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TSRA Review of Cardiothoracic Surgery Available
Some of the most useful review materials in General Surgery are those written by residents, for residents. Until now, nothing like this has existed in Cardiothoracic Surgery. The Thoracic Surgery Residents Association (TSRA) is proud to announce the recent creation of just such a resource, the TSRA Review of Cardiothoracic Surgery. More than 50 cardiothoracic surgery residents from around the country contributed to the book, which covers General Thoracic, Adult Cardiac and Congenital Cardiac Surgery as well as Cardiothoracic Trauma and Critical Care. Details on obtaining the book (including free-of-charge formats) can be found at the TSRA website: (http://www.tsranet.org/sections/review_of_cardiothor/index.html).
Some of the most useful review materials in General Surgery are those written by residents, for residents. Until now, nothing like this has existed in Cardiothoracic Surgery. The Thoracic Surgery Residents Association (TSRA) is proud to announce the recent creation of just such a resource, the TSRA Review of Cardiothoracic Surgery. More than 50 cardiothoracic surgery residents from around the country contributed to the book, which covers General Thoracic, Adult Cardiac and Congenital Cardiac Surgery as well as Cardiothoracic Trauma and Critical Care. Details on obtaining the book (including free-of-charge formats) can be found at the TSRA website: (http://www.tsranet.org/sections/review_of_cardiothor/index.html).
Some of the most useful review materials in General Surgery are those written by residents, for residents. Until now, nothing like this has existed in Cardiothoracic Surgery. The Thoracic Surgery Residents Association (TSRA) is proud to announce the recent creation of just such a resource, the TSRA Review of Cardiothoracic Surgery. More than 50 cardiothoracic surgery residents from around the country contributed to the book, which covers General Thoracic, Adult Cardiac and Congenital Cardiac Surgery as well as Cardiothoracic Trauma and Critical Care. Details on obtaining the book (including free-of-charge formats) can be found at the TSRA website: (http://www.tsranet.org/sections/review_of_cardiothor/index.html).
New Data Largely Discount 'July Phenomenon'
"Don’t have surgery in July!" This is the folk wisdom regarding the purported "July Phenomenon" – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. "Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?" is the intuitive assumption.
A recent study reported in ‘Surgery’, however, showed that this concern is unfounded.
Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034).
The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).
The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62).
In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, pediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.
To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007.
They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the "first academic quarter," or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30).
They assessed the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.
The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%).
Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).
"Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a ‘July Phenomenon’ in surgical patients," the authors stated.
Discrepancies between the previous ACS-NSQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).
They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).
"New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease," they suggested.
A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns.
For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.
In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.
The researchers disclosed no conflicts that the journal deemed relevant to report.
"Don’t have surgery in July!" This is the folk wisdom regarding the purported "July Phenomenon" – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. "Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?" is the intuitive assumption.
A recent study reported in ‘Surgery’, however, showed that this concern is unfounded.
Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034).
The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).
The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62).
In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, pediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.
To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007.
They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the "first academic quarter," or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30).
They assessed the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.
The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%).
Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).
"Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a ‘July Phenomenon’ in surgical patients," the authors stated.
Discrepancies between the previous ACS-NSQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).
They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).
"New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease," they suggested.
A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns.
For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.
In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.
The researchers disclosed no conflicts that the journal deemed relevant to report.
"Don’t have surgery in July!" This is the folk wisdom regarding the purported "July Phenomenon" – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. "Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?" is the intuitive assumption.
A recent study reported in ‘Surgery’, however, showed that this concern is unfounded.
Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034).
The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).
The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62).
In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, pediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.
To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007.
They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the "first academic quarter," or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30).
They assessed the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.
The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%).
Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).
"Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a ‘July Phenomenon’ in surgical patients," the authors stated.
Discrepancies between the previous ACS-NSQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).
They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).
"New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease," they suggested.
A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns.
For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.
In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.
The researchers disclosed no conflicts that the journal deemed relevant to report.
Major Finding: Mortality was significantly increased (though less than 1%) in only 1 of the 10 most common operations – lower artery bypass grafting – at the beginning of the academic year as compared with any other quarter.
Data Source: A database analysis of 89,473 patients undergoing the 10 most common inpatient operative procedures from 2005 to 2007.
Disclosures: The authors had no disclosures deemed relevant to report by the journal.
Resident Editors Wanted
Resident Editors Wanted
Are you going to be a cardiothoracic surgeon resident for the next year, and are you interested in becoming a resident editor of Thoracic Surgery News? Please send your CV to Dr. Yolonda Colson at [email protected] or Dr. Yolonda Colson c/o Thoracic Surgery News, 2275 Research Blvd. Suite #400 Rockville, MD 20850.
Resident Editors Wanted
Are you going to be a cardiothoracic surgeon resident for the next year, and are you interested in becoming a resident editor of Thoracic Surgery News? Please send your CV to Dr. Yolonda Colson at [email protected] or Dr. Yolonda Colson c/o Thoracic Surgery News, 2275 Research Blvd. Suite #400 Rockville, MD 20850.
Resident Editors Wanted
Are you going to be a cardiothoracic surgeon resident for the next year, and are you interested in becoming a resident editor of Thoracic Surgery News? Please send your CV to Dr. Yolonda Colson at [email protected] or Dr. Yolonda Colson c/o Thoracic Surgery News, 2275 Research Blvd. Suite #400 Rockville, MD 20850.
