Therapeutic Plasma Exchange Practices in Intensive Care Unit.

OBJECTIVE: To observe the indications, practices and outcome of therapeutic plasma exchange (TPE) in a tertiary care ICU. MATERIALS AND METHODS: The study involves retrospective analysis of 56 patients who underwent TPE between May 2011 and August 2013. Data relating to demographics, diagnosis, category of indication, number of sessions, volume and type of replacement solutions were collected. RESULTS: Category I indications were 50%, with a mean of 3.32 sessions per patient. Per session volume exchanged was 9775.1 ± 11812.9 mL and replacement volume was 7414 ± 6993.03 mL. Fresh frozen plasma (FFP), crystalloids, cryopoorplasma and PRBC constituted 62.9%, 22%, 9.9% and 5.3% of volume replacement, respectively. TPE was terminated in three patients for Transfusion Associated Acute Lung Injury (TRALI), hypotension and cardiac arrest respectively. Clinical improvement was noted in 82% of patients and overall mortality rate was 12.5%. CONCLUSION: TPE is feasible and well tolerated in ICU with favorable disease resolution and outcome. Common indications included sickle cell and myasthenia crisis and blood products were the most commonly used for volume replacement. HOW TO CITE THIS ARTICLE: Ranganathan L, Menon R, Ramakrishnan N, Venkatraman R, Ramachandran P. Therapeutic Plasma Exchange Practices in Intensive Care Unit. Indian J Crit Care Med 2019;23(7):336-338.

Resident case coverage in the era of the 80-hour workweek.

OBJECTIVES: The purpose of our study was to evaluate resident case coverage before and after the implementation of duty-hour restrictions and discuss its potential impact on surgical attendings. DESIGN: We reviewed cases before (6/2002 to 6/2003) and after (6/2008 to 6/2009) the implementation of duty-hour restrictions, retrospectively. SETTING: Academic-affiliated community surgical residency program. PARTICIPANTS: Full-time academic faculty and surgical residents. RESULTS: Of 5253 cases performed in the year before the 80-hour workweek, 4466 (85%) were covered by residents and 787 (15%) were uncovered. Of the 6123 cases performed after the 80-hour workweek restrictions, 3694 (60%) were covered by residents and 2429 (40%) were uncovered. Despite an increase in operations and faculty, significantly fewer cases were covered by residents when comparing the time-restricted and non-time-restricted periods (85% vs 60%, p < 0.005). CONCLUSIONS: The number of surgical cases without resident participation has increased significantly in the 80-hour workweek. Departments should reevaluate faculty expectations relative to time management, compensation, and nonclinical responsibilities.

The eighty-hour workweek: surgical attendings' perspectives.

OBJECTIVE: The year 2008 was a sentinel year in resident education; this was the first graduating general surgery class trained entirely under the 80-hour workweek. The purpose of this study was to evaluate attending surgeon perceptions of surgical resident attitudes and performance before and after duty-hour restrictions. DESIGN: An electronic survey was sent to all surgical teaching institutions in North Carolina. Both surgeon and hospital characteristics were documented. The survey consisted of questions designed to assess residents' attitudes/performance before and after the implementation of the work-hour restriction. RESULTS: In all, 77 surveys were returned (33% response rate). The survey demonstrated that 92% of educators who responded to the survey recognized a difference between the restricted residents (RRs) and the nonrestricted residents (NRRs), and most respondents (67%) attributed this to both the work-hour restrictions and the work ethic of current residents. Most attending surgeons reported no difference between the RRs and the NRRs in most categories; however, they identified a negative change in the areas of work ethic, technical skills development, decision-making/critical-thinking skills, and patient ownership among the RR group. Most surgeons expressed less trust (55%) with patient care and less confidence (68%) in residents' ability to operate independently in the RR group. Eighty-nine percent indicated that additional decreases in work hours would continue to hamper the mission of timely and comprehensive resident education. CONCLUSIONS: The perception of surgical educators was that RRs are clearly different from the NRRs and that the primary difference is in work ethic and duty-hour restrictions. Although similar in most attributes, RRs are perceived as having a lower baseline work ethic and a less developed technical skill set, decision-making ability, and sense of patient ownership. Subsequent study is needed to evaluate these concerns.

