These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment ...Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
Objectives Aortic valve replacement is accepted as a standard treatment for aortic stenosis and regurgitation. To help plan the national requirement for conventional and catheter-based procedures, we ...have analyzed the Society for Cardiothoracic Surgery in Great Britain and Ireland audit database to look at changes in practice over time. Methods All patients undergoing conventional aortic valve replacement with or without coronary artery surgery from April 2004 to March 2009 were included. The main outcome measures were changes in the number, characteristics, operative details, and in-hospital mortality. We have looked particularly at trends and outcomes in elderly and high-risk patients (EuroSCORE of 10 or more) who may now be considered for percutaneous aortic valve insertion. Results A total of 41,227 patients underwent aortic valve surgery over 5 years with an in-hospital mortality of 4.1%. The annual number increased from 7396 in 2004-2005 to 9333 in 2008-2009, with significant increases ( P < .0005) in mean age (68.8-70.2 years), the proportion of patients with aortic stenosis (62.4%-65.1%), octogenarians (13.6%-18.4%), high-risk patients (24.6%-27.7%), and those receiving biological valves (65.4%-77.8%). The incidence of permanent cerebrovascular accident was 1.2% and 1.0% in patients having only an aortic valve replacement. The dialysis rate was 4.5% and the reoperation rate for bleeding was 6.6%. Overall mortality decreased from 4.4% in 2004-2005 to 3.7% in 2008-2009. Survival to a mean follow-up of 2.5 years was 89%. Conclusions We have seen a large increase in annual volume of aortic valve replacements, with more patients undergoing surgery for aortic stenosis and an increase in surgery in the elderly and high-risk patients.
Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also ...occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.
Lung cancer is the leading cause of cancer death. Surgery remains the main method of managing early-stage disease. Minimal-access video-assisted thoracoscopic surgery results in less tissue trauma ...than open surgery; however, it is not known if it improves patient outcomes.
To compare the clinical effectiveness and cost-effectiveness of video-assisted thoracoscopic surgery lobectomy with open surgery for the treatment of lung cancer.
A multicentre, superiority, parallel-group, randomised controlled trial with blinding of participants (until hospital discharge) and outcome assessors conducted in nine NHS hospitals. Adults referred for lung resection for known or suspected lung cancer, with disease suitable for both surgeries, were eligible. Participants were followed up for 1 year.
Participants were randomised 1 : 1 to video-assisted thoracoscopic surgery lobectomy or open surgery. Video-assisted thoracoscopic surgery used one to four keyhole incisions without rib spreading. Open surgery used a single incision with rib spreading, with or without rib resection.
The primary outcome was self-reported physical function (using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30) at 5 weeks. Secondary outcomes included upstaging to pathologic node stage 2 disease, time from surgery to hospital discharge, pain in the first 2 days, prolonged pain requiring analgesia at > 5 weeks, adverse health events, uptake of adjuvant treatment, overall and disease-free survival, quality of life (Quality of Life Questionnaire Core 30, Quality of Life Questionnaire Lung Cancer 13 and EQ-5D) at 2 and 5 weeks and 3, 6 and 12 months, and cost-effectiveness.
A total of 503 patients were randomised between July 2015 and February 2019 (video-assisted thoracoscopic surgery,
= 247; open surgery,
= 256). One participant withdrew before surgery. The mean age of patients was 69 years; 249 (49.5%) patients were men and 242 (48.1%) did not have a confirmed diagnosis. Lobectomy was performed in 453 of 502 (90.2%) participants and complete resection was achieved in 429 of 439 (97.7%) participants. Quality of Life Questionnaire Core 30 physical function was better in the video-assisted thoracoscopic surgery group than in the open-surgery group at 5 weeks (video-assisted thoracoscopic surgery,
= 247; open surgery,
= 255; mean difference 4.65, 95% confidence interval 1.69 to 7.61;
= 0.0089). Upstaging from clinical node stage 0 to pathologic node stage 1 and from clinical node stage 0 or 1 to pathologic node stage 2 was similar (
≥ 0.50). Pain scores were similar on day 1, but lower in the video-assisted thoracoscopic surgery group on day 2 (mean difference -0.54, 95% confidence interval -0.99 to -0.09;
= 0.018). Analgesic consumption was 10% lower (95% CI -20% to 1%) and the median hospital stay was less (4 vs. 5 days, hazard ratio 1.34, 95% confidence interval 1.09, 1.65;
= 0.006) in the video-assisted thoracoscopic surgery group than in the open-surgery group. Prolonged pain was also less (relative risk 0.82, 95% confidence interval 0.72 to 0.94;
= 0.003). Time to uptake of adjuvant treatment, overall survival and progression-free survival were similar (
≥ 0.28). Fewer participants in the video-assisted thoracoscopic surgery group than in the open-surgery group experienced complications before and after discharge from hospital (relative risk 0.74, 95% confidence interval 0.66 to 0.84;
< 0.001 and relative risk 0.81, 95% confidence interval 0.66 to 1.00;
= 0.053, respectively). Quality of life to 1 year was better across several domains in the video-assisted thoracoscopic surgery group than in the open-surgery group. The probability that video-assisted thoracoscopic surgery is cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year is 1.
