Reduce intraoperative albumin utilisation in cardiac surgical patients: a quality improvement initiative

BACKGROUND

Albumin continues to be used routinely by cardiac anaesthesiologists perioperatively despite lack of evidence for improved outcomes. The Multicenter Perioperative Outcomes Group (MPOG) data ranked our institution as one of the highest intraoperative albumin users during cardiac surgery. Therefore, we designed a quality improvement project (QIP) to introduce a bundle of interventions to reduce intraoperative albumin use in cardiac surgical patients.

METHODS

Our institutional MPOG data were used to analyse the FLUID-01-C measure that provides the number of adult cardiac surgery cases where albumin was administered intraoperatively by anaesthesiologists from 1 July 2019 to 30 June 2022. The QIP involved introduction of the following interventions: (1) education about appropriate albumin use and indications (January 2021), (2) email communications reinforced with OR teaching (March 2021), (3) removal of albumin from the standard pharmacy intraoperative medication trays (April 2021), (4) grand rounds presentation discussing the QIP and highlighting the interventions (May 2021) and (5) quarterly provider feedback (starting July 2021). Multivariable segmented regression models were used to assess the changes from preintervention to postintervention time period in albumin utilisation, and its total monthly cost.

RESULTS

Among the 5767 cardiac surgery cases that met inclusion criteria over the 3-year study period, 16% of patients received albumin intraoperatively. The total number of cases that passed the metric (albumin administration was avoided), gradually increased as our interventions went into effect. Intraoperative albumin utilisation (beta=-101.1, 95% CI -145 to -56.7) and total monthly cost of albumin (beta=-7678, 95% CI -10712 to -4640) demonstrated significant decrease after starting the interventions.

CONCLUSIONS

At a single academic cardiac surgery programme, implementation of a bundle of simple and low-cost interventions as part of a coordinated QIP were effective in significantly decreasing intraoperative use of albumin, which translated into considerable costs savings.

Intraoperative transfusion practices and perioperative outcome in the European elderly: A secondary analysis of the observational ETPOS study

The demographic development suggests a dramatic growth in the number of elderly patients undergoing surgery in Europe. Most red blood cell transfusions (RBCT) are administered to older people, but little is known about perioperative transfusion practices in this population. In this secondary analysis of the prospective observational multicentre European Transfusion Practice and Outcome Study (ETPOS), we specifically evaluated intraoperative transfusion practices and the related outcomes of 3149 patients aged 65 years and older. Enrolled patients underwent elective surgery in 123 European hospitals, received at least one RBCT intraoperatively and were followed up for 30 days maximum. The mean haemoglobin value at the beginning of surgery was 108 (21) g/l, 84 (15) g/l before transfusion and 101 (16) g/l at the end of surgery. A median of 2 [1-2] units of RBCT were administered. Mostly, more than one transfusion trigger was present, with physiological triggers being preeminent. We revealed a descriptive association between each intraoperatively administered RBCT and mortality and discharge respectively, within the first 10 postoperative days but not thereafter. In our unadjusted model the hazard ratio (HR) for mortality was 1.11 (95% CI: 1.08-1.15) and the HR for discharge was 0.78 (95% CI: 0.74-0.83). After adjustment for several variables, such as age, preoperative haemoglobin and blood loss, the HR for mortality was 1.10 (95% CI: 1.05-1.15) and HR for discharge was 0.82 (95% CI: 0.78-0.87). Pre-operative anaemia in European elderly surgical patients is undertreated. Various triggers seem to support the decision for RBCT. A closer monitoring of elderly patients receiving intraoperative RBCT for the first 10 postoperative days might be justifiable. Further research on the causal relationship between RBCT and outcomes and on optimal transfusion strategies in the elderly population is warranted. A thorough analysis of different time periods within the first 30 postoperative days is recommended.

Effect of Intraoperative Dexmedetomidine on Recovery of Gastrointestinal Function After Abdominal Surgery in Older Adults: A Randomized Clinical Trial

IMPORTANCE

Postoperative ileus is common after abdominal surgery, and small clinical studies have reported that intraoperative administration of dexmedetomidine may be associated with improvements in postoperative gastrointestinal function. However, findings have been inconsistent and study samples have been small. Further examination of the effects of intraoperative dexmedetomidine on postoperative gastrointestinal function is needed.

OBJECTIVE

To evaluate the effects of intraoperative intravenous dexmedetomidine vs placebo on postoperative gastrointestinal function among older patients undergoing abdominal surgery.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, double-blind, placebo-controlled randomized clinical trial was conducted at the First Affiliated Hospital of Anhui Medical University in Hefei, China (lead site), and 12 other tertiary hospitals in Anhui Province, China. A total of 808 participants aged 60 years or older who were scheduled to receive abdominal surgery with an expected surgical duration of 1 to 6 hours were enrolled. The study was conducted from August 21, 2018, to December 9, 2019.