Employment and satisfaction trends among general surgery residents from a community hospital.

BACKGROUND: Physician satisfaction is an important and timely issue in health care. A paucity of literature addresses this question among general surgeons. PURPOSE: To review employment patterns and job satisfaction among general surgery residents from a single university-affiliated institution. METHODS: All general surgery residents graduating from 1986 to 2006, inclusive, were mailed an Institutional Review Board-approved survey, which was then returned anonymously. Information on demographics, fellowship training, practice characteristics, job satisfaction and change, and perceived shortcomings in residency training was collected. RESULTS: A total of 31 of 34 surveys were returned (91%). Most of those surveyed were male (94%) and Caucasian (87%). Sixty-one percent of residents applied for a fellowship, and all but 1 were successful in obtaining their chosen fellowship. The most frequent fellowship chosen was plastic surgery, followed by minimally invasive surgery. Seventy-one percent of residents who applied for fellowship felt that the program improved their competitiveness for a fellowship. Most of the sample is in private practice, and of those, 44% are in groups with more than 4 partners. Ninety percent work less than 80 hours per week. Only 27% practice in small towns (population <50,000). Of the 18 graduates who practice general surgery, 94% perform advanced laparoscopy. Sixty-seven percent of our total sample cover trauma, and 55% of the general surgeons perform endoscopy. These graduates wish they had more training in pancreatic, hepatobiliary, and thoracic surgery. Eighty-three percent agreed that they would again choose a general surgery residency, 94% of those who completed a fellowship would again choose that fellowship, and 90% would again choose their current job. Twenty-three percent agreed that they had difficulty finding their first job, and 30% had fewer job offers than expected. Thirty-five percent of the graduates have changed jobs: 29% of the residents have changed jobs once, and 6% have changed jobs at least twice since completing training. Reasons for leaving a job included colleague issues (82%), financial issues (82%), inadequate referrals (64%), excessive trauma (64%), and marriage or family reasons (55% and 55%, respectively). One half to three fourths of the graduates wished they had more teaching on postresidency business and financial issues, review of contracts, and suggestions for a timeline for finding a job. CONCLUSIONS: Although general surgical residencies prepare residents well technically, they do not seem to be training residents adequately in the business of medicine. This training can be conducted by attendings, local attorneys, office managers, and past residents with the expectation that job relocations can decrease and surgeon career satisfaction can increase.

Residency training in pyloromyotomy: a survey of 331 pediatric surgeons.

PURPOSE: Both pediatric and general surgeons perform pyloromyotomy. Laparoscopic pyloromyotomy (LAP), and changes in referral patterns have affected the training of pediatric surgery fellows and general surgery residents. We surveyed pediatric surgeons regarding these issues. METHODS: We mailed an Institutional Review Board of New Hanover Regional Medical Center-approved survey to 701 members of the American Pediatric Surgical Association within the United States to determine each surgeon's preferred technique for pyloromyotomy (LAP vs Ramstedt or transumbilical procedures [OPEN]), practice setting, involvement with trainees, and opinions regarding pyloromyotomy. Significance was determined using chi(2) analyses. RESULTS: A total of 331 (48%) surgeons responded: 197 (60%) performed most or all OPEN, and 85 (26%), most or all LAP. Laparoscopic pyloromyotomy was more likely in academic practices and children's hospitals (P < .05). Residents under surgeons performing LAP were less likely to participate (58% vs 91%; P < .05) or gain competence (22% vs 42%; P < .5). Only 34% of surgeons performing LAP believed that general surgery residents should learn pyloromyotomy, whereas 67% of surgeons performing OPEN believed that residents should learn the procedure (P < .05). A total of 307 (93%) surgeons believed at least 4 OPEN were necessary to become competent, but 126 (44%) reported that their residents performed fewer than 4. Only 104 (31%) surgeons believed that their residents were competent in pyloromyotomy. There were 303 (92%) surgeons who believed that pyloromyotomy should be performed only by pediatric surgeons when possible. CONCLUSIONS: Most general surgical residents are not learning pyloromyotomy, in part because of the adoption of laparoscopic technique, limited operative experience, and the opinion of most pediatric surgeons that the procedure should be performed only by pediatric surgeons.