Selected Online Resources
AATS Resident Resources: www.aats.org/TSR/index.html
CTSNET Residents Section: www.ctsnet.org/sections/residents
Thoracic Surgery Directors Association: www.tsda.org
Thoracic Surgery News: www.thoracicsurgerynews.com
Thoracic Surgery Residents Association: www.tsranet.org
Thoracic Surgery Foundation for Research and Education: www.tsfre.org
AATS Resident Resources: www.aats.org/TSR/index.html
CTSNET Residents Section: www.ctsnet.org/sections/residents
Thoracic Surgery Directors Association: www.tsda.org
Thoracic Surgery News: www.thoracicsurgerynews.com
Thoracic Surgery Residents Association: www.tsranet.org
Thoracic Surgery Foundation for Research and Education: www.tsfre.org
AATS Resident Resources: www.aats.org/TSR/index.html
CTSNET Residents Section: www.ctsnet.org/sections/residents
Thoracic Surgery Directors Association: www.tsda.org
Thoracic Surgery News: www.thoracicsurgerynews.com
Thoracic Surgery Residents Association: www.tsranet.org
Thoracic Surgery Foundation for Research and Education: www.tsfre.org
Some General Thoracic Surgery Milestones
Note: The definitions of ‘first’ and ‘successful’ can be contentious in any branch of history, and the history of medicine is no exception. The dates and events listed below have at least some legitimate consensus behind them.
1882 First documented human pulmonary resection: a failure which led to suicide of the surgeon (H. M. Block)
1891 First partial lung resection (Theodore Tuffler)
1895 First documented successful pneumnectomy: a multiple stage cautery method (William Macewen)
1904 Low pressure ventilation chamber devised to maintain lung expansion during thoracotomy (Ferdinand Saurbruch)
1924 First successful pulmonary embolectomy (Martin Kirshner).
1929 First successful one-stage lobectomy (Harold Brunn)
1931 First successful one-stage ligation of entire pulmonary hilum (Rudolph Nissen)
1933 First successful one-stage pneumonectomy with mediastinal dissection and individual ligation of main vessels (William Reinhoff)
1938 First clinical use of mechanical ventilator, the Frecken "Spiropulsator" (Clarence Crafoord)
1941 First successful one-stage repair of congenital artresia of the esophagus with distal tracheoescophageal fistula (Cameron Haight)
1949 First report of radical pneumonectomy for lung cancer (P. R. Allison).
Compiled from the following sources:
- Radical Surgery for Lung Cancer, William H. Watson, Cancer 1956 9:1167-1172.
- The Magnificent Century of Cardiothoracic Surgery, Amer Chaikhouni, Heart Views, 2007 8:161-164.
Note: The definitions of ‘first’ and ‘successful’ can be contentious in any branch of history, and the history of medicine is no exception. The dates and events listed below have at least some legitimate consensus behind them.
1882 First documented human pulmonary resection: a failure which led to suicide of the surgeon (H. M. Block)
1891 First partial lung resection (Theodore Tuffler)
1895 First documented successful pneumnectomy: a multiple stage cautery method (William Macewen)
1904 Low pressure ventilation chamber devised to maintain lung expansion during thoracotomy (Ferdinand Saurbruch)
1924 First successful pulmonary embolectomy (Martin Kirshner).
1929 First successful one-stage lobectomy (Harold Brunn)
1931 First successful one-stage ligation of entire pulmonary hilum (Rudolph Nissen)
1933 First successful one-stage pneumonectomy with mediastinal dissection and individual ligation of main vessels (William Reinhoff)
1938 First clinical use of mechanical ventilator, the Frecken "Spiropulsator" (Clarence Crafoord)
1941 First successful one-stage repair of congenital artresia of the esophagus with distal tracheoescophageal fistula (Cameron Haight)
1949 First report of radical pneumonectomy for lung cancer (P. R. Allison).
Compiled from the following sources:
- Radical Surgery for Lung Cancer, William H. Watson, Cancer 1956 9:1167-1172.
- The Magnificent Century of Cardiothoracic Surgery, Amer Chaikhouni, Heart Views, 2007 8:161-164.
Note: The definitions of ‘first’ and ‘successful’ can be contentious in any branch of history, and the history of medicine is no exception. The dates and events listed below have at least some legitimate consensus behind them.
1882 First documented human pulmonary resection: a failure which led to suicide of the surgeon (H. M. Block)
1891 First partial lung resection (Theodore Tuffler)
1895 First documented successful pneumnectomy: a multiple stage cautery method (William Macewen)
1904 Low pressure ventilation chamber devised to maintain lung expansion during thoracotomy (Ferdinand Saurbruch)
1924 First successful pulmonary embolectomy (Martin Kirshner).
1929 First successful one-stage lobectomy (Harold Brunn)
1931 First successful one-stage ligation of entire pulmonary hilum (Rudolph Nissen)
1933 First successful one-stage pneumonectomy with mediastinal dissection and individual ligation of main vessels (William Reinhoff)
1938 First clinical use of mechanical ventilator, the Frecken "Spiropulsator" (Clarence Crafoord)
1941 First successful one-stage repair of congenital artresia of the esophagus with distal tracheoescophageal fistula (Cameron Haight)
1949 First report of radical pneumonectomy for lung cancer (P. R. Allison).
Compiled from the following sources:
- Radical Surgery for Lung Cancer, William H. Watson, Cancer 1956 9:1167-1172.
- The Magnificent Century of Cardiothoracic Surgery, Amer Chaikhouni, Heart Views, 2007 8:161-164.
ACS Ultrasound Course Now Available
A comprehensive course in ultrasound for residents that can be conducted at their institution is now available from the American College of Surgeons Division of Education in a CD-ROM format. Beginning with the "Ultrasound for Residents: A Basic Course," surgical residents are introduced to basic concepts in the physics of ultrasound, instrumentation and scanning techniques, and clinical applications. This introduction is followed by "Ultrasound for Residents: A Skills Companion," which provides residents with an overview of ultrasound related to breast, vascular, thyroid, and parathyroid, and abdominal applications.
Purchase of "Ultrasound for Residents: The Complete Course" gives purchasers an annual subscription that allows 1 year of unlimited access to course content for an unlimited number of surgical residents. Registration of participants is required for each offering of the course.
This course bundle does not provide AMA PRA Category 1 CME Credit TM.
A certificate of completion will be provided upon conclusion of the course including pre-/post-test requirements.