INTERVENTIONS

Dexmedetomidine infusion (a loading dose of 0.5 μg/kg over 15 minutes followed by a maintenance dose of 0.2 μg/kg per hour) or placebo infusion (normal saline) during surgery.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to first flatus. Secondary outcomes were postoperative gastrointestinal function measured by the I-FEED (intake, feeling nauseated, emesis, physical examination, and duration of symptoms) scoring system, time to first feces, time to first oral feeding, incidence of delirium, pain scores, sleep quality, postoperative nausea and vomiting, hospital costs, and hospital length of stay.

RESULTS

Among 808 patients enrolled, 404 were randomized to receive intraoperative dexmedetomidine, and 404 were randomized to receive placebo. In total, 133 patients (60 in the dexmedetomidine group and 73 in the placebo group) were excluded because of protocol deviations, and 675 patients (344 in the dexmedetomidine group and 331 in the placebo group; mean [SD] age, 70.2 [6.1] years; 445 men [65.9%]) were included in the per-protocol analysis. The dexmedetomidine group had a significantly shorter time to first flatus (median, 65 hours [IQR, 48-78 hours] vs 78 hours [62-93 hours], respectively; P < .001), time to first feces (median, 85 hours [IQR, 68-115 hours] vs 98 hours [IQR, 74-121 hours]; P = .001), and hospital length of stay (median, 13 days [IQR, 10-17 days] vs 15 days [IQR, 11-18 days]; P = .005) than the control group. Postoperative gastrointestinal function (as measured by the I-FEED score) and delirium incidence were similar in the dexmedetomidine and control groups (eg, 248 patients [72.1%] vs 254 patients [76.7%], respectively, had I-FEED scores indicating normal postoperative gastrointestinal function; 18 patients [5.2%] vs 12 patients [3.6%] had delirium on postoperative day 3).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, the administration of intraoperative dexmedetomidine reduced the time to first flatus, time to first feces, and length of stay after abdominal surgery. These results suggest that this therapy may be a viable strategy to enhance postoperative recovery of gastrointestinal function among older adults.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR1800017232.

Liberal blood transfusion strategies and associated infection in orthopedic patients: A meta-analysis

OBJECTIVE

It remains unclear whether transfusion strategies during orthopedic surgery and infection are related. The purpose of this study is to evaluate whether liberal blood transfusion strategies contribute to infection risk in orthopedic patients by analyzing randomized controlled trials (RCTs).

METHODS

RCTs with liberal versus restrictive red blood cell (RBC) transfusion strategies were identified by searching PubMed, Embase, the Cochrane Central Register of Controlled Trials from their inception to July 2019. Ten studies with infections as outcomes were included in the final analysis. According to the Jadad scale, all studies were considered to be of high quality.

RESULTS

Ten trials involving 3938 participants were included in this study. The pooled risk ratio (RR) for the association between liberal transfusion strategy and infection was 1.34 (95% confidence intervals [CI], 0.94-1.90; P = .106). The sensitivity analysis indicated unstable results, and no significant publication bias was observed.

CONCLUSION

This pooled analysis of RCTs demonstrates that liberal transfusion strategies in orthopedic patients result in a nonsignificant increase in infections compared with more restrictive strategies. The conclusions are mainly based on retrospective studies and should not be considered as recommendation before they are supported by larger scale and well-designed RCTs.

The value of the intraoperative assessment of the SLN via frozen section in the post Z0011 era

INTRODUCTION

Sentinel node (SN) assessment via frozen section (FS) has declined since the publication of Z0011 which modified the management of a specific group of patients with positive SN. The risk of misleading the surgeons to a preventable ALND and the cost are among the main factors for that. The aim of our study is to assess the value of FS in the post Z0011.

MATERIAL AND METHODS

244 patients out of 434 were eligible for an upfront SLNB. Based on the final histology and the clinical data we selected the eligible for breast conserving surgery patients (55.4%). 78 patients had positive SN and 26 of them fulfilled the criteria of Z0011. We assessed the false negative findings, the impact on the management and the indications and value of FS in the post Z0011 era.

RESULTS

Overall, there were 12 FN cases out of which 7 were macrometastases (8.97%). Only in one case there were > 2 positive LN and 3 patients needed mastectomy. The remaining cases fulfilled the criteria of Z0011 and needed no further surgery hence in 96.1% of the cases the axillary status was correctly assessed via FS and the reoperation rate was 1.2%. On the contrary, if FS was not used, at least 21.3% of the patents would have needed reoperation based on the today's guidelines.

DISCUSSION

We believe FS is still valuable and may spare a significant percentage of patients from a second operation (SNB) without leading to axillary overtreatment if used wisely.

