Should surgeons take a break after an intraoperative death? Attitude survey and outcome evaluation
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《英国医生杂志》
1 MRC Cancer Cell Unit, University of Cambridge, Cambridge CB2 2XZ, 2 Department of Surgery, University of Cambridge, Cambridge CB2 2QQ, 3 Papworth Hospital, Cambridge CB3 8RE, 4 MRC Biostatistics Unit, Institute of Public Health, Cambridge CB2 2SR
Correspondence to: Samer Nashef sam.nashef@papworth.nhs.uk
Abstract
A survey of Welsh consultant orthopaedic surgeons highlighted the lack of consensus about working after an intraoperative death.1 The survey arose after an inquiry was conducted into the intraoperative deaths of two patients on the same elective surgical list. Expert witnesses advised that after an intraoperative death surgeons should cease operating that day. Sheriff Albert Sheehan recommended that the Scottish Royal Colleges and the Scottish Intercollegiate Guidelines Network consider whether guidelines or advice were needed.2 As yet, no guidelines have been produced (personal communication, Royal College of Surgeons of Edinburgh and Scottish Intercollegiate Guidelines Network).
In the Welsh study only one of the 16 orthopaedic surgeons who had experienced a patient's intraoperative death decided to cancel further operations that day.1 Given the differences between cardiac and non-cardiac surgery, Briffa has suggested that cardiac surgeons may behave differently.3 Many anaesthetists feel that intraoperative death affects them equally, if not more so.4
We explored and compared the attitudes of cardiac surgeons and anaesthetists to working after an intraoperative death. We also sought to determine whether an intraoperative death has an adverse effect on subsequent operations by the same surgeon.
Methods
In total, 371 (76%) consultants returned completed questionnaires, reflecting 3463 consultant years of experience (table 1). They reported an estimated 3672 intraoperative deaths, and 70% experienced an intraoperative death at least annually. The anaesthetists had been consultants longer than the surgeons (P = 0.02). More surgeons (53%) than anaesthetists (22%) had stopped working for the rest of the day after an intraoperative death (P < 0.01), though factors influencing the decision to stop were similar in both groups, with fatigue being the most important consideration. Similar proportions of surgeons (27%) and anaesthetists (26%) thought they should stop working after an intraoperative death. Most surgeons and anaesthetists wanted guidelines (54/27/19% and 52/23/24% for/against/neither, respectively). Both groups agreed that guidelines should differentiate between elective and emergency cases, and likely versus unexpected deaths. Anaesthetists were more likely to want guidelines to cover junior medical staff and other operating theatre staff. Only 29% of surgeons and anaesthetists believed that an intraoperative death adversely affected their subsequent ability to work.
Table 1 Summary of responses to questionnaire on intraoperative deaths sent to all UK consultant cardiac surgeons and anaesthetists. Figures are numbers (percentages) unless stated otherwise*
Outcome study
Preoperative assessment of risk was missing in only six cardiac patients. There was no difference in case mix, age, sex, EuroSCORE, or Parsonnet score between cases and controls (table 2). Mortality and results are shown in table 3. Overall there was no difference (P = 0.83) in mortality between the cases (7.7%) performed after unselected intraoperative deaths and controls (7.9%).
Table 2 Profile of patients operated within 48 hours of an intraoperative death (cases) and matched controls
Table 3 Mortality in patients operated within 48 hours of intraoperative death compared with matched controls
Cases after an intraoperative death during emergency surgery had a higher mortality than their controls (odds ratio 1.34, 95% confidence interval 0.66 to 2.70), whereas those cases after an intraoperative death during elective surgery had a lower mortality than their own controls (0.69, 0.29 to 1.95). The difference in these odds ratios was not significant (P = 0.29). Similarly there was a higher mortality in cases after intraoperative death during high risk surgery compared with those after low risk surgery (1.22 v 0.67), but again this difference was not significant (P = 0.41).
Data on total hospital stay and intensive care unit stay were available for 1135 and 1110 patients, respectively. The median number of days (interquartile range) in intensive care unit was 0.85 (0.64-1.4) and 0.82 (0.16-1.1) for the cases and controls, respectively. Of the cases, 72 (32%) patients stayed more than a day in the intensive care unit whereas 248 (28%) of the control patients had a prolonged stay (1.8, 1.2 to 2.7; P = 0.003). Among survivors only, the odds ratio for prolonged intensive care unit stay was 1.6 (1.1 to 2.5, P = 0.02). The median (interquartile range) hospital stay (days) among the cases and controls was 8.8 (6.0-14) and 8.8 (5.9-14), respectively (P = 0.08). However, the surviving patients operated within 48 hours of an intraoperative death also had significantly longer hospital stays (P = 0.02; relative change 1.15, 1.03 to 1.24) than their matched controls.
Discussion
Smith IC, Jones MW. Surgeons' attitudes to intraoperative death: questionnaire survey. BMJ 2001;322: 896-7.
Sheehan AV. Fatal accidents and sudden deaths inquiry. Falkirk: Sheriff Court House, 26 January 1999.
Briffa N. Surgeons' attitudes to intraoperative death. Cardiac surgeons might have different attitudes. BMJ 2001;323: 341-2.
Seinfert BC. Anaesthetic departments need action plans to deal with such catastrophes. BMJ 2001;323: 341-2.
National adult cardiac surgical database 1998. London: Society of Cardiothoracic Surgeons of Great Britain and Ireland, May 1999.
Parsonnet V, Dean D, Bernstein AD. A method of uniform stratification of risk for evaluating the results of surgery in acquired heart disease. Circulation 1989;79(suppl I): I3-12.
