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Is the Association of Cardiothoracic Anaesthetists responsible for perpetuating flawed practices?
- Richard G Fiddian-Green (5 March 2005)
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Can surgeons operate without anaesthetists?
- Oliver R Dearlove (7 March 2005)
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Cardiac Surgery is a Team Sport
- David N Hunter (13 March 2005)
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Re: Cardiac Surgery is a Team Sport
- BABAR B CHAUDHRI (14 March 2005)
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Richard G Fiddian-Green, None None
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ProfessorTreasure concludes that, "survival [in cardiac surgery]is determined by factors in perioperative care that probably outweigh those attributable to variation in technical skill of the specialised surgeons involved". Agreed. He adds that, "the Association of Cardiothoracic Anaesthetists is collecting data ...to give insight into variation in case selection, work up, intraoperative management, and postoperative care of pneumonectomy" which has a much higher mortality [10% to 15$]. What a waste of time, effort and money. Anaesthetists seem to be bending over backwards in the past 10 years to justify their continued, but flawed and ancient, practice of focusing their intraoperative attentions on perfusion to the exclusion of tissue energetics. I had assumed that the message had been received long before the delayed publication of my invited review of the measurement of gastric intramucosal pH in British Journal of Anaesthesia in May 1885 (1). I was clearly wrong for a month earlier a paper written by anaesthetists intimately inolved in evaluating the technology chose to substitute the term tissue perfusion for tissue oxygenation (2). The practice has continued ultimately to the exclusion of the trm tissue oxygnation and indeed the measurement of pH per se with authorative support (3,4). These efforts have culminated in a european, multicenter, observational study evaluating automated online tonometry displays of measurements of gastric-to-endtidal carbon dioxide (Pr-etCO2) to the exclusion of intramucosal pH as an index of "gastrointestinal perfusion" during surgery(5). These developments are of concern for huge opportunities to improve outcomes, especially from pnenumonectomy, appear to have been squandered. If the Association of Cardiothoracic Anaesthetists has been responsible its leadership leaves much to be desired. The sooner the misconceptions about tissue perfusion are addressed the better. 1. Fiddian-Green RG. Gastric intramucosal pH, tissue oxygenation and acid-base balance. Br J Anaesth. 1995 May;74(5):591-606. 2, Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg. 1995 Apr;130(4):423-9. 3. Dantzker DR. Monitoring tissue oxygenation. The search for the grail. Chest. 1997 Jan;111(1):12-4. 4. Dantzker DR. Monitoring tissue oxygenation : the quest continues. Chest. 2001 Sep;120(3):701-2 5. Lebuffe G, Vallet B, Takala J, Hartstein G, Lamy M, Mythen M, Bakker J, Bennett D, Boyd O, Webb A. A european, multicenter, observational study to assess the value of gastric-to-end tidal PCO2 difference in predicting postoperative complications. Anesth Analg. 2004 Jul;99(1):166-72. Competing interests: Patents issued in my name |
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Oliver R Dearlove, Consultant Anaesthetist Royal Manchester Children's Hospital
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There are two papers on anaesthetists as a risk factor in cardiac surgery. I have not seen them referred to in the recent discussions. Great surgeons do great operations and we have all seen them bask in the glory on television. How many say, well it wasn’t me, it was the nurses/junior staff/ anaesthetists/ intensive care unit/biochemistry department? How many would believe them? And yet when things look bleak, it is a different story. How many believe them then? Oliver R Dearlove FRCA Conflicts – not a surgeon, hardly ever operated, and not a cardiac anaesthetist References 1. Slogoff S Keats AS Does peri operative myocardial ischaemia lead to post operative myocardial infarction? Anesthesiology 1985 62 107-14 2. Merry AF, Rage MC, Whitlock RM, Laycock GJ, Smith W, Stenhouse D Wild CJ. First time coronary artery by pass grafting: the anaesthetist as a risk factor. Br J Anaesthesia 1992 68 6-12 Competing interests: As script |
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David N Hunter, Consultant Anaesthetist Royal Brompton Hospital SW3
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It is interesting that Professor Treasure recognises that thoracic surgery is team dependant, though not as much as the long-term management of cystic fibrosis is; which of course is not surgeon led. However, he categorises survival from cardiac surgery as surgeon dependant - now that he no longer practices it. Oliver Dearlove has already quoted the obvious publications that dispute this ridiculous contention, if "scientific" evidence were necessary. However, even recognising that the anaesthetist is a key player, there are also other vital members of the team. Cardiac surgery is self-evidently a team sport, and it doesn't matter how much of a superstar the striker is, if any of the defence is below par then goals will be conceded. Surgeon specific data probably serves very little purpose, and is of little use to patients, whereas grouped unit data may well be of more relevance. Competing interests: Cardiothoracic anaesthetist |
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BABAR B CHAUDHRI, SPR Cardiothoracic Surgery Royal Infirmary, Glasgow
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I agree with David Hunter. Cardiac surgery is possible only with a team working towards the common goal. The focus directed towards the surgeon is due to the system at present which directly attributes outcome to that surgeon. The surgeon is held responsible for the outcome of operations performed. This is particularly so in cardiac surgery where well developed data collection and analysis exists. We don't talk about the influence of other members of the cardiac surgery team probably because it is hard to measure their impact upon outcome even though it is known that all components of the team may influence this outcome. I am not really sure whether the other professionals comprising this team would want to be scrutinised in the same fashion as cardiac surgeons. It is not clear that the publication of surgeon specific data has resulted in an improvement in standards; it has generated a lot of anxiety instead. Competing interests: None declared |
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