Crisis management for surgical teams and their leaders, lessons from the COVID-19 pandemic; A structured approach to developing resilience or natural organisational responses.

BACKGROUND: Multiple industries and organisations are afflicted by and respond to institutional crises daily. As surgeons, we respond to crisis frequently and individually such as with critically unwell patients or in mass casualty scenarios; but rarely, do we encounter institutional or multi-institutional crisis with multiple actors as we have seen with the COVID-19 pan-demic. Businesses, private industry and the financial sector have been in a more precar-ious position regarding crisis and consequently have developed rapid response strate-gies employing foresight to reduce risk to assets and financial liquidity. Moreover, large nationalised governmental organisations such as the military have strategies in place ow-ing to a rapidly evolving geopolitical climate with the expectation of immediate new chal-lenges either in the negotiating room or indeed the field of conflict. Despite both nation-alised and privatised healthcare systems existing, both appeared ill-prepared for the COVID-19 global crisis. METHODS: A narrative review of the literature was undertaken exploring the approach to crisis man-agement and models used in organisations exposed to institutional crises outside the field of medicine. RESULTS: There are many parallels between the organisational management of private business institutions, large military organisations and surgical organisational management in healthcare. Models from management consultancies and the armed forces were ex-plored discussed and adapted for the surgical leader providing a framework through which the surgical leader can bring about an successful response to an institutional crisis and ensure future resilience. CONCLUSION: We believe that healthcare, and surgeons (as leaders) in particular, can learn from these other organisations and industries to engage appropriate generic operational plans and contingencies in preparation for whatever further crises may arise in the future, both near and distant. As such, following a review of the literature, we have explored a number of models we believe are adaptable for the surgical community to ensure we remain a dy-namically responsive and ever prepared profession.

Manubrium-limited sternotomy decreases blood loss after aortic valve replacement surgery.

OBJECTIVES: Minimally invasive surgical approaches for aortic valve replacement (AVR) are growing in popularity in an attempt to decrease morbidity from conventional surgery. We have adopted a technique that divides only the manubrium and spares the body of the sternum. We sought to determine whether patients benefit from this less-invasive approach. METHODS: We retrospectively analysed our prospectively maintained database to review all isolated aortic valve replacements performed in an 18-month period from November 2011 to April 2013. RESULTS: One hundred and ninety-one patients were identified, 98 underwent manubrium-limited sternotomy (Mini-AVR) and 93 had a conventional median sternotomy (AVR). The two groups were well matched for preoperative variables and risk (mean logistic EuroSCORE mini-AVR 7.15 vs AVR 6.55, P = 0.47). Mean cardiopulmonary bypass and aortic cross-clamp times were 10 and 6 min longer, respectively, in the mini-AVR group (mean values 88 vs 78 min, P = 0.00040, and 66 vs 60 min, P = 0.0078, respectively). Mini-AVR patients had significantly less postoperative blood loss, 332 vs 513 ml, P = 0.00021, and were less likely to require blood products (fresh-frozen plasma and platelets), 24 vs 36%, P = 0.042. Postoperative complications and length of stay were similar (discharge on or before Day 4; mini-AVR 15 vs AVR 8%, P = 0.17). Valve outcome (paravalvular leak mini-AVR 2 vs AVR 1%, P = 1.00) and survival (mini-AVR 99 vs AVR 97%, P = 0.36) were equal. CONCLUSIONS: A manubrium-limited approach maintains outcomes achieved for aortic valve replacement by conventional sternotomy while significantly reducing postoperative blood loss and transfusion of blood products.

Coronary artery bypass grafting is associated with excellent long-term survival and quality of life: a prospective cohort study.

BACKGROUND: We investigated the long-term outcome of coronary artery bypass grafting both in terms of survival and quality of life. METHODS: Ten-year postsurgery survival was collated on patients undergoing coronary artery bypass grafting from 1994 to 1996, and quality of life was assessed using EQ-5D and a quality-of-life thermometer. We analyzed data from 1,180 patients. Mean age was 61 years, and 79% had triple-vessel disease. RESULTS: Thirty-day mortality was 3.3% (1.8% elective). Mean time to censorship for survivors was 9.9 years (range, 8.1 to 12.3 years). Ten-year survival was 66% across all patients, 70% for elective patients. Ten-year cardiac survival was 82%. Percutaneous intervention was required in 25 patients in the subsequent 10 years (2%), and only 4 required redo coronary artery bypass grafting (0.3%); 59% of patients reported no angina, and 88% of patients had grade II angina or better. Of 621 patients who were assessed for quality of life at 10 years, 530 (85%) had a quality of life within a 95% confidence interval of the score found in the general population with similar age. Poor quality of life was reported in 91 patients (14.7%). Significant predictors of poor long-term quality of life were current smoking, Canadian Cardiovascular Society grade III or IV, redo operation, female sex, diabetes, peripheral vascular disease, more than 2 days in intensive care, and chronic obstructive pulmonary disease. Twenty-five percent of patients with poor EQ-5D outcome had grade IV angina. Interestingly, age did not correlate with poor outcome, and administration of blood, arterial revascularization, left mainstem disease, or cross-clamp fibrillation had no impact on survival or outcome. CONCLUSIONS: Coronary artery bypass grafting is associated with excellent 10-year survival and quality of life.

Coronary bypass grafting using crossclamp fibrillation does not result in reliable reperfusion of the myocardium when the crossclamp is intermittently released: a prospective cohort study.

BACKGROUND: Cross-clamp fibrillation is a well established method of performing coronary grafting, but its clinical effect on the myocardium is unknown. We sought to measure these effects clinically using the Khuri Intramyocardial pH monitor. METHODS: 50 episodes of cross-clamping were recorded in 16 patients who underwent CABG with crossclamp-fibrillation. An Intramyocardial pH probe measured the level of acidosis in the anterior and posterior myocardium in real-time. The pH at the start and end of each period of cross-clamping was recorded. RESULTS: It became very apparent that the pH of some patients recovered quickly while others entirely failed to recover. Thus the patients were split into 2 groups according to whether the pH recovered to above 6.8 after the first crossclamp-release (N = 8 in each group). Initial pH was 7.133 (range 6.974-7.239). After the first period of crossclamping the pH dropped to 6.381 (range 6.034-6.684). The pH in recoverers prior to the second XC application was 6.990 (range 6.808-7.222) compared to only 6.455 (range 6.200-6.737) in patient's whose myocardium did not recover (P < 0.0005). This finding was repeated after the second XC release (mean pH 7.005 vs 6.537) and the third (mean pH 6.736 vs 6.376). However prior to separation from bypass the pH was close to the initial pH in both groups (7.062 vs 7.038). CONCLUSION: Crossclamp fibrillation does not result in reliable reperfusion of the myocardium between periods of crossclamping.

Use of intraaortic balloon pump in left ventricle rupture after mitral valve replacement.

Over 6 years of a single surgeon experience, 3 patients had left ventricle rupture following mitral valve replacement, despite preserving the posterior leaflet. The valve was re-replaced on bypass in all patients. Intraaortic balloon pump was inserted electively before coming off bypass. There were no intraoperative deaths, reexploration, or excessive bleeding. An intraaortic balloon pump is an ideal adjuvant to left ventricle repair for ruptured ventricle following mitral valve replacement on cardiopulmonary bypass.