Successful intraoperative management in patients with abdominal compartment syndrome induced by giant liposarcomas: Two case reports

RATIONALE

Giant intra-abdominal liposarcomas weighing over 20 kg often increase the intra-abdominal pressure (IAP), which has severe effects on the cardiovascular and respiratory systems. Abdominal compartment syndrome is defined typically as the combination of a raised IAP of 20 mm Hg or higher and new onset of organ dysfunction or failure. The anesthetic management and perioperative management are very challenging.

PATIENTS CONCERNS

We presented 2 patients with rare giant growing liposarcoma of the abdomen, weighing 21 kg and over 35 kg, respectively. Circulatory management was particularly difficult in the first case, while respiratory management and massive blood loss was very challenging in the second one.

DIAGNOSIS

With a computed tomography scan and peritoneal-to-abdominal height ratio measurement, preoperatively the risk of developing intra-abdominal hypertension and abdominal compartment syndrome was recognized early in each patient. The inferior vena cava and right atrium of the first patient was compressed and malformed due to the uplifted diaphragm, while there was severe decreased lung volume and increased airway resistance, because of rare giant retroperitoneal liposarcomas in the second case. Histologic examination revealed dedifferentiated liposarcoma in both cases.

INTERVENTIONS

Both of the patients underwent resection surgery with multiple monitoring; transesophageal echocardiography monitoring in the first case and pressure-controlled ventilation volume guaranteed mechanical ventilation mode in both cases.

OUTCOMES

Intraoperatively and postoperatively no cardiopulmonary complications in both patients. The first patient was discharged without any complications on postoperative day 10, and the second patient underwent another surgery because of anastomotic leakage resulting from bowel resection.

LESSONS

Multiple monitorings, in particular transesophageal echocardiography should be considered in patients with increased IAP due to a giant mass, while an appropriate lung protection ventilation strategy is crucial in these patients.

Access to Technology and Education for the Development of Minimally Invasive Spine Surgery Techniques in Latin America

OBJECTIVE

To evaluate access to the technologies and education needed to perform minimally invasive spine surgery (MISS) in Latin America.

METHODS

We designed a questionnaire to evaluate surgeons' practice characteristics, access to different technologies, and training opportunities for MISS techniques. The survey was sent to members and registered users of AO Spine Latin from January 6-20, 2020. The major variables studied were nationality, specialty (orthopedics or neurosurgery), level of hospital (primary, secondary, tertiary), number of surgeries performed per year by the spine surgeon, types of spinal pathologies commonly managed, and number of MISS performed per year. Other variables involved specific access to different technologies: intraoperative fluoroscopy, percutaneous screws, cages, tubular retractors, microscopy, intraoperative computed tomography, neuronavigation imaging, and bone morphogenetic protein. Finally, participants were asked about main obstacles to performing MISS and their access to education on MISS techniques in their region.

RESULTS

The questionnaires were answered by 306 members of AO Spine Latin America across 20 different countries. Most answers were obtained from orthopedic surgeons (57.8%) and those with over 10 years of experience (42.4%). Most of the surgeons worked in private practice (46.4%) and performed >50 surgeries per year (44.1%), but only 13.7% performed >50 MISS per year, mainly to manage degenerative pathologies (87.5%). Most surgeons always had access to fluoroscopy (79%). Only 26% always had access to percutaneous screws, 24% to tubular retractors, 34.3% to cages (anterior lumbar interbody fusion, lateral lumbar interbody fusion, or transforaminal lumbar interbody fusion), and 43% to microscopy. Regarding technologies, 71% reported never having access to navigation, 83% computed tomography, and 69.3% bone morphogenetic protein. The main limitations expressed for widely used MISS technologies were the high implant costs (69.3%) and high navigation costs (49.3%). Most surgeons claimed access to online education activities (71%), but only 44.9% reported access to face-to-face events and 28.8% to hands-on activities, their limited access largely because the courses were expensive (62.7%) or few courses were available on MISS in their region (51.3%).

CONCLUSIONS

Most surgeons in Latin America have limited resources to perform MISS, even in private practice. The main constraints are implant costs, access to technologies, and limited face-to-face educational opportunities.

Clinical practice on intra-operative fluid therapy in Poland: A point prevalence study

Intra-operative fluid therapy (IFT) is the cornerstone of peri-operative management as it may significantly influence the treatment outcome. Therefore, we sought to evaluate nationwide clinical practice regarding IFT in Poland.A cross-sectional, multicenter, point-prevalence study was performed on April 5, 2018, in 31 hospitals in Poland. Five hundred eighty-seven adult patients undergoing non-cardiac surgery were investigated. The volume and type of fluids transfused with respect to the patient and procedure risk were assessed.The study group consisted of 587 subjects, aged 58 (interquartile range [IQR] 40-67) years, including 142 (24%) American Society of Anesthesiology Physical Status (ASA-PS) class III+ patients. The median total fluid dose was 8.6 mL kg h (IQR 6-12.5), predominantly including balanced crystalloids (7.0 mL kg h, IQR 4.9-10.6). The dose of 0.9% saline was low (1.6 mL kg h, IQR 0.8-3.7). Synthetic colloids were used in 66 (11%) subjects. The IFT was dependent on the risk involved, while the transfused volumes were lower in ASA-PS III+ patients, as well as in high-risk procedures (P < .05).The practice of IFT is liberal but is adjusted to the preoperative risk. The consumption of synthetic colloids and 0.9% saline is low.