For more information, you can visit www.facs.org/education/ultrasound/residents.html or contact the Program for Verification of Surgical Knowledge and Skills at 866-918-479 or via e-mail at [email protected]. ☐
A comprehensive course in ultrasound for residents that can be conducted at their institution is now available from the American College of Surgeons Division of Education in a CD-ROM format. Beginning with the "Ultrasound for Residents: A Basic Course," surgical residents are introduced to basic concepts in the physics of ultrasound, instrumentation and scanning techniques, and clinical applications. This introduction is followed by "Ultrasound for Residents: A Skills Companion," which provides residents with an overview of ultrasound related to breast, vascular, thyroid, and parathyroid, and abdominal applications.
Purchase of "Ultrasound for Residents: The Complete Course" gives purchasers an annual subscription that allows 1 year of unlimited access to course content for an unlimited number of surgical residents. Registration of participants is required for each offering of the course.
This course bundle does not provide AMA PRA Category 1 CME Credit TM.
A certificate of completion will be provided upon conclusion of the course including pre-/post-test requirements.
For more information, you can visit www.facs.org/education/ultrasound/residents.html or contact the Program for Verification of Surgical Knowledge and Skills at 866-918-479 or via e-mail at [email protected]. ☐
A comprehensive course in ultrasound for residents that can be conducted at their institution is now available from the American College of Surgeons Division of Education in a CD-ROM format. Beginning with the "Ultrasound for Residents: A Basic Course," surgical residents are introduced to basic concepts in the physics of ultrasound, instrumentation and scanning techniques, and clinical applications. This introduction is followed by "Ultrasound for Residents: A Skills Companion," which provides residents with an overview of ultrasound related to breast, vascular, thyroid, and parathyroid, and abdominal applications.
Purchase of "Ultrasound for Residents: The Complete Course" gives purchasers an annual subscription that allows 1 year of unlimited access to course content for an unlimited number of surgical residents. Registration of participants is required for each offering of the course.
This course bundle does not provide AMA PRA Category 1 CME Credit TM.
A certificate of completion will be provided upon conclusion of the course including pre-/post-test requirements.
For more information, you can visit www.facs.org/education/ultrasound/residents.html or contact the Program for Verification of Surgical Knowledge and Skills at 866-918-479 or via e-mail at [email protected]. ☐
APDVS: Tapping the Minds of Vascular Trainees
CHICAGO – Vascular surgery trainees are increasingly turning to online texts for clinical information and seek more training on the business aspects of vascular surgery and noninvasive laboratory studies, according to a survey by the Association of Program Directors in Vascular Surgery.
The survey included 163 respondents, of which 46 were in an integrated (0-5) residency program and 117 were currently in or new graduates of an independent (5+2) program.
When asked how they obtained clinical information on the wards or prior to an operation, integrated program respondents said online text books were their go-to source, while independent responders preferred a traditional textbook. Asking a colleague came in second for both groups.
"You can certainly figure out why that might be," said Dr. Michael Dalsing who reported the findings at the annual meeting of the Peripheral Vascular Surgical Society. "If you’re a PGY 1 - 3, patient care is your primary concern. While for those with additional levels of training, specific vascular concerns and surgery are most important."
One-on-one instruction was the best way both groups of trainees reported learning new information. Integrated residents were less enthusiastic than independent residents about small group discussions, while simulation training ranked higher among integrated residents.
When asked to grade their overall program, both programs ranked their endovascular training as excellent.
"Less than a decade you would not have seen endovascular training as the best part of their program, and now nearly 70% said it’s excellent," said Dr. Dalsing, of Indiana University.
Other "excellent" ratings included involvement of teaching faculty, open abdominal and aortic/mesenteric/renal training, didactic teaching and responsiveness to resident stresses. Appropriate performance feedback and support in their job search received "good" marks.
When asked if training in a specific area was appropriate, the business aspects of vascular surgery were judged the most underserved among both integrated and independent (69% vs. 70%) trainees, followed by coding and billing (66% and 64%). The next closest area in need of more attention was formal clinical research training, with just 27% and 35% of trainees, respectively, expressing this opinion. Surgical training and vascular lab/venous training were judged "just right" by more than 75% of respondents.
The ability to actually perform noninvasive vascular laboratory studies requires more attention, with a whopping 49% of integrated program trainees and 59% of independent program trainees viewing training in this area as "fair or nonexistent." Training in vascular laboratory interpretation received the same marks by 29% and 34% of trainees, respectively. About 85% of all trainees, however, view noninvasive vascular lab training as essential in future practice.
Dr. Joseph Mills, of the University of Arizona, rose from the audience to express alarm at these findings and asked what is being done to standardize the curriculum in the vascular lab. Dr. Dalsing said that CDs are available to educators to standardize training, but added that educators will have to become more aggressive in quantifying that the educational experience at their institution has met expected standards.
The two groups of trainees were split over the 80-hour work week. Independent trainees were significantly more likely than integrated trainees to view the 80-hour work week as detrimental to the continuity of care (62% vs. 24%, P value = .0001), while integrated trainees were significantly more likely to view the rule as essential to avoid fatigue and errors (82% vs. 42%, P = .0001).
CHICAGO – Vascular surgery trainees are increasingly turning to online texts for clinical information and seek more training on the business aspects of vascular surgery and noninvasive laboratory studies, according to a survey by the Association of Program Directors in Vascular Surgery.
The survey included 163 respondents, of which 46 were in an integrated (0-5) residency program and 117 were currently in or new graduates of an independent (5+2) program.
When asked how they obtained clinical information on the wards or prior to an operation, integrated program respondents said online text books were their go-to source, while independent responders preferred a traditional textbook. Asking a colleague came in second for both groups.
"You can certainly figure out why that might be," said Dr. Michael Dalsing who reported the findings at the annual meeting of the Peripheral Vascular Surgical Society. "If you’re a PGY 1 - 3, patient care is your primary concern. While for those with additional levels of training, specific vascular concerns and surgery are most important."
One-on-one instruction was the best way both groups of trainees reported learning new information. Integrated residents were less enthusiastic than independent residents about small group discussions, while simulation training ranked higher among integrated residents.
When asked to grade their overall program, both programs ranked their endovascular training as excellent.