Ethnic minorities were under-represented compared with the UK population (< 5%), but the cohort reflected the lung cancer population.
Video-assisted thoracoscopic surgery lobectomy was associated with less pain, fewer complications and better quality of life without any compromise to oncologic outcome. Use of video-assisted thoracoscopic surgery is highly likely to be cost-effective for the NHS.
Evaluation of the efficacy of video-assisted thoracoscopic surgery with robotic assistance, which is being offered in many hospitals.
This trial is registered as ISRCTN13472721.
This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in
; Vol. 26, No. 48. See the NIHR Journals Library website for further project information.
The Society of Thoracic Surgeons Task Force on Resuscitation After Cardiac Surgery provides this professional society perspective on resuscitation in patients who arrest after cardiac surgery. This ...document was created using a multimodal methodology for evidence generation and includes information from existing guidelines, from the International Liaison Committee on Resuscitation, from our own structured literature reviews on issues particular to cardiac surgery, and from an international survey on resuscitation hosted by CTSNet. In gathering evidence for this consensus paper, searches were conducted using the MEDLINE keywords "cardiac surgery," "resuscitation," "guideline," "thoracic surgery," "cardiac arrest," and "cardiac massage." Weight was given to clinical studies in humans, although some case studies, mannequin simulations of potential protocols, and animal models were also considered. Consensus was reached using a modified Delphi method consisting of two rounds of voting until 75% agreement on appropriate wording and strength of the opinions was reached. The Society of Thoracic Surgeons Workforce on Critical Care was enlisted in this process to provide a wider variety of experiences and backgrounds in an effort to reinforce the opinions provided. We start with the premise that external massage is ineffective for an arrest due to tamponade or hypovolemia (bleeding), and therefore these subsets of patients will receive inadequate cerebral perfusion during cardiac arrest in the absence of resternotomy. Because these two situations are common causes for an arrest after cardiac surgery, the inability to provide effective external cardiopulmonary resuscitation highlights the importance of early emergency resternotomy within 5 minutes. In addition, because internal massage is more effective than external massage, it should be used preferentially if other quickly reversible causes are not found. We present a protocol for the cardiac arrest situation that includes the following recommendations: (1) successful treatment of a patient who arrests after cardiac surgery is a multidisciplinary activity with at least six key roles that should be allocated and rehearsed as a team on a regular basis; (2) patients who arrest with ventricular fibrillation should immediately receive three sequential attempts at defibrillation before external cardiac massage, and if this fails, emergency resternotomy should be performed; (3) patients with asystole or extreme bradycardia should undergo an attempt to pace if wires are available before external cardiac massage, then optionally external pacing followed by emergency resternotomy; and (4) pulseless electrical activity should receive prompt resternotomy after quickly reversible causes are excluded. Finally, we recommend that full doses of epinephrine should not be routinely given owing to the danger of extreme hypertension if a reversible cause is rapidly resolved. Protocols are given for excluding reversible airway and breathing complications, for left ventricular assist device emergencies, for the nonsternotomy patient, and for safe emergency resternotomy. We believe that all cardiac units should have accredited policies and protocols in place to specifically address the resuscitation of patients who arrest after cardiac surgery.
Following its introduction in 1992, the growth of minimally invasive thoracic surgery was initially hampered by the lack of specialized instruments, impeded visualization and stapling. However, in ...subsequent years these challenges were somewhat overcome and video-assisted thoracoscopic surgery (VATS) became the preferred modality of many centers. More recently, robotic surgery has come to the fore. Whilst it offers outstanding precision via robotic wristed instruments, robotic surgery is expensive and has safety implications as the surgeon is away from the patient's side. Wristed VATS instruments offer a new, exciting alternative. By placing the robotic-like wristed instruments in the hands of the surgeon, a concept we call surgeon-powered robotics, the benefits of robotic surgery can be achieved by the patient's side. We describe our experience of the ArtiSential® wristed instruments and discuss the benefits and challenges of this technology. By combining wristed instruments with the latest surgeon-controlled 3D camera technology, surgeon-powered robotics is an affordable reality.