A multicentre, prospective, observational cohort study of variation in practice in perioperative analgesia strategies in elective laparoscopic colorectal surgery (the LapCoGesic study)

INTRODUCTION

Enhanced recovery programmes are established as an essential part of laparoscopic colorectal surgery. Optimal pain management is central to the success of an enhanced recovery programme and is acknowledged to be an important patient reported outcome measure. A variety of analgesia strategies are employed in elective laparoscopic colorectal surgery ranging from patient-controlled analgesia to local anaesthetic wound infiltration catheters. However, there is little evidence regarding the optimal analgesia strategy in this cohort of patients. The LapCoGesic study aimed to explore differences in analgesia strategies employed for patients undergoing elective laparoscopic colorectal surgery and to assess whether this variation in practice has an impact on patient-reported and clinical outcomes.

MATERIALS AND METHODS

A prospective, multicentre, observational cohort study of consecutive patients undergoing elective laparoscopic colorectal resection was undertaken over a two-month period. The primary outcome measure was postoperative pain scores at 24 hours. Data analysis was conducted using SPSS version 22.

RESULTS

A total of 103 patients undergoing elective laparoscopic colorectal surgery were included in the study. Thoracic epidural was used in 4 (3.9%) patients, spinal diamorphine in 56 (54.4%) patients and patient-controlled analgesia in 77 (74.8%) patients. The use of thoracic epidural and spinal diamorphine were associated with lower pain scores on day 1 postoperatively (P < 0.05). The use of patient-controlled analgesia was associated with significantly higher postoperative pain scores and pain severity.

DISCUSSION

Postoperative pain is managed in a variable manner in patients undergoing elective colorectal surgery, which has an impact on patient reported outcomes of pain scores and pain severity.

Comparison study between open and laparoscopic liver resection in a Saudi tertiary center

Objectives:

To compare King Saud University Medical City experience in laparoscopic liver resection with our previously established database for open resections.

Methods:

A retrospective study was conducted at King Saud University Medical City, Riyadh, Saudi Arabia. All adult patients who underwent liver resection from 2006 to 2017 were included. Patients who had their procedure converted to open were excluded.

Results:

Among the 111 liver resections included, 22 (19.8%) were performed laparoscopically and 89 (80.1%) were performed using the open technique. Malignancy was the most common indication in both groups (78.5%). The mean operative time was 275 min (SD 92.2) in the laparoscopic group versus 315 min (SD 104.3) in the open group. Intraoperative blood transfusion was required in the laparoscopic (9%) and open groups (31.4%). The morbidity rate was 13.6% in the laparoscopic group and 31.4% in the open group, and the mortality rate was 0% in the laparoscopic group and 5.6% in the open group.

Conclusion:

Laparoscopic liver resection appears to be a safe technique and can be performed in various benign and malignant cases.

Phase III Trial of Intravenous Mannitol Versus Placebo During Nephron-sparing Surgery: Post Hoc Analysis of 3-yr Outcomes

Our recently reported phase III trial demonstrated that patients undergoing nephron-sparing surgery (NSS) with an estimated glomerular filtration rate (eGFR) of ≥45 ml/min/1.73 m² who received mannitol had no improvement in renal function at 6 mo compared with those who received placebo. Some authors have suggested that benefit is restricted to subgroups, such as those with comorbidities. We assessed whether preoperative eGFR, or other patient and surgical factors modified the effect of mannitol on postoperative outcomes at 6 mo and with extended follow-up. We also assessed whether mannitol was associated with differences in long-term GFR years after surgery. No significant difference between the mannitol or placebo groups (mean eGFR difference: 1.4; 95% confidence interval: -2.6, 5.3; p = 0.5) was found in the 134 patients with known eGFR at 3 yr after NSS. At both 6 mo and 3 yr, the effect of mannitol was not significantly modified by patient or surgical factors including preoperative eGFR. In summary, we validated our original trial conclusions by finding that intraoperative use of mannitol does not improve either short- or long-term renal function in patients undergoing NSS. Specifically, there is no evidence that comorbidities, including lower preoperative eGFR, modify the effect of mannitol. PATIENT SUMMARY: Use of mannitol at the time of partial nephrectomy does not improve either short- or long-term renal function even in patients with comorbidities, including lower preoperative renal function. The routine use of intraoperative mannitol should be discontinued.