"Less than a decade you would not have seen endovascular training as the best part of their program, and now nearly 70% said it’s excellent," said Dr. Dalsing, of Indiana University.
Other "excellent" ratings included involvement of teaching faculty, open abdominal and aortic/mesenteric/renal training, didactic teaching and responsiveness to resident stresses. Appropriate performance feedback and support in their job search received "good" marks.
When asked if training in a specific area was appropriate, the business aspects of vascular surgery were judged the most underserved among both integrated and independent (69% vs. 70%) trainees, followed by coding and billing (66% and 64%). The next closest area in need of more attention was formal clinical research training, with just 27% and 35% of trainees, respectively, expressing this opinion. Surgical training and vascular lab/venous training were judged "just right" by more than 75% of respondents.
The ability to actually perform noninvasive vascular laboratory studies requires more attention, with a whopping 49% of integrated program trainees and 59% of independent program trainees viewing training in this area as "fair or nonexistent." Training in vascular laboratory interpretation received the same marks by 29% and 34% of trainees, respectively. About 85% of all trainees, however, view noninvasive vascular lab training as essential in future practice.
Dr. Joseph Mills, of the University of Arizona, rose from the audience to express alarm at these findings and asked what is being done to standardize the curriculum in the vascular lab. Dr. Dalsing said that CDs are available to educators to standardize training, but added that educators will have to become more aggressive in quantifying that the educational experience at their institution has met expected standards.
The two groups of trainees were split over the 80-hour work week. Independent trainees were significantly more likely than integrated trainees to view the 80-hour work week as detrimental to the continuity of care (62% vs. 24%, P value = .0001), while integrated trainees were significantly more likely to view the rule as essential to avoid fatigue and errors (82% vs. 42%, P = .0001).
CHICAGO – Vascular surgery trainees are increasingly turning to online texts for clinical information and seek more training on the business aspects of vascular surgery and noninvasive laboratory studies, according to a survey by the Association of Program Directors in Vascular Surgery.
The survey included 163 respondents, of which 46 were in an integrated (0-5) residency program and 117 were currently in or new graduates of an independent (5+2) program.
When asked how they obtained clinical information on the wards or prior to an operation, integrated program respondents said online text books were their go-to source, while independent responders preferred a traditional textbook. Asking a colleague came in second for both groups.
"You can certainly figure out why that might be," said Dr. Michael Dalsing who reported the findings at the annual meeting of the Peripheral Vascular Surgical Society. "If you’re a PGY 1 - 3, patient care is your primary concern. While for those with additional levels of training, specific vascular concerns and surgery are most important."
One-on-one instruction was the best way both groups of trainees reported learning new information. Integrated residents were less enthusiastic than independent residents about small group discussions, while simulation training ranked higher among integrated residents.
When asked to grade their overall program, both programs ranked their endovascular training as excellent.
"Less than a decade you would not have seen endovascular training as the best part of their program, and now nearly 70% said it’s excellent," said Dr. Dalsing, of Indiana University.
Other "excellent" ratings included involvement of teaching faculty, open abdominal and aortic/mesenteric/renal training, didactic teaching and responsiveness to resident stresses. Appropriate performance feedback and support in their job search received "good" marks.
When asked if training in a specific area was appropriate, the business aspects of vascular surgery were judged the most underserved among both integrated and independent (69% vs. 70%) trainees, followed by coding and billing (66% and 64%). The next closest area in need of more attention was formal clinical research training, with just 27% and 35% of trainees, respectively, expressing this opinion. Surgical training and vascular lab/venous training were judged "just right" by more than 75% of respondents.
The ability to actually perform noninvasive vascular laboratory studies requires more attention, with a whopping 49% of integrated program trainees and 59% of independent program trainees viewing training in this area as "fair or nonexistent." Training in vascular laboratory interpretation received the same marks by 29% and 34% of trainees, respectively. About 85% of all trainees, however, view noninvasive vascular lab training as essential in future practice.
Dr. Joseph Mills, of the University of Arizona, rose from the audience to express alarm at these findings and asked what is being done to standardize the curriculum in the vascular lab. Dr. Dalsing said that CDs are available to educators to standardize training, but added that educators will have to become more aggressive in quantifying that the educational experience at their institution has met expected standards.
The two groups of trainees were split over the 80-hour work week. Independent trainees were significantly more likely than integrated trainees to view the 80-hour work week as detrimental to the continuity of care (62% vs. 24%, P value = .0001), while integrated trainees were significantly more likely to view the rule as essential to avoid fatigue and errors (82% vs. 42%, P = .0001).
Impact of Fellowship Programs on Residents' Case Logs Examined
BOCA RATON, FLA. – Coexisting subspecialty fellowship programs have at most only minimal adverse impact on general surgery residency training operative volumes, according to a national study sponsored by the American Board of Surgery.
The analysis also demonstrated that fellowship-bound general surgery residents tend to select additional cases in their chosen future subspecialty, thereby in effect creating a self-directed early tracking program, Dr. John B. Hanks said at the annual meeting of the American Surgical Association.
The American Board of Surgery (ABS) conducted the study in response to concerns that because 80% of general surgery residents pursue fellowship training, an insufficient number of cases could be available for resident training. But the national data indicate that this is not a problem, according to Dr. Hanks, professor and chief of general surgery at the University of Virginia, Charlottesville.
The study entailed detailed analysis of the operative logs of 976 applicants to the 2009 ABS qualifying exam. The applicants came from 246 general surgery residency programs. In all, 97 of these residency programs coexisted with a vascular surgery fellowship program, 35 with a colorectal surgery fellowship program, 80 with a minimally invasive surgery training program, and 12 with an endocrine surgery fellowship program. The investigators scrutinized case volumes for predefined key operations in the areas of vascular, colorectal, endocrine, and minimally invasive surgery (MIS).
Residents bound for fellowships in vascular, colorectal, and endocrine surgery performed significantly more total cases in each of those areas than did general surgery residents who were not bound for fellowships. For example, operative logs for the 90 vascular surgery fellowship–bound residents showed a mean experience of 165 vascular cases, compared with 123 cases for the other general surgery residents. And residents headed for colorectal surgery fellowships had a mean of 204 colorectal surgery cases, compared with 163 for all other general surgery residents.
