Fewer transfusions are still more-red blood cell transfusions affect long-term mortality in cardiac surgery.

OBJECTIVES: Previous studies indicated higher long-term mortality after the transfusion of allogeneic red blood cells (RBC); newer recommendations emphasize lower transfusion rates. The consequences of the transfusion of RBCs in cardiac surgery are unclear because later studies focused on transfusion triggers and short-term outcomes. Reports on long-term complications after cardiac surgery are few. MATERIAL AND METHODS: The mandatory Western Denmark Heart Registry was used to identify all adult cardiac operations performed in 4 centres from 2000 to 2019. Patients with multiple entries or previous cardiac operations, special/complex procedures, dying within 30 days and not eligible for follow-up were excluded. RESULTS: A total of 32,581 adult cardiac operations performed in 4 centres from 2000 to 2019 were included. The Kaplan-Meier survival plot for low-risk patients undergoing simple cardiac operations showed a significantly lower 15-year survival (0.384 vs 0.661) of patients who received perioperative RBC transfusions [odds ratio 2.43 (confidence level 2.23-2.66)]. The risk decreased with increasing comorbidity or age. No difference was found in high-risk patients. The adjusted risk ratio after an RBC transfusion, including age, sex, comorbidity and surgery, was 1.62 (1.48-1.77). CONCLUSIONS: Despite reduced transfusion rates, long-term follow-up on especially low-risk patients undergoing comparable cardiac operations still demonstrates substantially more deaths of patients receiving perioperative RBC transfusions. Even transfusion of 1-2 units is associated with increased long-term mortality.

A Study of Surgical Residents' Self-Assessment of Open Surgery Skills Using Gap Analysis.

BACKGROUND: Surgical residents need structured and objective feedback to develop their skills and become capable of performing surgical procedures autonomously. A shortage of experienced surgical staff has prompted residents to seek feedback from self-assessment and peer assessments. OBJECTIVES: We investigated whether surgical residents can reliably rate their own and their peers' basic surgical skills using the Global Rating Scale (GRS) from the Objective Structured Assessment of Technical Skills. METHODS: The study was a prospective and descriptive study conducted using gap analysis at the Copenhagen Academy for Medical Education and Simulation (Copenhagen, Denmark) from 2016 to 2017. Surgical residents were recruited during a course in basic open surgical skills. Among 102 course participants, 53 met the inclusion criteria and 22 participated in the study. RESULTS: We recruited surgical residents based in the Capital Region and Zealand Region of Demark, and 42% of eligible residents participated in the study. Surgical residents underestimated their own surgical performance (median, 17 [range, 15-18] vs. 20 [range, 19.75-22]; P < 0.001). They also rated their peers lower than an experienced rater did (median 10 [range, 8.75-14] vs. 15 and median 20.5 [range, 19-22] vs. 23; both P < 0.001). Gap analysis revealed residents had unrecognized strengths (ie, self-underappraisal) in most GRS domains. CONCLUSIONS: Ratings are unreliable when surgical residents assess their own and their peers' performances using GRS. A gap analysis revealed unrecognized strengths in time and motion, instrument handling, knowledge of instruments and sutures, and knowledge of specific procedure as well as unrecognized weaknesses in flow of operation and forward planning.

The Challenges of Dyad Practice in Simulation Training of Basic Open Surgical Skills-A Mixed-Method Study.

INTRODUCTION: Simulation training at home improves access to training, but motivation can be difficult to maintain. Dyad training could keep trainees motivated. This study aimed to examine the effect of self-regulated training of basic surgical skills in pairs versus individually. METHODS: One hundred one medical doctors were included in this prospective, mixed-method, simulation-based study. Participants were randomized to train individually or in pairs during a 6-week course in open surgical skills, consisting of didactic instructions and self-directed training at home. Trainees kept a training log and filled in a questionnaire. Skills were tested before and after the course. Tests were rated by an expert using the Objective Structured Assessment of Technical Skills Global Rating Scale. RESULTS: Ninety-seven doctors completed the study. We found no differences in test score between dyad and individual trainees. Dyad trainees compared with individual trainees improved by 7.23 points (intercept estimate) versus 6.94 points, respectively (P = 0.881). Dyad trainees trained less frequently [7.3 times (intercept estimate) vs. 12.1 times, P < 0.001, but for longer intervals compared with individual trainees (68 minutes vs. 38 minutes)]. Dyad trainees reported benefits such as having a sparring partner, receiving feedback, corrections, increased motivation, having fun, and more structured training sessions. However, the coordination of training sessions was difficult. CONCLUSIONS: No differences were found between dyad trainees and individual trainees in improvement of surgical skills. Off-site dyad training led to fewer, but longer training sessions, which may have negatively impacted the effectiveness of training. Dyad trainees perceived dyad training beneficial.

