CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

May 16th, 2011

Sleep Deprivation Not as Bad as We Think for Cardiac Surgeons

Sleep deprivation in cardiac surgeons does not lead to worse surgical outcomes, according to a study published in the Archives of Surgery. Michael Chu and colleagues collected sleep information from six consultant surgeons working at a large hospital in Ontario, Canada and outcome data from their 4,047 patients who underwent cardiac surgery from 2004 through 2009.

Of the 4,407 procedures:

  • 83 were performed by a surgeon with 0 to 3 hours of sleep
  • 1595 with 3 to 6 hours
  • 2369 with more than 6 hours

Mortality and major complications did not differ significantly across the groups:

  • Mortality: 3.6% in the 0-3 hour group, 2.8% in the 3-6 hour group, and 3.4% in the 6+ hour group (p=0.53)

Observed versus expected ratio of major complications:

  • 1.20 in the 0-3 hour group, 0.95 in the 3-6 hour group, and 1.07 in the 6+ hour group (p=0.25)

The researchers also found that the age of the surgeons did not significantly affect outcomes.

The authors write that their findings “may have important ramifications in restricting current trainee work hours when future practice may demand optimal performance during sleep-deprived conditions.” Although the ACGME has imposed limitations on work hours for medical trainees, the authors point to studies, including their own, that undermine “the intuitive belief that reduced work hours improves daytime fatigue, trainee performance, and, hence, patient safety…. the findings of our study might suggest reassessment of this belief when contemplating trainee work-hour limitations.”

In an invited critique, David Yuh writes that the “reassuring” results of the study “may not be reflected in future generations of cardiac surgeons” because under new regulations, surgical trainees may not “enjoy the purported benefits of comparatively long hours, including physiologic and mental conditioning and following the course of an acute disease process from beginning to end.” He asks:

“Will patient safety be paradoxically compromised by young practicing cardiac surgeons who can more easily convince themselves that delaying the coronary revascularization of an ischemic patient or repair of an acute ascending aortic dissection for a few hours of extra sleep will actually improve their technical or cognitive performance and therefore serve the best interests of the patient?”

Categories: Cardiac Surgery
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4 Responses to “Sleep Deprivation Not as Bad as We Think for Cardiac Surgeons”

  1. Steven Greer, MD says:
    May 16, 2011 at 4:59 pm

    None of these data are statistically significant, and the study was retrospective. Who knows how well the confounding variables were handled. This study was commissioned for the sole purpose of justifying a practice, operating without sleep, that numerous other NEJM etc trials have shown to be unsafe

    Competing interests pertaining specifically to this post, comment, or both:
    none

  2. William DeMedio, MD says:
    May 16, 2011 at 8:44 pm

    I believe a well rested surgeon would be more alert and able than a sleep deprived surgeon. The study was not large enough. The only time we should be using people with 0-3 hours of sleep to do surgery is in a mass casualty or combat situation when we have no choice. The same is true of driving, flying, and doing any potentially hazardous endeavour.

    Competing interests pertaining specifically to this post, comment, or both:
    None

  3. Alfonso E. Sierra, MD says:
    May 17, 2011 at 8:01 am

    If I am the patient, I don’t want to be electively operated that day for my friend who is a very good cardiac surgeon all other things considered.

    Competing interests pertaining specifically to this post, comment, or both:
    None

  4. Karen Politis, MD says:
    May 18, 2011 at 4:18 pm

    As a physician working in and out of the OR, I have a hunch that performing a structured task with a lot of supportive staff around you, like cardiac surgery, would be reasonably safe even when the performer is fatigued, as long as there are no unexpected or rare complications that require swift decisions in an atmosphere of extreme stress and uncertainty. Even in such situations there usually is a team of colleagues that one can call for help, especially during working hours. The problem with fatigue is much worse in an environment with constant distractions, an overwhelming workload and a great degree of uncertainty i.e. working in the ER. In such situations it is easy to forget to attend to detail, make biased decisions and get frustrated when unexpected problems arise, especially when the fatigued physician is working alone, often with unfamiliar or inexperienced staff, and without timely supervision from seniors or support and advice from peers. Being a hero in the OR is not the same as being an unsung hero in the ER. Fatigue will bring our the worst in all of us when the chips are down. The OR in Ontario where the report comes from is probably a very good place to work.

    Competing interests pertaining specifically to this post, comment, or both:
    No conflicts of interest.