In contrast, residents who were headed for an MIS fellowship and those who were not averaged a similar number of minimally invasive operations.
With regard to the effect of coexisting fellowship programs on general surgery residents’ operative experience in those specific areas, there was a negative impact only for MIS. Residents in general surgery training programs with a coexisting MIS fellowship averaged about 10% fewer MIS cases than did residents in institutions without a fellowship.
"That difference reaches statistical significance, although the practical significance of this effect may be open for debate," Dr. Hanks observed.
The situation was different for residents at institutions with coexisting colorectal or vascular surgery fellowships; those fellowships had no impact on general surgery residents’ case volumes in those specialty-specific areas. And the presence of a coexisting endocrine surgery fellowship was actually associated with a significant increase in endocrine surgery case volumes for all residents, he continued.
Discussant Dr. Layton F. Rikkers cautioned that the ABS study describes national trends using broad strokes, and the data don’t necessarily apply to any individual residency program.
"As an example, the only fellowship we developed at the University of Wisconsin, Madison, during the time I was chairman there was a vascular surgery fellowship," said Dr. Rikkers, professor of surgery at the university and past president of the ABS. "The year prior to developing the fellowship, our residents were in the 93rd percentile nationally with respect to vascular surgery cases done. Over the many years since that fellowship was established, our residents are in the 10th to 20th percentile for vascular surgery cases."
Dr. Hanks declared having no financial conflict of interest.
The significance of this is hard to determine, precisely because of the reason stated by Dr. Rikkers – impact on individual programs cannot be assessed, and likely varies greatly from program to program. For example, in some instances the additional specialty cases may be uncovered by residents, and in that situation no impact would be seen. In others, the cases might be directly "poached" from the general surgery residencies. A final scenario might be one in which an initial downturn is seen in general surgery cases, which is overcome over a period of years as the presence of a fellowship often drives up case volumes at an institution.
Another confounding issue generated by the lack of individual institutional information is that the case volumes in certain specialties may be higher in institutions that attract more residents to a specific field – prominence of a specialty in a given institution may impact resident choice of specialty. Indeed, rather than residents choosing to do more cases in their chosen field, they may in fact have chosen their field based on greater exposure to the specialty. This cannot be parsed out from the data at hand.
No mention is made of the involvement of the residents in the pre-operative and post-operative care of the patients when participation is outside of usual service assignments. If this is not robust, benefits to patients and trainees may be lessened.
Dr. Cynthia K. Shortell is a professor of surgery and chief of vascular surgery and program director, vascular residency at Duke University Medical Center, Durham, N.C., and an associate medical editor for Vascular Specialist.
The significance of this is hard to determine, precisely because of the reason stated by Dr. Rikkers – impact on individual programs cannot be assessed, and likely varies greatly from program to program. For example, in some instances the additional specialty cases may be uncovered by residents, and in that situation no impact would be seen. In others, the cases might be directly "poached" from the general surgery residencies. A final scenario might be one in which an initial downturn is seen in general surgery cases, which is overcome over a period of years as the presence of a fellowship often drives up case volumes at an institution.
Another confounding issue generated by the lack of individual institutional information is that the case volumes in certain specialties may be higher in institutions that attract more residents to a specific field – prominence of a specialty in a given institution may impact resident choice of specialty. Indeed, rather than residents choosing to do more cases in their chosen field, they may in fact have chosen their field based on greater exposure to the specialty. This cannot be parsed out from the data at hand.
No mention is made of the involvement of the residents in the pre-operative and post-operative care of the patients when participation is outside of usual service assignments. If this is not robust, benefits to patients and trainees may be lessened.
Dr. Cynthia K. Shortell is a professor of surgery and chief of vascular surgery and program director, vascular residency at Duke University Medical Center, Durham, N.C., and an associate medical editor for Vascular Specialist.
The significance of this is hard to determine, precisely because of the reason stated by Dr. Rikkers – impact on individual programs cannot be assessed, and likely varies greatly from program to program. For example, in some instances the additional specialty cases may be uncovered by residents, and in that situation no impact would be seen. In others, the cases might be directly "poached" from the general surgery residencies. A final scenario might be one in which an initial downturn is seen in general surgery cases, which is overcome over a period of years as the presence of a fellowship often drives up case volumes at an institution.
Another confounding issue generated by the lack of individual institutional information is that the case volumes in certain specialties may be higher in institutions that attract more residents to a specific field – prominence of a specialty in a given institution may impact resident choice of specialty. Indeed, rather than residents choosing to do more cases in their chosen field, they may in fact have chosen their field based on greater exposure to the specialty. This cannot be parsed out from the data at hand.
No mention is made of the involvement of the residents in the pre-operative and post-operative care of the patients when participation is outside of usual service assignments. If this is not robust, benefits to patients and trainees may be lessened.
Dr. Cynthia K. Shortell is a professor of surgery and chief of vascular surgery and program director, vascular residency at Duke University Medical Center, Durham, N.C., and an associate medical editor for Vascular Specialist.
BOCA RATON, FLA. – Coexisting subspecialty fellowship programs have at most only minimal adverse impact on general surgery residency training operative volumes, according to a national study sponsored by the American Board of Surgery.
The analysis also demonstrated that fellowship-bound general surgery residents tend to select additional cases in their chosen future subspecialty, thereby in effect creating a self-directed early tracking program, Dr. John B. Hanks said at the annual meeting of the American Surgical Association.
The American Board of Surgery (ABS) conducted the study in response to concerns that because 80% of general surgery residents pursue fellowship training, an insufficient number of cases could be available for resident training. But the national data indicate that this is not a problem, according to Dr. Hanks, professor and chief of general surgery at the University of Virginia, Charlottesville.
