Complications in Cardiothoracic Surgery

Avoidance and Treatment

Alex G. Little, Walter H. Merrill, Alex G. Little, MD, Walter H. Merrill, MD

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN: 9781405181037
• eBook ISBN: 9781444360882
• Edition: 2
• Topic: Medicine
• Subtopic: Cardiology

Written to supplement standard textbooks and operative atlases, this updated reference concentrates on the issue of complication prevention and treatment. By challenging the contributors to address specific issues related to both intraoperative techniques and post-operative care that will reduce the incidence of complications, Drs. Little and Merrill present a book that reinforces the commitment to excellence in cardiothoracic surgery.

The book opens with a section on general topics with regard to cardiothoracic surgical complications, including thoracic incisions, postoperative arrhythmias, and myocardial preservation. Then Drs. Little and Merrill draw on their expertise in thoracic and cardiac surgery, respectively. They have assembled a team of experts to address specific diseases encountered and operations performed by cardiac and general thoracic surgeons.

With advice developed through years of experience by some of the most respected names in the field, Complications in Cardiothoracic Surgery: Avoidance and Treatment, 2nd Edition makes an ideal introduction for the new trainee and the perfect refresher for the practicing surgeon.

CHAPTER 1

Preventing Complications: New Frontiers of Safety Science in Cardiothoracic Surgery

Paul N Uhlig, William R Berry, Ellen Raboin, Jeffrey Brown, Joel T Erskin, Ann Hendrich and Daniel Raemer

This chapter is written by an interdisciplinary team of authors with experience studying and applying safety science in cardiothoracic surgery. Paul Uhlig is a cardiothoracic surgeon with special expertise in high reliability clinical teamwork. Bill Berry is a cardiothoracic surgeon whose full-time work concerns patient safety and risk management. Ellen Raboin has expertise in group processes and team interactions and special expertise in action research regarding teamwork and safety in health care environments. Jeffrey Brown is an aviation safety and human factors expert with extensive experience in implementing and studying teamwork in cardiac surgery and other health care settings. Joel Erskin is a cardiothoracic surgery physician assistant and former USAF pilot, safety educator, and hospital commander, who co-led early efforts to improve health care outcomes on the basis of principles of aviation safety. Ann Hendrich is a nationally recognized nurse executive and health care leader with expertise in transforming clinical care processes to improve safety and reliability. Dan Raemer is a biomedical engineer and leader in the field of health care simulation with expertise in critical event simulation and team training in cardiothoracic surgery. The chapter is written jointly from all of these perspectives.

In the same way as new approaches to cardiothoracic surgical operations are reshaping and transforming the specialty, new approaches for decreasing risk and improving patient safety are transforming the way that cardiothoracic surgical care is organized and practiced. This transformation is driving significant changes in surgical practice, education, and certification. Most importantly, it is producing better and safer patient care and a better experience of care for patients and practitioners alike.

Evidence supporting the effectiveness of these new approaches comes from pioneering studies in health care and from more fully developed research in other areas of high-risk human teamwork such as aviation, space flight, nuclear power plant operations, and similar high consequence human activities where safety has been extensively studied. For us, incorporating these new approaches into our own daily work has been a remarkable experience. As experienced clinicians and scientists familiar with previous methods for achieving quality and safety in healthcare, it seems evident to us that the new ways are significantly better than the ways in which we were trained. We believe that convincing data will follow. For us, it is impossible to go back.

Accordingly, this chapter is written somewhat differently than chapters in most surgical textbooks. It is an invitational summary of emerging concepts, intended to introduce you to new ideas and help you explore them in your own practice. We believe that as you consider these ideas and incorporate them into your work, you will find them to be as fascinating, surprising, and hopeful as they are for us.

Tuesday morning, 7:05 a.m.

Claire shoots a quick smile at Marilyn as the two women in surgical scrubs walk briskly toward the pump room between OR 29 and 30. Marilyn, the manager of OR cardiac nursing, has been here since 5:30 a.m. getting things ready for the day. As usual, Claire is running a little late, carrying her motorcycle helmet in one hand and her loupes in the other. “Good morning, Claire. You’re in 29 today,” says Marilyn, acknowledging Claire’s smile. “The cine for your first case is up on the computer, but we’re having a little trouble finding the H and P.” “Thanks, Marilyn,” says Claire, “I’ll get it for you. The office must have forgotten to send it over last night.”

An hour later, Claire has settled comfortably into her OR routine. Her iPod is docked and playing the third track of her opening playlist, a Ravel orchestration of Mussorgsky’s Pictures at an Exhibition. The IMA is down and Claire is placing the last cannulation suture. As usual, the room is relaxed and happy. It always is for Claire’s cases, Marilyn thinks to herself as she catches up on her charting in the computer.