Nashef SAM, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R and the EuroSCORE study group. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999;16: 9-13.
White SM. Death on the table. Anaesthesia 2003;58: 515-9.(Antony R Goldstone, clini)
Correspondence to: Samer Nashef sam.nashef@papworth.nhs.uk
Abstract
A survey of Welsh consultant orthopaedic surgeons highlighted the lack of consensus about working after an intraoperative death.1 The survey arose after an inquiry was conducted into the intraoperative deaths of two patients on the same elective surgical list. Expert witnesses advised that after an intraoperative death surgeons should cease operating that day. Sheriff Albert Sheehan recommended that the Scottish Royal Colleges and the Scottish Intercollegiate Guidelines Network consider whether guidelines or advice were needed.2 As yet, no guidelines have been produced (personal communication, Royal College of Surgeons of Edinburgh and Scottish Intercollegiate Guidelines Network).
In the Welsh study only one of the 16 orthopaedic surgeons who had experienced a patient's intraoperative death decided to cancel further operations that day.1 Given the differences between cardiac and non-cardiac surgery, Briffa has suggested that cardiac surgeons may behave differently.3 Many anaesthetists feel that intraoperative death affects them equally, if not more so.4
We explored and compared the attitudes of cardiac surgeons and anaesthetists to working after an intraoperative death. We also sought to determine whether an intraoperative death has an adverse effect on subsequent operations by the same surgeon.
Methods
In total, 371 (76%) consultants returned completed questionnaires, reflecting 3463 consultant years of experience (table 1). They reported an estimated 3672 intraoperative deaths, and 70% experienced an intraoperative death at least annually. The anaesthetists had been consultants longer than the surgeons (P = 0.02). More surgeons (53%) than anaesthetists (22%) had stopped working for the rest of the day after an intraoperative death (P < 0.01), though factors influencing the decision to stop were similar in both groups, with fatigue being the most important consideration. Similar proportions of surgeons (27%) and anaesthetists (26%) thought they should stop working after an intraoperative death. Most surgeons and anaesthetists wanted guidelines (54/27/19% and 52/23/24% for/against/neither, respectively). Both groups agreed that guidelines should differentiate between elective and emergency cases, and likely versus unexpected deaths. Anaesthetists were more likely to want guidelines to cover junior medical staff and other operating theatre staff. Only 29% of surgeons and anaesthetists believed that an intraoperative death adversely affected their subsequent ability to work.
Table 1 Summary of responses to questionnaire on intraoperative deaths sent to all UK consultant cardiac surgeons and anaesthetists. Figures are numbers (percentages) unless stated otherwise*
Outcome study
Preoperative assessment of risk was missing in only six cardiac patients. There was no difference in case mix, age, sex, EuroSCORE, or Parsonnet score between cases and controls (table 2). Mortality and results are shown in table 3. Overall there was no difference (P = 0.83) in mortality between the cases (7.7%) performed after unselected intraoperative deaths and controls (7.9%).
Table 2 Profile of patients operated within 48 hours of an intraoperative death (cases) and matched controls
Table 3 Mortality in patients operated within 48 hours of intraoperative death compared with matched controls
Cases after an intraoperative death during emergency surgery had a higher mortality than their controls (odds ratio 1.34, 95% confidence interval 0.66 to 2.70), whereas those cases after an intraoperative death during elective surgery had a lower mortality than their own controls (0.69, 0.29 to 1.95). The difference in these odds ratios was not significant (P = 0.29). Similarly there was a higher mortality in cases after intraoperative death during high risk surgery compared with those after low risk surgery (1.22 v 0.67), but again this difference was not significant (P = 0.41).
Data on total hospital stay and intensive care unit stay were available for 1135 and 1110 patients, respectively. The median number of days (interquartile range) in intensive care unit was 0.85 (0.64-1.4) and 0.82 (0.16-1.1) for the cases and controls, respectively. Of the cases, 72 (32%) patients stayed more than a day in the intensive care unit whereas 248 (28%) of the control patients had a prolonged stay (1.8, 1.2 to 2.7; P = 0.003). Among survivors only, the odds ratio for prolonged intensive care unit stay was 1.6 (1.1 to 2.5, P = 0.02). The median (interquartile range) hospital stay (days) among the cases and controls was 8.8 (6.0-14) and 8.8 (5.9-14), respectively (P = 0.08). However, the surviving patients operated within 48 hours of an intraoperative death also had significantly longer hospital stays (P = 0.02; relative change 1.15, 1.03 to 1.24) than their matched controls.
Discussion
Smith IC, Jones MW. Surgeons' attitudes to intraoperative death: questionnaire survey. BMJ 2001;322: 896-7.
Sheehan AV. Fatal accidents and sudden deaths inquiry. Falkirk: Sheriff Court House, 26 January 1999.
Briffa N. Surgeons' attitudes to intraoperative death. Cardiac surgeons might have different attitudes. BMJ 2001;323: 341-2.
Seinfert BC. Anaesthetic departments need action plans to deal with such catastrophes. BMJ 2001;323: 341-2.
National adult cardiac surgical database 1998. London: Society of Cardiothoracic Surgeons of Great Britain and Ireland, May 1999.
Parsonnet V, Dean D, Bernstein AD. A method of uniform stratification of risk for evaluating the results of surgery in acquired heart disease. Circulation 1989;79(suppl I): I3-12.
Nashef SAM, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R and the EuroSCORE study group. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999;16: 9-13.
White SM. Death on the table. Anaesthesia 2003;58: 515-9.(Antony R Goldstone, clini)