications and recommended changes to practice. CONCLUSION: Health professionals suffered emotional distress and often changed their behaviour following a surgical incident. Both organizations and individual clinicians can do a great deal to support staff in the aftermath of serious incidents.

Experience with sodium fluorescein flow cytometry in the determination of red cell volume.

Sodium fluorescein flow cytometry for the calculation of red cell volume is an exciting proposition in that the repeatability of the technique in a short time frame should allow for applications such as the measurement of surgical red cell volume loss. Our results found that the rapid decay in fluorescence negated the usefulness of this technique as currently described. However, further investigation into the behaviour of the sodium fluorescein labelled red blood cells may allow for the mathematical correction of the fluorescent red cell population prior to red cell volume calculation.

Rationalizing blood transfusion in cardiac surgery: the impact of a red cell volume-based guideline on blood usage and clinical outcome.

BACKGROUND AND OBJECTIVES: Cardiac surgery is currently considered one of the heaviest users of red blood cells. An explanation may be found, in part, in considering the effect of the heavy clear fluid load associated with cardiopulmonary bypass. This may result in the artificial depression of haemoglobin concentration, overestimating the requirement for red cell transfusion if this is the sole parameter considered. To address this issue, we examined the impact of a red cell volume-based transfusion guideline on transfusion requirement. MATERIALS AND METHODS: This was a single-centre, randomized controlled trial. The cohort of 86 patients was allocated to receive red cells as per the red cell volume guideline (group RCV) or standard haemoglobin concentration-based departmental policy (group C). Outcome measures were red cell transfusion and clinical outcome. RESULTS: All preoperative data were comparable between the two groups. A significantly fewer percentage of patients in group RCV were transfused red cells (RCV = 32.6% vs. C = 53.5%, P = 0.05). No significant difference was found between any of the outcome measures with the exception of median hospital stay (RCV = 5.9 days vs. C = 6.8 days, P = 0.02). CONCLUSION: In elective cardiac surgery patients, considering haemoglobin concentration alone may overestimate the requirement for red cell transfusion. More research is required to determine the impact of restrictive transfusion policies on clinical outcome following cardiac surgery.

Rationalizing blood transfusion in cardiac surgery: preliminary findings with a red cell volume-based model.

BACKGROUND AND OBJECTIVES: Cardiac surgery, utilizing extracorporeal circulation, is associated with a heavy fluid load that may significantly depress haemoglobin concentration. Thus, considering haemoglobin alone may be an inaccurate method of replacing red cell volume loss. This study was designed to examine the impact on red cell transfusion of a red cell volume-based guideline. MATERIALS AND METHODS: Patients were randomized to receive red cells as dictated by the red cell volume-based guideline or a haemoglobin-based protocol. End-points considered were red cell transfusion and clinical outcome. RESULTS: Patients transfused as per the red cell volume-based guideline received significantly less red cells with no associated difference in clinical outcome. CONCLUSION: Considering haemoglobin concentration alone may significantly overestimate the requirement for red cell transfusion in elective cardiac surgery patients.

Factors predicting loss and gain of red cell volume in cardiac surgery patients.

Haemoglobin may be a poor indicator of changes in red cell volume (RCV) because of factors such as haemodilution. This study has been designed to analyse what peri-operative variables may be associated with loss or gain in RCV due to bleeding or transfusion. Prospective observational study. Single centre study based in a regional cardiac surgery centre. Twenty-nine elective adult cardiac surgery patients. Loss and gain of RCV were measured in theatre and for the first 24 h post-operatively. Patient and operative factors analysed were age, sex, height, weight, body surface area (BSA), induction haematocrit (Hct), estimated pre-operative RCV and antiplatelet therapy taken less than 7 days before operation, cardiopulmonary bypass (CPB) time, aortic occlusion time, minimum and maximum CPB temperatures and fluid administered. Age, sex, height, weight, BSA and induction Hct were found to predict red cell transfusion but not RCV loss. The total number of red cells transfused was significantly associated with RCV lost when expressed as a percentage reduction in the estimated pre-operative RCV but not the absolute RCV lost. Pre-operative RCV, as predicted by the variables outlined above, is more important than RCV lost in triggering red cell transfusion.

Management of blunt thoracic aortic injury.

Blunt traumatic aortic transection (TAT) is an uncommon injury in clinical practice that is associated with a high morbidity and mortality. The approach to patients with such an injury is controversial with specific regard to the most effective diagnostic tools, timing of surgical intervention and mechanisms of spinal cord protection. Chest X-ray with widening of the mediastinum is unreliable as a diagnostic tool. Contrast enhanced helical CT Scan has replaced the traditional angiography as the screening diagnostic tool of choice Emergency thoracotomy and repair should be reserved for the few patients with isolated TAT without any major concomitant injuries. Delayed management approach with aggressive blood pressure control and serial radiological monitoring is a safe and recommended option for those with severe concomitant injuries or other medical co-morbidity that puts surgery at high risk. Active augmentation of the distal perfusion pressure during cross clamp offers the best protection against development of paraplegia during open surgical repair. Endovascular stenting offers a minimally invasive method of treatment but the long-term durability of the endovascular stent is still unknown. We feel that the greater feasibility of the endovascular repair in the acute phase of the thoracic injury is an advantage over the open surgery and should be the treatment of choice in patients with severe concomitant injuries.

Cor triatriatum sinister presenting in the adult as mitral stenosis.

Cor triatriatum sinister is a rare congenital defect in which the left atrium is divided by a fibromuscular membrane into two distinct chambers. Classically, patients present in infancy although in some cases they remain asymptomatic until adulthood. The clinical features on presentation can mimic those of mitral stenosis due to the obstructive properties of the membrane. Cor triatriatum sinister presented in this case in an adult as mitral stenosis. Factors that may be relevant in determining late presentation are also discussed.