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Anesthesiology:
doi: 10.1097/01.anes.0000368878.03059.88
Education: Anesthesia Literature Review

Perioperative Medicine

Lichtor, J. Lance M.D.; Antognini, Joseph F. M.D., Editors

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Risks of complications by attending physicians after performing nighttime procedures. JAMA 2009; 302:1565–72

Despite increased public interest in the association between resident physician fatigue and medical errors, there are few studies assessing the relationships between experienced physicians' work hours, sleep, and patient safety.
A matched retrospective cohort study of procedures performed by attending physicians (86 surgeons and 134 obstetricians/gynecologists) who had been in the hospital performing another procedure involving for at least part of the preceding night (12:00 am–6:00 am, postnighttime procedures) was conducted to determine whether sleep opportunities are associated with risk of complications the following day. Matched control procedures included as many as five procedures of the same type performed by the same physician on days without preceding overnight procedures.
A total of 919 surgical and 957 obstetrical postnighttime procedures were matched with 3,552 and 3,945 control procedures, respectively. There were no differences in overall procedures with complications (5.4 vs. 4.9%) or preventable complications (4.6 vs. 4.7%) between postnighttime and control procedures, respectively. Differences were not observed in the types of complications between the two groups. Complications occurred more frequently (6.2 vs. 3.4%) in postnighttime procedures with sleep opportunities of 6 h or less compared with more than 6 h. Postnighttime procedures completed after working more than 12 h had nonsignificantly higher complication rates compared with 12 h or less (6.5 vs. 4.3%).
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Interpretation
Complication rates from elective procedures performed by attending surgeons who worked during the previous night and then got less than 6 h of sleep were higher (6.2%) than if sleep exceeded 6 h (3.4%). More work is needed to determine whether the same work rules that apply for residents or most attending anesthesiologists should also apply to attending surgeons.
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Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms. Ann Surg 2009;250:818–24

The feasibility and effectiveness of endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) remain controversial because of a lack of consistent reports and prospective data.
This study used questionnaires to collect information about experiences with EVAR for RAAAs from 49 centers worldwide. Updated questionnaires were also obtained from 13 centers that were committed to providing EVAR treatment for all anatomically suitable RAAAs. Single study center data from one of the authors' institutions were also included.
Overall, 30-day mortality after EVAR in 1,037 patients was 21.2%. Centers performing EVAR for RAAAs whenever possible did so in 49.1% (28–79%) of patients, had a 30-day mortality of 19.7% (range, 0–32%) for EVAR patients (n = 680) and 36.3% (8–53%) for open repair patients (n = 763; P < 0.0001). Supraceliac aortic balloon control was obtained in 19.1%, and abdominal compartment syndrome was treated by decompression in 12.2% of EVAR patients, respectively.
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Interpretation
Patients with RAAAs have a high mortality rate. EVAR was associated with lower mortality than open repair, suggesting that the former treatment might be better for patients with favorable anatomy.
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Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: The PROXI randomized clinical trial. JAMA 2009; 302:1543–50

After abdominal surgery, surgical site infection is a common and serious postoperative complication. Optimization of perioperative oxygenation may provide a benefit via improved tissue oxygenation tension and resultant tissue healing. However, the data for use of high inspiratory oxygen concentrations during and immediately after surgery remain controversial.
The PROXI trial was a double-blind randomized clinical trial conducted in 14 Danish hospitals with patients (1,400) undergoing acute or elective laparotomy to assess the benefit:risk profile of 80% oxygen use. Patients were randomly assigned to receive either 80 or 30% oxygen during and for 2 h after surgery.
No significant differences were observed in the incidence of surgical site infection or pulmonary complications between groups.
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Interpretation
No differences were observed in surgical site infections when breathing 30 or 80% oxygen during and for 2 h after abdominal surgery. Pulmonary complications, including atelectasis, pneumonia, or respiratory failure, were also not different between groups. Whether high Fio2 should be the standard for preventing surgical site infection for most operations is not clear.
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On-pump versus off-pump coronary-artery bypass surgery. New Engl J Med 2009; 361:1827–37

The use of cardiopulmonary bypass (on-pump) coronary artery bypass grafting (CABG) has been shown to improve ischemic symptoms and prolong survival. However, postoperative complications, such as hemodynamic instability, may be reduced when CABG is performed without cardiopulmonary bypass (off-pump CABG).
A controlled, single-blind, randomized prospective study was conducted to compare morbidity and mortality in patients (N = 2,203) scheduled for urgent or elective CABG with either on-pump or off-pump procedures.
Compared with the on-pump CABG group (n = 1,099), the off-pump CABG group (n = 1,104) had a greater 1-yr composite (death, repeat revascularization procedure, or nonfatal myocardial infarction) outcome (9.9 vs. 7.4%). The proportion of patients with fewer grafts completed than originally planned was significantly higher (17.8 vs. 11.1%), and the overall rate of graft patency was lower (82.6 vs. 87.8%, P < 0.01) in the off-pump group. At the 1-yr follow-up, there were more deaths from cardiac causes in the off-pump group compared with the on-pump group (2.7 vs. 1.3%). There was no significant difference between off-pump and on-pump CABG in the rate of the 30-day composite (death or complications) outcome (7.0 and 5.6%, respectively; P = 0.19), neuropsychologic outcomes, or short-term use of major resources.
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Interpretation
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Patients who underwent off-pump coronary artery bypass surgery, compared with those who received on-pump surgery, had worse composite outcome (death, myocardial infarction, or revascularization procedure) and lower graft patency at 1yr. These data do not support the routine use of off-pump CABG.

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