The study entailed detailed analysis of the operative logs of 976 applicants to the 2009 ABS qualifying exam. The applicants came from 246 general surgery residency programs. In all, 97 of these residency programs coexisted with a vascular surgery fellowship program, 35 with a colorectal surgery fellowship program, 80 with a minimally invasive surgery training program, and 12 with an endocrine surgery fellowship program. The investigators scrutinized case volumes for predefined key operations in the areas of vascular, colorectal, endocrine, and minimally invasive surgery (MIS).
Residents bound for fellowships in vascular, colorectal, and endocrine surgery performed significantly more total cases in each of those areas than did general surgery residents who were not bound for fellowships. For example, operative logs for the 90 vascular surgery fellowship–bound residents showed a mean experience of 165 vascular cases, compared with 123 cases for the other general surgery residents. And residents headed for colorectal surgery fellowships had a mean of 204 colorectal surgery cases, compared with 163 for all other general surgery residents.
In contrast, residents who were headed for an MIS fellowship and those who were not averaged a similar number of minimally invasive operations.
With regard to the effect of coexisting fellowship programs on general surgery residents’ operative experience in those specific areas, there was a negative impact only for MIS. Residents in general surgery training programs with a coexisting MIS fellowship averaged about 10% fewer MIS cases than did residents in institutions without a fellowship.
"That difference reaches statistical significance, although the practical significance of this effect may be open for debate," Dr. Hanks observed.
The situation was different for residents at institutions with coexisting colorectal or vascular surgery fellowships; those fellowships had no impact on general surgery residents’ case volumes in those specialty-specific areas. And the presence of a coexisting endocrine surgery fellowship was actually associated with a significant increase in endocrine surgery case volumes for all residents, he continued.
Discussant Dr. Layton F. Rikkers cautioned that the ABS study describes national trends using broad strokes, and the data don’t necessarily apply to any individual residency program.
"As an example, the only fellowship we developed at the University of Wisconsin, Madison, during the time I was chairman there was a vascular surgery fellowship," said Dr. Rikkers, professor of surgery at the university and past president of the ABS. "The year prior to developing the fellowship, our residents were in the 93rd percentile nationally with respect to vascular surgery cases done. Over the many years since that fellowship was established, our residents are in the 10th to 20th percentile for vascular surgery cases."
Dr. Hanks declared having no financial conflict of interest.
BOCA RATON, FLA. – Coexisting subspecialty fellowship programs have at most only minimal adverse impact on general surgery residency training operative volumes, according to a national study sponsored by the American Board of Surgery.
The analysis also demonstrated that fellowship-bound general surgery residents tend to select additional cases in their chosen future subspecialty, thereby in effect creating a self-directed early tracking program, Dr. John B. Hanks said at the annual meeting of the American Surgical Association.
The American Board of Surgery (ABS) conducted the study in response to concerns that because 80% of general surgery residents pursue fellowship training, an insufficient number of cases could be available for resident training. But the national data indicate that this is not a problem, according to Dr. Hanks, professor and chief of general surgery at the University of Virginia, Charlottesville.
The study entailed detailed analysis of the operative logs of 976 applicants to the 2009 ABS qualifying exam. The applicants came from 246 general surgery residency programs. In all, 97 of these residency programs coexisted with a vascular surgery fellowship program, 35 with a colorectal surgery fellowship program, 80 with a minimally invasive surgery training program, and 12 with an endocrine surgery fellowship program. The investigators scrutinized case volumes for predefined key operations in the areas of vascular, colorectal, endocrine, and minimally invasive surgery (MIS).
Residents bound for fellowships in vascular, colorectal, and endocrine surgery performed significantly more total cases in each of those areas than did general surgery residents who were not bound for fellowships. For example, operative logs for the 90 vascular surgery fellowship–bound residents showed a mean experience of 165 vascular cases, compared with 123 cases for the other general surgery residents. And residents headed for colorectal surgery fellowships had a mean of 204 colorectal surgery cases, compared with 163 for all other general surgery residents.
In contrast, residents who were headed for an MIS fellowship and those who were not averaged a similar number of minimally invasive operations.
With regard to the effect of coexisting fellowship programs on general surgery residents’ operative experience in those specific areas, there was a negative impact only for MIS. Residents in general surgery training programs with a coexisting MIS fellowship averaged about 10% fewer MIS cases than did residents in institutions without a fellowship.
"That difference reaches statistical significance, although the practical significance of this effect may be open for debate," Dr. Hanks observed.
The situation was different for residents at institutions with coexisting colorectal or vascular surgery fellowships; those fellowships had no impact on general surgery residents’ case volumes in those specialty-specific areas. And the presence of a coexisting endocrine surgery fellowship was actually associated with a significant increase in endocrine surgery case volumes for all residents, he continued.
Discussant Dr. Layton F. Rikkers cautioned that the ABS study describes national trends using broad strokes, and the data don’t necessarily apply to any individual residency program.
"As an example, the only fellowship we developed at the University of Wisconsin, Madison, during the time I was chairman there was a vascular surgery fellowship," said Dr. Rikkers, professor of surgery at the university and past president of the ABS. "The year prior to developing the fellowship, our residents were in the 93rd percentile nationally with respect to vascular surgery cases done. Over the many years since that fellowship was established, our residents are in the 10th to 20th percentile for vascular surgery cases."
Dr. Hanks declared having no financial conflict of interest.
Test Your Knowledge of Dealing With Air Embolism
A 56-year-old male is undergoing an aortic valve replacement through a full sternotomy with standard aortic and right atrial cannulation at a temperature of 34 degrees. You are preparing to place your last annulus suture when you notice a large bolus of air travel through your arterial line, into the arterial perfuser and into the patient’s aorta.
Directed questions:
1. What organ is at greatest risk for damage due to massive air embolism?
2. What is the first instruction you should give to your perfusionist when you first note an air embolism?
3. What is the first instruction you should give to your anesthesiologist?
4. What strategy can be used to "de-air" the cerebral circulation?
5. What neuroprotective strategies can be employed intraoperatively?
6. What therapeutic adjuncts can be employed postoperatively to minimize neurologic sequelae?
7. What is most common source of air emboli?
8. What routine strategies can be employed to minimize the risk of massive air embolism?
Key Points and Answers to Questions:
1. The greatest concern from massive air embolism is a stroke. Massive air embolism is rare with an estimated frequency of less than 0.01% but carries a significant morbidity and mortality.