Basic open surgical training course.

INTRODUCTION: Fewer open surgical procedures are performed, and thus a need to learn open surgical techniques outside the operating room has emerged. Simulation training offers the possibility to train in a safe environment before operating on patients. The purpose of this study is to evaluate the effect of a simulation-based course in basic open surgical skills and to describe its pedagogical foundation, content and organisation. METHODS: Surgical trainees at the beginning of their surgical career participated in a basic open surgical skills course and were assessed before the course, after the course and during a one-day course operating on live sedated pigs using the Objective Structures Assessment of Technical Skills (OSATS) instrument. RESULTS: We found that the course participants matched the target group. The participants' OSATS score increased from 12.1 in the pre-test to 19.9 points (p < 0.0001) in the post-test. The completion rate was 99% and the failure rate was 11%. The course met 13 out of 14 requirements for a simulation-based course. CONCLUSIONS: The basic open surgical skills course teaches trainees the basic skills for open surgery including knot tying, suturing, dissection and surgical assistance. The course significantly increases the participants' surgical abilities and meets requirements for a well-structured simulation course. FUNDING: Equipment was provided by Copenhagen Academy for Medical Education and Simulation, Capital Region, Copenhagen, Denmark. The authors have no conflicts of interest or financial ties to disclose. TRIAL REGISTRATION: The study did not require registration as this is a retrospective quality control study using anonymised participant data.

[Mechanical circulatory support by means of a subclavian pump in a patient suffering acute heart failure].

A 65-year-old female patient suffered biventricular failure due to severe lymphoid myocarditis. Mechanical circulatory support was established with peripheral arterial-venous extracorporeal membrane oxygenation (AV-ECMO). The left ventricle was relieved by subclavian Impella 5.0. AV-ECMO was weaned with the use of only Impella 5.0 until the 17th day of use, whereupon Impella was phased out. This case report illustrates the use-fulness of combined peripheral VA-ECMO with subclavian Impella 5.0 with the prospect of single use of the subclavian Impella 5.0 until cardiac recovery thereby avoiding central cannulation.

High thoracic epidural analgesia as an adjunct to general anesthesia is associated with better outcome in low-to-moderate risk cardiac surgery patients.

OBJECTIVE: The purpose of this study was to evaluate the addition of high thoracic epidural analgesia (HTEA) to general anesthesia in cardiac surgery patients to enhance the fast-track and improvement in outcome. DESIGN: Retrospective cohort study of prospectively registered data using population-based healthcare databases. PARTICIPANTS: One thousand seven hundred thirteen consecutive patients scheduled for elective coronary artery bypass grafting, aortic valve replacement, mitral valve surgery, and combinations eligible for supplementation with epidural analgesia. One thousand sixteen patients were matched and analyzed. SETTING: University hospital, single center. INTERVENTION: To minimize bias and confounding, epidural patients were matched using EuroSCORE criteria to nonepidural in a 1:1 ratio requiring exact match on sex, age, patient factors, cardiac factors, and procedure type together with normal/moderate/poor left ventricular function, insulin-dependent diabetes, and on-pump/off-pump surgery. All together, 1,016 patients (508 each group) were identified with matching criteria. MEASUREMENTS AND MAIN RESULTS: Outcome parameters were 30-day and 6-month mortality, postoperative dialysis, stroke, and myocardial infarction. Univariate analysis showed that epidural analgesia was associated with lower 6-month mortality (p = 0.021), lower frequency of postoperative dialysis (p = 0.029), and lower frequency of myocardial infarction (p = 0.049). No difference was seen in stroke (p = 0.341). However, adjusted odds ratio of selected perioperative variables showed that HTEA only had a positive impact on the frequency of postoperative dialysis (0.22 [0.06-0.74]). CONCLUSION: This large, uniquely matched single-center cohort was generated, and, subject to the listed limitations the authors concluded that supplemental HTEA to general anesthesia had a better outcome in low-risk cardiac surgery patients, with a significantly lower 6-month mortality rate compared with the control group. However, regression analysis revealed that HTEA only had an independently positive effect on the frequency of postoperative dialysis.