Evolving safety practices in the setting of modern complex operating room: role of nurses

Operating room (OR) nursing previously referred to patient care provided during the intra-operative phase and the service provided within the OR itself. With the expansion of responsibilities of nurses, OR nursing now includes pre-operative and post-operative periods, therefore peri-operative nursing is accepted as a nursing process in OR in the contemporary medical literature. Peri-operative nurses provide care to the surgical patients during the entire process of surgery. They have several roles including those of manager or a director, clinical practitioner (scrub nurse, circulating nurse and nurse anesthetist), educator as well as researcher. Although, utmost priority is placed on insuring patient safety and well-being, they are also expected to participate in professional organization, continuing medical education programs and participating in research activities. A Surgical Patient Safety Checklist formulated by the World Health Organization serves as a major guideline to all activities in OR, and peri-operative nurses are key personnel in its implementation. Communication among the various players of a procedure in OR is key to successful patient outcome, and peri-operative nurses have a central role in making it happen. Setting up of OR in military conflict zones or places that suffering a widespread natural disaster poses a unique challenge to nursing. This review discusses all aspects of peri-operative nursing and suggests points of improvement in patient care.

Laparoscopic Lymph Node Biopsy: Efficacy and Advantages

BACKGROUND

Diagnosis of abdominal lymphadenopathy is challenging when not accompanied by peripheral lymphadenopathy. Computed tomography-guided core-needle biopsy has largely replaced open procedures in recent years, but this approach is limited by access to the anatomic region and the amount of tissue acquired.

OBJECTIVES

To demonstrate the feasibility of the laparoscopic approach in obtaining abdominal lymph node biopsies and to evaluate the diagnostic adequacy of the technique.

METHODS

We reviewed the data of patients who underwent laparoscopic lymph node biopsy between 2014 and 2014 in our department. Demographics, intra-operative parameters and postoperative course were examined, as were histological reports. Postoperative complications were categorized according to the Clavien-Dindo(CD) classification.

RESULTS

Between 2004 and 2014, 57 laparoscopic biopsies were performed for intra-abdominal lymphadenopathy. One case was a repeated attempt due to limited histologic material. The mean age was 49.5 ± 19.6 years. There were two conversions to open laparotomy, one due to small bowel injury and the other due to a sizable mass. Overall, 56 cases had full clinical data: 48 cases (85.7%) had CD=0, six (10.7%) had CD=1, one postoperative severe complication (CD=3) and one mortality (CD=5), which was related to preexisting hepatic insufficiency. Mean hospital stay was 1.6 days. Overall, adequate tissue samples were acquired in 96.7% and only 3 of these cases resulted in inconclusive diagnoses.

CONCLUSIONS

Laparoscopic lymph node biopsy is a viable alternative to the currently available methods of tissue retrieval. It provides an access for nodes which are inaccessible percutaneously, and may allow a superior diagnostic yield.

Contrast Utilization During Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Contemporary Multicenter Registry

BACKGROUND

Administration of a large amount of contrast volume during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) may lead to contrast-induced nephropathy.

METHODS

We examined the association of clinical, angiographic and procedural variables with contrast volume administered during 1330 CTO-PCI procedures performed at 12 experienced United States centers.

RESULTS

Technical and procedural success was 90% and 88%, respectively, and mean contrast volume was 289 ± 138 mL. Approximately 33% of patients received >320 mL of contrast (high contrast utilization group). On univariable analysis, male gender (P=.01), smoking (P=.01), prior coronary artery bypass graft surgery (P=.04), moderate or severe calcification (P=.01), moderate or severe tortuosity (P=.04), proximal cap ambiguity (P=.01), distal cap at a bifurcation (P<.001), side branch at the proximal cap (P<.001), blunt/no stump (P=.01), occlusion length (P<.001), higher J-CTO score (P=.02), use of antegrade dissection and reentry or retrograde approach (P<.001), ad hoc CTO-PCI (P=.04), dual arterial access (P<.001), and 8 Fr guide catheters (P<.001) were associated with higher contrast volume; conversely, diabetes mellitus (P=.01) and in-stent restenosis (P=.01) were associated with lower contrast volume. On multivariable analysis, moderate/severe calcification (P=.04), distal cap at a bifurcation (P<.001), ad hoc CTO-PCI (P<.001), dual arterial access (P=.01), 8 Fr guide catheters (P=.02), and use of antegrade dissection/reentry or the retrograde approach (P<.001) were independently associated with higher contrast use, whereas diabetes (P=.02), larger target vessel diameter (P=.03), and presence of "interventional" collaterals (P<.001) were associated with lower contrast utilization.

CONCLUSIONS

Several baseline clinical, angiographic, and procedural characteristics are associated with higher contrast volume administration during CTO-PCI.

An intraoperative irrigation regimen to reduce the surgical site infection rate following adolescent idiopathic scoliosis surgery

INTRODUCTION

The aim of this study was to compare the efficacy of a gentamicin antibiotic intraoperative irrigation regimen (regimen A) with a povidone-iodine intraoperative irrigation regimen (regimen B) and to evaluate the ability of adjunctive local vancomycin powder (regimen C) to reduce the surgical site infection (SSI) rate following idiopathic scoliosis correction.