“ACT is 300,” says Dave. It has been at least 2 months since he has done an on-pump case with Claire, maybe longer, he thinks to himself. He is sure it has been at least 2 months, because that is how long the contract negotiations with the hospital have been going on. He sighs and shakes his head thinking about those negotiations. What a mess. As chief of perfusion services, the contract negotiations have occupied every nonclinical moment of his days and quite a few restless nights, too, for what seems like an eternity. Fewer on-pump cases, in fact fewer cases overall since the surgical group opened their own hospital 2 years ago. Dave is 58. He has been a perfusionist here since he finished training 30 years ago. Before that he was a respiratory therapist. So much has changed, he thinks to himself, as he sits down behind his pump.

Claire’s voice interrupts his thoughts, “OK to clamp and cut?” Dave leans forward, accidentally bumping his clipboard, which falls to the floor. He reaches down to retrieve the clipboard, turns off the arterial pump head, clamps several lines, and replies, “OK to clamp and cut.” Claire watches Dave settle back into his seat. Marilyn is right, Claire reflects, remembering something Marilyn mentioned yesterday. Marilyn said that Dave didn’t restock cannulas last week and seemed preoccupied. He is different somehow, Claire thinks to herself, not the same steady Dave who took me under his wing when I started here 4 years ago. Maybe I should talk to him sometime.

A few minutes later, Claire has finished cannulating. She double checks the aortic line for air and looks up at Dave. “Dave, you OK for going on?” she asks. Dave nods. Claire takes the clamp off the venous line. “On bypass please, Dave, drift to 34, keep the cardioplegia warm.” Claire watches as dark red blood swirls into the venous line and drains toward the pump. She scans the field and watches the heart begin to empty. She thinks of her patient, Jim, a 40-year-old man with a bicuspid aortic valve. His LAD lesion had been a surprise. A new valve and one graft. Not a bad first case of the day.

Her mind flashes briefly to Jim’s family. She said hello to them on the way to the OR. Tiffany, Jim’s wife, had seemed so young. So had their four children. “Marilyn, can you let the family—,” she begins, but stops in mid sentence as her eyes move across the field to the aortic line. “Dave, is everything OK? The heart’s empty but I don’t see any blood in the aortic line, just prime.”

“I know,” says Dave. “I can’t flow. I don’t know. . .Oh, here it is. No, that isn’t it. I don’t know. For some reason. . . I can’t flow with the centrifugal pump. I’m changing to the backup pump head, the roller pump. It should take just a second.”

Claire is aware of the clicking of clamps and a flurry of activity as Dave rapidly resets his pump. “Susan, I need that line clamp back,” Claire says to her scrub nurse, “right now.” Claire looks at the monitor and watches as the arterial pressure drops through 30. She scans the lines and surgical field, looking up across the drapes at John, the anesthesiologist, who is now at full attention at the head of the table. “Dave,” Claire says, “I’m clamping the venous line here at the field. John, go into Trendelenberg and run whatever fluids you’ve got wide open. Marilyn, would you see if anyone is in the pump room? Maybe Shelly can come in and help Dave.” Her heart sinks as she checks the arterial pressure again: 18 mm Hg and falling. Why didn’t he flow in before draining out, she thinks to herself. We’ve talked about that before. She watches the lines warily for air and asks Susan for another line clamp, just in case.

“I’ve switched over, Claire. Coming up on flow now,” says Dave. Claire feels a moment of relief as Dave opens a clamp and turns on the pump. What happens next will be etched in her mind forever. With a sudden, decompressive tearing sound a torrent of blood erupts from the pump, drenching Dave, turning the wall, the pump, and the ceiling red, and flooding the floor. Dave’s face is covered with blood and he cannot see. His mask is saturated and sucks so tightly to his face that he cannot breathe. He pulls frantically at the mask and reaches blindly, desperately for his pump control. Somehow he shuts off the pump and the torrent stops.

Claire looks up at the monitor. The pressure has settled flat at 12 mm Hg. Her mind is racing to absorb the scene: blood everywhere, total confusion in the room, the empty heart still beating as if oblivious, steep Trendelenberg, John determinedly squeezing in some sort of crystalloid, her patient warm with no blood volume and no blood pressure.

In her mind’s eye, as if in slow motion, she somehow sees Tiffany and the children sitting in the waiting room. Time changes and the door from the pump room opens. “Shelly! Thank God,” Claire says. “See if you can help Dave. I don’t know what happened but something just blew up. We’ve got no pressure, no volume, and the patient’s warm. John, Shelly, think with me.”

