Day and Night Transplant Outcomes Similar

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Video Source: JAMA

Action Points

  • Explain that a study of heart and lung transplant recipients found no difference in mortality at one year based on whether the patient was operated on during the daytime or night.
  • Note that the study was retrospective with data from a large registry.
Undergoing a thoracic organ transplant at night rather than during the daytime does not appear to increase a patient's risk of dying within a year, a retrospective registry study showed.

For heart transplant recipients, there were no significant differences in survival rates at 30 and 90 days or at one year based on the time of day the operation took place, according to Ashish Shah, MD, of Johns Hopkins Hospital, and colleagues.

For lung transplant recipients, patients who underwent surgery at night had a slightly but significantly lower survival rate at 90 days (91.7% versus 92.7%, P=0.02), although the difference was not significant at 30 days or one year, the researchers reported in the June 1 issue of the Journal of the American Medical Association.

Shah and his colleagues concluded that there is no clinically meaningful difference in survival based on what time of day heart and lung transplants are performed, which contrasts with several studies that have demonstrated poorer outcomes associated with nighttime surgery.

Worse care at night has been linked to staff fatigue, intraoperative shift changes, changes in nighttime staffing patterns, biological and circadian factors, technical lapses, greater reliance on residents, and decreased situational awareness, according to the researchers.

"Although each of these explanations has its merits, it is difficult to understand why thoracic transplant surgery teams would be uniquely immune to any of these problems," they wrote.

"Further investigation is warranted to understand why thoracic organ transplants do not appear to be associated with deleterious outcomes previously reported to be associated with nighttime surgery."

Shah and his colleagues performed a retrospective study of 16,573 heart transplant recipients and 10,545 lung transplant recipients in the United Network for Organ Sharing (UNOS) database from January 2000 through June 2010.

Nighttime surgery was defined as occurring between 7 p.m. and 7 a.m.

For both heart and lung transplants, about half of the recipients underwent surgery at night.

During a median follow-up of 32.2 months, the rate of all-cause death was 28.99%.

Among heart transplant recipients, there were no differences in survival rates between day and night surgery at 30 days (95% versus 95.2%), 90 days (92.6% versus 92.7%), and one year (88% versus 87.7%). All differences had P values of >0.05.

Survival rates also did not differ based on timing of surgery among the subset of heart transplant recipients who were bridged to transplant with a ventricular assist device.

Among lung transplant recipients, there were no differences in survival rates between day and night surgery at 30 days (96% versus 95.5%) and one year (83.8% versus 82.6%) (P>0.05 for both), but survival was significantly lower with nighttime surgery at 90 days in a multivariate analysis (HR for death 1.23, 95% CI 1.04 to 1.47).

"Although this difference warrants consideration and further investigation, we speculate this difference is detectable due to the high power associated with large registry data sets but is not clinically meaningful," the authors wrote. "The fact that 30-day and one-year mortality are not different further suggests that this difference, while statistically real, probably is not clinically significant."

Length of stay did not vary with the timing of surgery for either heart or lung transplant recipients.

There were mostly no differences in rates of surgical complications based on the time of day of the operation either. The lone exception was a slightly higher rate of airway dehiscence among lung transplant recipients who underwent surgery at night (1.7% versus 1.1%, P=0.02).

"The absolute difference we observed is small and likely not clinically significant but requires further evaluation," Shah and his colleagues wrote.

They noted some limitations of the study, including possible residual confounding, potential bias from different data entry practices at the centers that provide information to the registry, and the lack of information on staffing patterns and other systems-based practices.

The study was supported by a grant from the NIH. One of Shah's co-authors is the Hugh R. Sharp Cardiac Surgery Research Fellow. Another study author is the Irene Piccinini Investigator in Cardiac Surgery.

Shah reported that he had no conflicts of interest. One of his co-authors reported receiving research support from Thoratec, Heartware, and Medtronic.

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