METHODS

This was a retrospective, single centre, two-surgeon cohort study of paediatric scoliosis procedures involving 118 patients under the age of 18 years who underwent correction for idiopathic scoliosis over a period of 42 months. Patients' baseline characteristics, pseudarthrosis and rates of SSI were compared.

RESULTS

Baseline characteristics were comparable in all three groups, with the exception of sex distribution. Over a quarter (27%) of patients with regimen B were male compared with 13% and 6% for regimens A and C respectively. Patients were mostly followed up for a minimum of 12 months. The SSI rate for both superficial and deep infections was higher with regimen A (26.7%) than with regimens B and C (7.0% and 6.3% respectively). The SSI rates for regimens B and C were comparable. No patients developed complications related to vancomycin toxicity, metalwork failure or pseudarthrosis.

CONCLUSIONS

Wound irrigation with a povidone-iodine solution reduces SSIs following adolescent idiopathic scoliosis surgery. The direct application of vancomycin powder to the wound is safe but does not reduce the SSI rate further in low risk patients. Additional studies are needed to elucidate whether it is effective at higher doses and in high risk patient groups.

Intra-operative Use of Hemopatch®: Interim Results of a Nationwide European Survey of Surgeons

INTRODUCTION

Haemostasis is a critical part of surgery. Haemostatic agent selection is based upon a number of factors including surgeon's experience and choice. This post-marketing survey determined surgeons' intraoperative use and perception of Hemopatch® (Baxter Healthcare Corporation, Deerfield, IL), a resorbable collagen-based sealing haemostat.

METHODS AND PARTICIPANTS

A one-arm questionnaire was distributed to European general, cardiac, pulmonary, and urologic surgeons who used Hemopatch® to achieve haemostasis in situations where bleeding control by pressure, ligature, or conventional procedures had been ineffective or was impractical. Responses were summarized for patient characteristics, surgical procedures/techniques, and surgeons' assessment of Hemopatch® regarding their overall satisfaction and utilization characteristics of Hemopatch®.

RESULTS

Of 1028 responses received from seven European countries, the majority were from Germany (47.3%) or Italy (36%). Most cases were in males (60.7%), 50-75 years of age (61.8%), performed by an open approach (82.5%), with 52.7% general-, 16.2% cardiac-, 7.5% lung, 19.5% urologic-type procedures and 3.7% other/unknown. Successful haemostasis after two minutes of approximation occurred in 93.3% of patients (86.8%-96.9% across surgical subtypes), with similar rates by approach (93.1% open; 94.1% minimally-invasive), and patient's use of anticoagulant and/or antiplatelet agents (87.9% - 93.1%). Over 92% of surgeon's rated Hemopatch® as "excellent" or "good" in assessments of overall satisfaction, haemostasis efficacy, ease of preparation, ease of handling, flexibility/pliability, and tissue adherence. These characteristics were rated as excellent or good by 81% or more of surgeons in analyses by surgical subspecialty and surgical approach of open or minimally invasive.

CONCLUSIONS

Hemopatch® provides effective haemostasis across a variety of surgical procedures, both in open- and minimally-invasive, as well as in patients receiving anticoagulant and/or antiplatelet agents. Surgeon's generally rated their overall satisfaction with Hemopatch®, its haemostatic efficacy, and other characteristics as "much better" or "better" than their previously used haemostat.

Intraoperative transfusion practices in Europe

BACKGROUND

Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe.

METHODS

We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013.

RESULTS

The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl(-1) and increased to 9.8 (1.8) g dl(-1) after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2).

CONCLUSION

Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl(-1)), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold.

CLINICAL TRIAL REGISTRATION

NCT 01604083.

Selective Intraoperative Cholangiography in Laparoscopic Cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy (LC) is probably one of the most frequent surgical procedure performed worldwide. Intraoperative cholangiography (IOC) is required more often than in open procedures due to the need to clarify the anatomy or to diagnose common bile duct (CBD) stones.

AIM

The present study analyzes the value of IOC performed on selective basis following preoperative and intraoperative criteria. Our experience covers 15 years of surgical activity in Elias Surgery Department and, as a result of a continuous scientific concern on the matter, we developed a set of criteria that are analyzed and discussed.

MATERIAL AND METHOD

We studied the patients subjected to LC in our department between January 2013 and December 2014. A group of 945 patients was analyzed; IOC was performed in 147 cases. All IOC were selective procedures. The criteria were divided in two groups: Preoperative criteria (clinical, lab tests and imaging findings); Intraoperative criteria (dilated biliary ducts and obscure biliary anatomy).