Pausing the action

Pause for a moment and reflect about what you are experiencing as you read this story. If we have done our job well as authors, you have hopefully been drawn into the story. It may have become real for you. As a surgeon, you may be imagining yourself in Claire’s place, experiencing her stress and picturing what she should do next. Possibly, you have faced a similar situation in your career and could offer her advice.

This story is our attempt to show you the power of simulation in health care. Simulation is like a story brought to life. Throughout history, storytelling has been the main way that information has been passed among people. Even today, telling stories remains the most powerful form of communication. A well-designed simulation, like a good story, feels authentic. People in the simulation feel and act as if they are in a real situation.

We have paused our story to emphasize some important points about simulation and its value in helping people reflect about their actions in difficult situations. When actions can be paused, people often recognize things that are not evident when they are caught up in the flow of events. Much of the information within events is perishable, lost by the time the event is over. Simulation allows actions and perishable information to be captured, so that they can be reconsidered later.

Often the most important learning opportunity in simulation occurs after the simulation, when the people involved come together to review their experience (often recorded on videotape) and share their thoughts and observations in a debriefing. It is very helpful to have a trained facilitator guiding this conversation. It is often surprising to people how much their initial impressions of what happened can change as they see events unfold again, watch their own actions, and hear the perspectives of others.

Back to our story

In fact, this is a real story. Specifics of the case and the people have been changed. But the clinical situation happened exactly as the story describes.

What was the outcome? Working together, the surgical team recognized that enough blood was still present in the venous reservoir to restore an effective blood volume. The challenge was how to get the blood from the reservoir back into the patient in the short time that was available, without a functioning pump or arterial line.

Recalling past research training, the surgeon remembered giving volume in the laboratory by pouring saline into a funnel connected to the right atrium suspended above the heart. The venous reservoir was like the funnel; all they had to do was somehow get it above the patient. The surgeon focused the attention of the team on this goal. Improvising, the perfusionists were able to detach the venous reservoir from the pump and lift it above the level of the heart, allowing blood to drain back into the patient. The patient’s blood pressure normalized. After stabilizing the patient, cleaning the room, and changing out the pump, the rest of the operation proceeded uneventfully. The patient did well. After the operation, the patient and family were informed fully about the mishap and what was done.

What was the cause? The direct cause was an unrecognized clamp on the arterial line just downstream from the centrifugal pump head. The pump could not flow because of the clamp. The perfusionist switched to a backup roller pump that overpressurized the clamped arterial line and blew it out.

A deeper cause was distraction and fatigue of the perfusionist, a result of organizational circumstances. Contributing to the accident was a communications culture that led the nursing leader to “hint and hope” about changes she had noted rather than bringing her concerns openly and comfortably to the attention of the perfusionist and other team members. The communications culture also gave members of the team limited options for eliciting and responding to concerns in an effective way.

In this case, the outcome was good. Often when things go wrong, people are able to react and save the situation. Part of safety science deals with how to optimize crisis management. Another important part of safety science studies risk preconditions that can be proactively modified, making it less likely for an ...

Table of contents

• Cover
• Title
• Copyright
• List of Contributors
• Acknowledgement
• Preface
• Chapter 1: Preventing Complications: New Frontiers of Safety Science in Cardiothoracic Surgery
• Chapter 2: Thoracic Incisions
• Chapter 3: Arrhythmias following Cardiac and Thoracic Operations
• Chapter 4: Complications of Cardiopulmonary Bypass and Cardioplegia
• Chapter 5: Myocardial Protection: Why and How
• Chapter 6: Complications after Pulmonary Resection: Lobectomy and Pneumonectomy
• Chapter 7: Complications of Tracheobronchial Resection
• Chapter 8: Complications of Lung Volume Reduction Surgery
• Chapter 9: Complications of Lung Transplantation
• Chapter 10: Complications of Esophageal Resection
• Chapter 11: Complications of Minimally Invasive Esophagectomy
• Chapter 12: Operations for Benign Esophageal Disorders
• Chapter 13: Complications of Mediastinal Procedures
• Chapter 14: Complications of Pleural Operations and Procedures
• Chapter 15: Complications from Chest Wall Procedures
• Chapter 16: On-Pump Coronary Artery Bypass Grafting
• Chapter 17: Off-Pump Coronary Artery Surgery: A Safe Approach
• Chapter 18: Valvular Operations
• Chapter 19: Complications of Myocardial Reconstruction
• Chapter 20: Complications after Atrial Fibrillation Surgery
• Chapter 21: Heart Transplantation
• Chapter 22: Assist Devices
• Chapter 23: Aortic and Great Vessel Operations
• Index