2. Upon detection of air embolism, the cardiopulmonary bypass machine should be stopped to avoid further injection of air into the arterial circulation. An expeditious search for the source of the air should take place and steps taken to de-air the circuit to be able to resume cardiopulmonary bypass.
3. The patient should be placed in steep trendelenberg position to minimize further travel of air into the cerebral circulation. Hopefully, air will return into the proximal aorta and can be aspirated or drained via the aortotomy.
4. Retrograde cerebral perfusion can be performed to flush the air from the cerebral circulation. A cannula can be inserted into the superior vena cava and perfused with cold blood (< 20 degrees) in a retrograde fashion. The aorta may need to be opened to allow egress of air from the cerebral circulation.
5. In addition to retrograde cerebral perfusion, deep hypothermia and corticosteroids might be beneficial. Hypothermia decreases brain oxygen consumption and allows for more time for retrograde perfusion under circulatory arrest.
6. Postoperatively, continued use of steroids and moderate hypothermia might be beneficial and some have recommended barbiturate coma to minimize brain metabolism. Reports suggest a benefit of hyperbaric oxygen therapy in the immediate postoperative period. The benefit of hyperbaric oxygen therapy appears greatest when instituted within about 5 hours of surgery and seems less efficacious if there is a delay in the initiation of therapy.
7. The most common source of air emboli is unremoved air from the cardiac chambers.
8. Important strategies include careful inspection of the arterial circuit for air prior to initiation of bypass, stringent use of cardiopulmonary bypass safety alarms which monitor the reservoir level and bubble monitors to detect air in the cardiopulmonary bypass circuit, compulsive de-airing maneuvers at conclusion of surgery, and careful examination for residual intracardiac air with transesophageal echo.
Select References and Additional Resources
PIHammon JW. (2008). Extracorporeal Circulation: Perfusion System. In Cohn LH (Ed), Cardiac Surgery in the Adult. (3rd edition, 350-370). New York: McGraw-Hill.
PIKern JA, Arnold S. Massive Cerebral Embolization: Successful Treatment with Retrograde Perfusion. Annals of Thoracic Surgery. 69: 1266, 2000.
PIMills NL, Ochsner JL. Massive air embolism during cardiopulmonary bypass: causes, prevention and management. Journal of Thoracic and Cardiovascular Surgery. 80:708–717, 1980.
PIUtley JR. Techniques for avoiding neurologic injury during adult cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia. 10(1): 38-44, 1996.
PIZiser A, Adir Y, et al. Hyperbaric oxygen therapy for massive arterial air embolism during cardiac operations. Journal of Thoracic and Cardiovascular Surgery. 117(4): 818, 1999.
This Challenge was provided by Resident Medical Editor, Dr. Christian Peyre.
Body text goes here
Doctor’s Bio
Body text goes here
Doctor’s Bio
Body text goes here
Doctor’s Bio
A 56-year-old male is undergoing an aortic valve replacement through a full sternotomy with standard aortic and right atrial cannulation at a temperature of 34 degrees. You are preparing to place your last annulus suture when you notice a large bolus of air travel through your arterial line, into the arterial perfuser and into the patient’s aorta.
Directed questions:
1. What organ is at greatest risk for damage due to massive air embolism?
2. What is the first instruction you should give to your perfusionist when you first note an air embolism?
3. What is the first instruction you should give to your anesthesiologist?
4. What strategy can be used to "de-air" the cerebral circulation?
5. What neuroprotective strategies can be employed intraoperatively?
6. What therapeutic adjuncts can be employed postoperatively to minimize neurologic sequelae?
7. What is most common source of air emboli?
8. What routine strategies can be employed to minimize the risk of massive air embolism?
Key Points and Answers to Questions:
1. The greatest concern from massive air embolism is a stroke. Massive air embolism is rare with an estimated frequency of less than 0.01% but carries a significant morbidity and mortality.
2. Upon detection of air embolism, the cardiopulmonary bypass machine should be stopped to avoid further injection of air into the arterial circulation. An expeditious search for the source of the air should take place and steps taken to de-air the circuit to be able to resume cardiopulmonary bypass.
3. The patient should be placed in steep trendelenberg position to minimize further travel of air into the cerebral circulation. Hopefully, air will return into the proximal aorta and can be aspirated or drained via the aortotomy.
4. Retrograde cerebral perfusion can be performed to flush the air from the cerebral circulation. A cannula can be inserted into the superior vena cava and perfused with cold blood (< 20 degrees) in a retrograde fashion. The aorta may need to be opened to allow egress of air from the cerebral circulation.
5. In addition to retrograde cerebral perfusion, deep hypothermia and corticosteroids might be beneficial. Hypothermia decreases brain oxygen consumption and allows for more time for retrograde perfusion under circulatory arrest.
6. Postoperatively, continued use of steroids and moderate hypothermia might be beneficial and some have recommended barbiturate coma to minimize brain metabolism. Reports suggest a benefit of hyperbaric oxygen therapy in the immediate postoperative period. The benefit of hyperbaric oxygen therapy appears greatest when instituted within about 5 hours of surgery and seems less efficacious if there is a delay in the initiation of therapy.
7. The most common source of air emboli is unremoved air from the cardiac chambers.
8. Important strategies include careful inspection of the arterial circuit for air prior to initiation of bypass, stringent use of cardiopulmonary bypass safety alarms which monitor the reservoir level and bubble monitors to detect air in the cardiopulmonary bypass circuit, compulsive de-airing maneuvers at conclusion of surgery, and careful examination for residual intracardiac air with transesophageal echo.
Select References and Additional Resources
PIHammon JW. (2008). Extracorporeal Circulation: Perfusion System. In Cohn LH (Ed), Cardiac Surgery in the Adult. (3rd edition, 350-370). New York: McGraw-Hill.