RESULTS

IOC was performed in 147 cases. We had a positive result, a finding that changed surgical management of the patient after IOC in over 50% of cases. The biliary tree anatomy was cleared in 100% of cases. IOC required a median period of time of 11 minutes. There were no complications caused by IOC.

CONCLUSIONS

Intraoperative cholangiography, performed either routinely or selectively, represents an important tool in diagnosing unsuspected CBD stones during laparoscopic cholecystectomy. Criteria for selective IOC may significantly reduce the number of useless cholangiograms and are to be considered in daily practice. The main predictive factors used for selective intraoperative cholangiography in our study were: history of jaundice, elevated values of ALP, GGTP, SGO, SGP, and CBD diameter.

Orthopedic Implant Waste: Analysis and Quantification

The steadily increasing demand for orthopedic surgeries and declining rates of reimbursement by Medicare and other insurance providers have led many hospitals to look for ways to control the cost of these surgeries. We reviewed administrative records for a 1-year period and recorded total number of surgical cases, number of cases in which an implant was wasted, and cost of each wasted implant. We determined cost incurred because of implant waste, percentage of cases that involved waste, percentage of total implant cost wasted, and average cost of waste per case. We then analyzed the data to determine if case volume or years in surgical practice affected amount of implant waste. Results showed implant waste represents a significant cost for orthopedic procedures within all subspecialties and is an important factor to consider when developing cost-reduction strategies.

The feasibility of laparoscopic extended pelvic surgery for rectal cancer

PURPOSE

The present study aimed to assess the safety and feasibility of laparoscopic extended pelvic surgery for primary or recurrent rectal cancer.

METHODS

The data on 77 patients, who underwent extended pelvic surgery between February 2008 and June 2014, were retrospectively analyzed. The patients were divided, based on their treatment history, into an open surgery (OS) group (n = 41) and a laparoscopic surgery (LS) group (n = 36).

RESULTS

The operative time in the LS group was significantly longer than that in the OS group (766 vs. 561 min; p < 0.001). In contrast, the LS group was associated with a significantly lower volume of intraoperative blood loss (195 vs. 923 ml; p < 0.001), fluid balance (5.38 vs. 8.23 ml/kg/h; p < 0.001) and rate of complications (40.0 vs. 68.3 %; p = 0.035), and a significantly shorter postoperative hospital stay. The postoperative levels of colloid osmotic pressure and albumin were significantly higher in the LS group.

CONCLUSION

The operative time of the LS group was longer than that of the OS group; however, the LS group experienced less blood loss and fewer complications. Moreover, LS was associated with a reduction in intraoperative infusions and a reduced fluid balance, which maintained homeostasis.

Do postoperative antibiotics prevent abscess formation in complicated appendicitis?

Recent studies have shown that postoperative antibiotics in nonperforated appendicitis do not reduce infectious complications; however, there is no consensus on patients with complicated appendicitis. The aim of this study is to determine whether postoperative antibiotic administration in complicated appendicitis prevents intra-abdominal abscess formation. We conducted a retrospective chart review of all patients undergoing appendectomy from 2007 to 2012 at our institution. Patients with complicated appendicitis (perforated, gangrenous, or periappendiceal abscess) were identified and data collected including details of postoperative antibiotic administration and rates of postoperative abscess development. Of 444 charts reviewed, 52 patients were included. Forty-four patients received greater than 24 hours and eight patients received 24 hours or less of postoperative antibiotics. In those receiving greater than 24 hours of antibiotics, nine of 44 (20.5%) developed a postoperative abscess, and in those receiving 24 hours or less of antibiotics, two of eight (25.0%) developed a postoperative abscess (P = 1.0000). There is no significant difference in postoperative abscess development among those with complicated appendicitis who received greater than 24 hours of postoperative antibiotics compared with those who did not. Postoperative antibiotics may not provide an appreciable clinical benefit for preventing intra-abdominal abscesses; however, larger sample sizes and prospective studies are needed to confirm these findings.

Patterns of urinary catheter consults in a tertiary care hospital

INTRODUCTION

We reviewed the consultation patterns for difficult urethral catheter placement in tertiary care hospitals and developed a treatment algorithm for this common request.

MATERIALS AND METHODS

We identified all urethral catheter consults obtained by urology residents at three tertiary care hospitals from October 2009 through October 2010. Only consults for inability to place urethral catheter by the referring team were included; hematuria or clot retention were excluded. Patient age, date of consultation, consulting service, prior urologic history, initial number of attempts, and final outcome were recorded.

RESULTS

Eighty-one consults were recorded. Seventy-seven (96%) were male; the median age was 65 years. The most common consulting services were internal medicine (35%), intraoperative consults (17%), and the intensive care unit (17%). In 90% of cases, an initial attempt at catheter placement was attempted; 62% of these were made by nurses. Over half of patients had known urologic pathology. In 70% of cases, successful placement without other adjuncts was achieved by the urology resident. Twenty percent of patients required cystoscopic manipulation; nine percent required suprapubic tube placement.

