Commentary: Adapting for our patients: Reducing intraoperative adverse events as new technologies emerge

Central MessageAs new technologies emerge, cardiac surgeons must ensure that they are well trained in all aspects of the field and are familiar with all equipment used in their practice.See Article page 85. As new technologies emerge, cardiac surgeons must ensure that they are well trained in all aspects of the field and are familiar with all equipment used in their practice. See Article page 85. Cardiac surgery uses increasingly complex and high-risk interventions to care for patients with severe cardiovascular diseases. Although morbidity and mortality have improved significantly in the modern era of cardiac surgery, errors in the operating room remain a major cause of preventable adverse events and avoidable death.1Martinez E.A. Thompson D.A. Errett N.A. Kim G.R. Bauer L. Lubomski L.H. et al.High stakes and high risk: a focused qualitative review of hazards during cardiac surgery.Anaesthes Analges. 2011; 112: 1061-1074Crossref PubMed Scopus (29) Google Scholar,2Wahr J.A. Prager R.L. Abernathy III, J.H. Martinez E.A. Salas E. Seifert P.C. et al.Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (189) Google Scholar Therefore, it is prudent to examine individual cases of surgical missteps to learn from them and avoid repeating these mistakes in the future. In this issue of the Journal, Fukunaga and colleagues3Fukunaga N. Badiwala M.V. Yau T.M. Rao V. Cusimano R.J. Descending aortic thrombosis and acute type B dissection during central extracorporeal membrane oxygenation: a word of caution.J Thorac Cardiovasc Surg Tech. 2021; 6: 85-87Scopus (2) Google Scholar describe a case of inappropriate aortic cannula placement for central venoarterial extracorporeal membrane oxygenation and the complications that ensued. The arterial cannula used in this case was placed too deeply into the distal ascending aorta, with its tip residing in the descending thoracic aorta. The patient sustained a localized iatrogenic aortic dissection (iAD) near the cannula tip, cannula-related thrombosis, acute renal injury, and stroke, which may or may not have been related to the extracorporeal membrane oxygenation cannula. Fortunately, the patient successfully recovered from these complications and was discharged to home with no significant long-term sequelae. However, these and future downstream complications likely could have been prevented had the correct technique been used for cannula placement. This case provides 2 important learning points. First, cardiac surgeons must be well trained in all aspects of the field and be familiar with all the equipment used in their practice. Despite ample efforts to combat contributing system factors, individual human factors remain an important cause of intraoperative errors and patient injuries.4Fabri P.J. Zayas-Castro J.L. Human error, not communication and systems, underlies surgical complications.Surgery. 2008; 144: 557-565Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar In particular, a surgeon's lack of technical competence or knowledge is cited as a contributing factor in almost one-half of all surgical malpractice claims.5Rogers S.O. Gawande A.A. Kwaan M. Puopolo A.L. Yoon C. Brennan T.A. et al.Analysis of surgical errors in closed malpractice claims at 4 liability insurers.Surgery. 2006; 140: 25-33Abstract Full Text Full Text PDF PubMed Scopus (298) Google Scholar,6Regenbogen S.E. Greenberg C.C. Studdert D.M. Lipsitz S.R. Zinner M.J. Gawande A.A. Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients.Ann Surg. 2007; 246: 705-711Crossref PubMed Scopus (155) Google Scholar These were predominantly cases in which surgeons were practicing within their specialty but lacking knowledge or skill with specific tasks at hand.6Regenbogen S.E. Greenberg C.C. Studdert D.M. Lipsitz S.R. Zinner M.J. Gawande A.A. Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients.Ann Surg. 2007; 246: 705-711Crossref PubMed Scopus (155) Google Scholar With the adoption of novel therapies into the standard of care of cardiac surgery, surgeons must adapt and ensure they are properly trained to deliver these new standards. This is especially true regarding mechanical circulatory support, a subspecialty of cardiac surgery where new techniques and devices are continuously being introduced to our practices. A study among vascular surgeons in England identified equipment unfamiliarity to be significantly predictive of intraoperative failure.7Lear R. Riga C. Godfrey A.D. Falaschetti E. Cheshire N.H. Van Herzeele I. et al.Multicentre observational study of surgical system failures in aortic procedures and their effect on patient outcomes.Br J Surg. 2016; 103: 1467-1475Crossref PubMed Scopus (18) Google Scholar A formal training curriculum and high-fidelity simulation models can be used to gain knowledge and experience with these new techniques and technologies.8Lorusso R. Whitman G. Milojevic M. Raffa G. McMullan D.M. Boeken U. et al.2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients.Ann Thorac Surg. 2020; 111: P327-P369Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Second, cardiac surgeons must remain vigilant for iAD when using venoarterial extracorporeal membrane oxygenation. In this population, the reported incidence is as high as 1.4%.9Mariscalco G. Salsano A. Fiore A. Dalén M. Ruggieri V.G. Saeed D. et al.Peripheral versus central extracorporeal membrane oxygenation for postcardiotomy shock: multicenter registry, systematic review, and meta-analysis.J Thorac Cardiovasc Surg. 2020; 160: 1207-1216Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Early recognition of iAD is key to reducing mortality; it should always be suspected when there are sudden changes to systemic arterial pressure (and pulse waveform), decreases in flow rate, increases in extracorporeal membrane oxygenation arterial line pressure, and/or evidence of decreased organ perfusion.10Ram H. Dwarakanath S. Green A.E. Steyn J. Hessel E.A. Iatrogenic aortic dissection associated with cardiac surgery: a narrative review.J Cardiothorac Vasc Anesth. 2020; (https://doi.org/10.1053/j.jvca.2020.07.084 [Epub ahead of print])Abstract Full Text Full Text PDF Scopus (4) Google Scholar As shown in this report, transesophageal echocardiography is a safe and effective modality for diagnosing and guiding management of iAD in critically ill patients. Thus, as the field of cardiac surgery evolves, it remains incumbent on us to keep abreast of novel techniques and technologies. Our patients depend on it. Descending aortic thrombosis and acute type B dissection during central extracorporeal membrane oxygenation: A word of cautionJTCVS TechniquesVol. 6PreviewExtracorporeal membrane oxygenation (ECMO) is a valuable, life-saving modality for patients in shock. Some complications associated with ECMO are well known. We describe a case of simultaneous aortic thrombosis and acute type B aortic dissection (AD) caused by an arterial cannula placed in the descending aorta. Full-Text PDF Open Access

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