PIKern JA, Arnold S. Massive Cerebral Embolization: Successful Treatment with Retrograde Perfusion. Annals of Thoracic Surgery. 69: 1266, 2000.
PIMills NL, Ochsner JL. Massive air embolism during cardiopulmonary bypass: causes, prevention and management. Journal of Thoracic and Cardiovascular Surgery. 80:708–717, 1980.
PIUtley JR. Techniques for avoiding neurologic injury during adult cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia. 10(1): 38-44, 1996.
PIZiser A, Adir Y, et al. Hyperbaric oxygen therapy for massive arterial air embolism during cardiac operations. Journal of Thoracic and Cardiovascular Surgery. 117(4): 818, 1999.
This Challenge was provided by Resident Medical Editor, Dr. Christian Peyre.
A 56-year-old male is undergoing an aortic valve replacement through a full sternotomy with standard aortic and right atrial cannulation at a temperature of 34 degrees. You are preparing to place your last annulus suture when you notice a large bolus of air travel through your arterial line, into the arterial perfuser and into the patient’s aorta.
Directed questions:
1. What organ is at greatest risk for damage due to massive air embolism?
2. What is the first instruction you should give to your perfusionist when you first note an air embolism?
3. What is the first instruction you should give to your anesthesiologist?
4. What strategy can be used to "de-air" the cerebral circulation?
5. What neuroprotective strategies can be employed intraoperatively?
6. What therapeutic adjuncts can be employed postoperatively to minimize neurologic sequelae?
7. What is most common source of air emboli?
8. What routine strategies can be employed to minimize the risk of massive air embolism?
Key Points and Answers to Questions:
1. The greatest concern from massive air embolism is a stroke. Massive air embolism is rare with an estimated frequency of less than 0.01% but carries a significant morbidity and mortality.
2. Upon detection of air embolism, the cardiopulmonary bypass machine should be stopped to avoid further injection of air into the arterial circulation. An expeditious search for the source of the air should take place and steps taken to de-air the circuit to be able to resume cardiopulmonary bypass.
3. The patient should be placed in steep trendelenberg position to minimize further travel of air into the cerebral circulation. Hopefully, air will return into the proximal aorta and can be aspirated or drained via the aortotomy.
4. Retrograde cerebral perfusion can be performed to flush the air from the cerebral circulation. A cannula can be inserted into the superior vena cava and perfused with cold blood (< 20 degrees) in a retrograde fashion. The aorta may need to be opened to allow egress of air from the cerebral circulation.
5. In addition to retrograde cerebral perfusion, deep hypothermia and corticosteroids might be beneficial. Hypothermia decreases brain oxygen consumption and allows for more time for retrograde perfusion under circulatory arrest.
6. Postoperatively, continued use of steroids and moderate hypothermia might be beneficial and some have recommended barbiturate coma to minimize brain metabolism. Reports suggest a benefit of hyperbaric oxygen therapy in the immediate postoperative period. The benefit of hyperbaric oxygen therapy appears greatest when instituted within about 5 hours of surgery and seems less efficacious if there is a delay in the initiation of therapy.
7. The most common source of air emboli is unremoved air from the cardiac chambers.
8. Important strategies include careful inspection of the arterial circuit for air prior to initiation of bypass, stringent use of cardiopulmonary bypass safety alarms which monitor the reservoir level and bubble monitors to detect air in the cardiopulmonary bypass circuit, compulsive de-airing maneuvers at conclusion of surgery, and careful examination for residual intracardiac air with transesophageal echo.
Select References and Additional Resources
PIHammon JW. (2008). Extracorporeal Circulation: Perfusion System. In Cohn LH (Ed), Cardiac Surgery in the Adult. (3rd edition, 350-370). New York: McGraw-Hill.
PIKern JA, Arnold S. Massive Cerebral Embolization: Successful Treatment with Retrograde Perfusion. Annals of Thoracic Surgery. 69: 1266, 2000.
PIMills NL, Ochsner JL. Massive air embolism during cardiopulmonary bypass: causes, prevention and management. Journal of Thoracic and Cardiovascular Surgery. 80:708–717, 1980.
PIUtley JR. Techniques for avoiding neurologic injury during adult cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia. 10(1): 38-44, 1996.
PIZiser A, Adir Y, et al. Hyperbaric oxygen therapy for massive arterial air embolism during cardiac operations. Journal of Thoracic and Cardiovascular Surgery. 117(4): 818, 1999.
This Challenge was provided by Resident Medical Editor, Dr. Christian Peyre.
Major Finding: Text.
Data Source: Text.
Disclosures: Text.
Some Online Resources
AATS Resident Resources:
www.aats.org/TSR/index.html
CTSNET Residents Section:
www.ctsnet.org/sections/residents
Thoracic Surgery Directors Association:
www.tsda.org
Thoracic Surgery Foundation for Research and Education:
www.tsfre.org
Thoracic Surgery News:
www.thoracicsurgerynews.com
Thoracic Surgery Residents Association:
www.tsranet.org
Body text goes here
Doctor’s Bio
Body text goes here
Doctor’s Bio
Body text goes here
Doctor’s Bio
AATS Resident Resources:
www.aats.org/TSR/index.html
CTSNET Residents Section:
www.ctsnet.org/sections/residents
Thoracic Surgery Directors Association:
www.tsda.org
Thoracic Surgery Foundation for Research and Education:
www.tsfre.org
Thoracic Surgery News:
www.thoracicsurgerynews.com
Thoracic Surgery Residents Association:
www.tsranet.org
AATS Resident Resources:
www.aats.org/TSR/index.html
CTSNET Residents Section:
www.ctsnet.org/sections/residents
Thoracic Surgery Directors Association:
www.tsda.org
Thoracic Surgery Foundation for Research and Education:
www.tsfre.org
Thoracic Surgery News:
www.thoracicsurgerynews.com
Thoracic Surgery Residents Association:
www.tsranet.org
Major Finding: Text.
Data Source: Text.
Disclosures: Text.