Building a Collaborative Culture: Focus on Psychological Safety and Error Reporting.

BACKGROUND: At a Midwestern academic medical center, we introduced a structured teamwork training program to cardiothoracic operating room members with a goal of greater than or equal to 90% reporting positive psychological safety after the program. METHODS: We conducted teamwork training over 3 months. We distributed confidential questionnaires before the training, and then at 6 months and 12 months after the training. The primary outcome was the percentage of respondents reporting good or excellent psychological safety. Surveys were also distributed at the end of each case. Secondary outcomes were medical errors reported. Comparisons between percentages were evaluated with chi-square test. We examined the turnover of nurses and surgical technologists. RESULTS: Positive psychological safety was reported by 57 of 73 (78.1%) at baseline and by 60 of 68 (88.2%) at 12 months (difference = 10.1%; 95% confidence interval, -2.4% to 23.4%; P = .122). On the daily survey, 93.9% (n = 2786 of 2987) of operating room team members strongly agreed with the statement "I felt comfortable speaking up with questions and concerns" during the last quarter of the study. Reported medical errors decreased from 7.44% (n = 78 of 1048) in the first 6 months of the study to 4.65% (n = 55 of 1184) in the second 6 months (difference = 2.79%; 95% confidence interval, 0.8% to 4.8%; P = .005). In 2015, 19 nurses of a pool of 40 (47.5%) left, followed by 7 (17.5%) in 2016 and 10 (25%) in 2017. CONCLUSIONS: Overall, the results of this study suggest that structured teamwork training in the cardiothoracic operating room environment has the potential to improve teamwork, psychological safety, and communication, and potentially also patient outcomes.

Optimizing management of replacement fluids for therapeutic plasma exchange: Use of an automated mathematical model to predict post-procedure fibrinogen and antithrombin levels in high-risk patients.

BACKGROUND: Therapeutic plasma exchange (TPE) utilizes an extracorporeal circuit to remove pathologic proteins causing serious illness. When processing a patient's entire blood volume through an extracorporeal circuit, proteins responsible for maintaining hemostatic system homeostasis can reach critically low levels if replacement fluid types and volumes are not carefully titrated, which may increase complications. METHODS: The charts from 27 patients undergoing 46 TPE procedures were reviewed to evaluate the accuracy of our predictive mathematical model, utilizing the following patient information: weight, hematocrit, pre- and post-TPE factor levels (fibrinogen, n = 46, and antithrombin, n = 23), process volume and volumes of fluids (eg, plasma, albumin, and normal saline) administered during TPE and adverse events during and after TPE. RESULTS: Altogether, 25% of patients experienced minor adverse events that resolved spontaneously or with management. There were no bleeding or thrombotic complications. The mean difference between predicted and measured post-TPE fibrinogen concentrations was -0.29 mg/dL (SD ±23.0, range -59 to 37), while percent difference between measured and predicted fibrinogen concentration was 0.94% (SD ±10.8, range of -22 to 19). The mean difference between predicted and measured post-TPE antithrombin concentrations were 0.89% activity (SD ±10.0, range -23 to 14), while mean percent difference between predicted and measured antithrombin concentrations was 3.87% (SD ±14.5, range -25 to 38). CONCLUSIONS: Our model reliably predicts post-TPE fibrinogen and antithrombin concentrations, and may help optimize patient management and attenuate complications.

Acute Presentation of Bioprosthetic Mitral Valve Thrombosis in a Patient on Venoarterial Extracorporeal Membranous Oxygenation.

The management of patients presenting with bioprosthetic valve thrombosis presents a major clinical challenge from a diagnostic and management standpoint. This patient population becomes especially challenging to manage when presenting with cardiogenic shock and additional risks for bleeding. In this clinical conference, the authors present the case of a 64-year-old male who developed intraoperative bioprosthetic mitral valve thrombosis and cardiogenic shock necessitating support with venoarterial extracorporeal membrane oxygenation. The discussion focuses on the diagnostic challenges with transesophageal echocardiography and the difficulty in determining the proper approach to systemic anticoagulation.

Coronary Sinus Catheter-Induced Heart Block During Aortic Valve Replacement: A Case Report.

Conduction abnormalities after cardiac surgery are common as is spontaneous resolution of these abnormalities. However, 1%-3% of patients will require placement of a permanent pacemaker. Patients with preexisting conduction abnormalities, undergoing reoperation, preexisting pulmonary hypertension and undergoing mitral or aortic valve operations are at a higher risk for requiring a permanent pacemaker. We present the first case described in the literature of a patient with a preexisting left bundle branch block, and heart failure with a reduced left ventricular ejection fraction of 25% who developed complete heart block after placement of a coronary sinus catheter.

Successful Continuous Adductor Canal Block Placement in a Patient With Absent Sartorius Muscle: A Case Report.

We report a novel case of a patient who presented for elective total knee arthroplasty and had distorted adductor canal anatomy due to previous sartorius rotational flap surgery. Despite the lack of a sartorius muscle on the intended operative limb, we describe the successful placement of a continuous adductor canal block. This case is a clinically relevant example that highlights the importance of the vastoadductor membrane as the anatomical anteromedial boundary for the adductor canal, and that it remains intact even after sartorius muscle flap surgery.

Resurgence of Vaccine-Preventable Diseases in the United States: Anesthetic and Critical Care Implications.

Vaccine-preventable diseases (VPDs) such as measles and pertussis are becoming more common in the United States. This disturbing trend is driven by several factors, including the antivaccination movement, waning efficacy of certain vaccines, pathogen adaptation, and travel of individuals to and from areas where disease is endemic. The anesthesia-related manifestations of many VPDs involve airway complications, cardiovascular and respiratory compromise, and unusual neurologic and neuromuscular symptoms. In this article, we will review the presentation and management of 9 VPDs most relevant to anesthesiologists, intensivists, and other hospital-based clinicians: measles, mumps, rubella, pertussis, diphtheria, influenza, meningococcal disease, varicella, and poliomyelitis. Because many of the pathogens causing these diseases are spread by respiratory droplets and aerosols, appropriate transmission precautions, personal protective equipment, and immunizations necessary to protect clinicians and prevent nosocomial outbreaks are described.