The internal thoracic artery is the most effective conduit for coronary artery bypass surgery; however, most patients have multivessel disease and require additional saphenous vein or radial artery ...grafts. In this systematic review of the literature and meta-analysis, we aim to compare reported patency rates for these conduits and explore if differences are homogeneous across follow-up intervals. A literature search was performed using Embase, Medline, Cochrane Library, Google Scholar and randomised controlled trial databases to identify studies published between 1965 and October 2009. All studies reporting angiographic comparison of saphenous vein and radial artery conduit patency were included, irrespective of language. The end point was angiographic graft patency stratified over different follow-up intervals. Meta-analysis was performed according to recommendations from the Cochrane Collaboration and Meta-analysis Of Observational Studies in Epidemiology guidelines. We used a random-effect model and the odds ratio as the summary statistic. A total of 35 studies were identified. They reported early patency (≤1 year, 6795 grafts), medium-term patency (1-5 years, 3232 grafts) and long-term patency (>5 years, 1157 grafts). Significant variation of comparative patency existed across different follow-up intervals. Early saphenous vein patency was similar to radial artery patency with odds ratio of 1.04 (95% confidence interval 0.68-1.61). Medium-term saphenous vein patency, however, deteriorated significantly (odds ratio 2.06, 95% confidence interval 1.29-3.29). Similarly, long-term patency was better for radial artery conduits (odds ratio 2.28, 95% confidence interval 1.32-3.94). Heterogeneity was due to angiographic patency characteristics and related to risk of bias. In conclusion, the findings of this systematic review of the published literature and meta-analysis support the use of radial artery in preference to saphenous vein conduits for coronary artery bypass surgery.
There has been declining interest in cardiothoracic surgery amongst medical graduates. This survey examines the exposure of British medical students to cardiothoracic surgery in various settings and ...its relationship with students' interest in the speciality.
A questionnaire composed of 14 quantitative and qualitative items was distributed amongst 162 medical students. The survey included questions on demographics, interest in cardiothoracic surgery, mechanisms of exposure to the speciality and desire to pursue a career in cardiothoracic surgery before and after exposure.
Amongst the surveyed students, 71.0% reported exposure to cardiothoracic surgery as part of their medical school curricula and 24.7% reported extracurricular exposure. Of the students, 46.7% reported clinical exposure. Overall, 27.1% of students reported interest in a career in cardiothoracic surgery, which was higher amongst students who had curricular (29.6%), clinical (35.5%) or extracurricular exposure (50.0%). Amongst interested students, 43.2% engaged in extracurricular cardiothoracic activities compared with 16.1% of students not interested in pursuing the speciality. Confidence in career choice after exposure increased more in interested students (20.4%) than not interested students (1.6%). Students rated exposure and mentorship as the most important factor in promoting a career in cardiothoracic surgery.
Medical students with an interest in cardiothoracic surgery are more likely to organize independent attachments in the speciality and attend extracurricular events; however, many students might fail to identify cardiothoracic surgery as an area of interest because of the lack of exposure at medical school.
ObjectivesTo describe a new, international, prospective surgical registry developed to accompany the clinical implementation of the Versius Robotic Surgical System by accumulating real-world evidence ...of its safety and effectiveness.InterventionsThis robotic surgical system was introduced in 2019 for its first live-human case. With its introduction, cumulative database enrollment was initiated across several surgical specialties, with systematic data collection via a secure online platform.Main outcome measuresPre-operative data include diagnosis, planned procedure(s), characteristics (age, sex, body mass index and disease status) and surgical history. Peri-operative data include operative time, intra-operative blood loss and use of blood transfusion products, intra-operative complications, conversion to an alternative technique, return to the operating room prior to discharge and length of hospital stay. Complications and mortality within 90 days of surgery are also recorded.ResultsThe data collected in the registry are analyzed as comparative performance metrics, by meta-analyses or by individual surgeon performance using control method analysis. Continual monitoring of key performance indicators, using various types of analyses and outputs within the registry, have provided meaningful insights that help institutions, teams and individual surgeons to perform most effectively and ensure optimal patient safety.ConclusionsHarnessing the power of large-scale, real-world registry data for routine surveillance of device performance in live-human surgery from first use will enhance the safety and efficacy outcomes of innovative surgical techniques. Data are crucial to driving the evolution of robot-assisted minimal access surgery while minimizing risk to patients.Trial registration numberCTRI/2019/02/017872.
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