CONCLUSIONS

Catheterization was achieved without adjunct procedures in the majority of consults. These results support an algorithm in which all patients without a prior history of lower urinary tract pathology should undergo an initial placement attempt by the primary service physician. They also underscore the need for educational efforts to improve non-urologists' comfort level with placement of a standard Foley or Coudé catheter.

The silicone ring tourniquet in orthopaedic operations of the extremities

Tourniquets provide a bloodless field in limb operations and their introduction in orthopaedic operative technique has been considered as a landmark. A new tourniquet device, a silicone ring tourniquet (SRT) (HemaClear or S-MART, OHK Medical Devices, Haifa, Israel), was introduced into clinical practice a few years ago. A few clinical studies as well as comparative studies in volunteers have reported its use in a relatively small number of cases. The aim of this prospective study is to report the clinical use of this device in a large number of patients, including all possible applications of a tourniquet. The SRT was used in 536 cases including 337 male and 119 female patients with a mean age of 43.7 years (range 6 to 87 years). The average tourniquet time was 58.5 minutes (range 6 to 180 minutes). It was applied in 362 (67.5%) elective and in 174 (32.5%) trauma cases including fractures (n:109, 62.6%) and soft-tissue injuries (n:65, 37.4%). The most frequent application site was the femur (n:255, 47.6%), followed by the forearm (n:154, 28.7%), humerus (n:65, 12.1%), and calf (n:62, 11.6%). Because the device is sterile it was possible to use it in operations in which the pneumatic tourniquet cannot be used, such as open reduction and internal fixation of humeral shaft and femoral supracondylar fractures. In 14 patients (2.6%), the tourniquet failed intraoperatively, and the cause was an unexpected raised blood pressure. The SRT - with a pre-set pressure according to the size and the tension model - is easy to apply. It is sterile, and occupies a narrow area of the limb. Its application combines three functions at the same time: exsanguination, tourniquet, and stockinet application. Although it cannot entirely replace the classic pneumatic tourniquet, it is a safe and useful device in orthopaedic operations because of its advantages.

Effects of intraoperative colloid administration on outcome in a population-based general surgical cohort: a propensity score analysis

BACKGROUND

Many studies on colloids have recently been retracted, leaving us with uncertain evidence of their safety. We aimed to analyze whether intraoperative colloid administration is associated with postoperative complications.

METHODS

The prospectively compiled database of the ARISCAT study of a large, representative cohort of general surgical patients was reanalyzed to compare outcomes according to whether intraoperative colloids were administered or not; a propensity score was used to adjust for potential confounders. The primary outcomes were major postoperative complications. Secondary outcomes were postoperative hospital-free days within 90 days and mortality at 30 and 90 days. In a retrospective survey we asked each center's data collectors to estimate the proportions of the different colloids administered during the study period.

RESULTS

Of 2462 patients analyzed, 556 (22.6%) received some type of colloid intraoperatively. The median (25th-75th percentile) of total fluids administered was significantly higher in patients receiving colloids (10.0 [6.9-14.1] mL·kg-1·h-1 vs. 8.8 [6.0-12.8] mL·kg-1·h-1 for patients not receiving colloids; P<0.01). The median volume of colloids administered was 7.5 (6.3-10.4) mL·kg-1. An estimated 75.7% of the patients received third-generation hydroxyethyl starches (130/0.4). Significantly associated complications, after propensity score adjustment, were atelectasis, respiratory infection, bronchospasm, arrhythmia, sepsis, paralytic ileum, and hyperglycemia. Patients receiving colloids had 1.9 fewer postoperative hospital-free days (P<0.006). There were no significant differences in 30- and 90-day mortality.

CONCLUSION

Our study suggests an association of intraoperative colloid administration, mainly of 130/0.4 hydroxyethyl starches, with diverse major postoperative complications and longer hospital stay. Controlled studies are urgently needed to assess the safety profile of colloid use in surgical patients.

Intraoperative consultation in digestive surgery. A consecutive series of 800 frozen sections

AIM

To assess indications and quality of frozen sections in digestive surgery.

PATIENTS AND METHODS

All the frozen sections from the department of digestive surgery from Amiens hospital performed between 01/07/2006 and 01/07/2010 were assessed. Assessment of frozen section forms, reading of pathology reports, and reviewing of frozen section slides were performed.

RESULTS

Eight hundred frozen sections were performed in 349 patients. From one to 14 surgical specimens were sent for frozen section (mean 2.3). Frozen sections were performed in 77% of the cases for cancer surgery (n=268), most of the time pancreatic surgery (28.4%) and liver surgery (24.6%). Frozen sections were performed in 69% of the cases for diagnosis, in 29% of the cases to assess surgical margins and in 2% of the cases to assess if tissue specimen was appropriate for pathological diagnosis. Frozen sections were sent all days of the week (except Saturday and Sunday), during all the year, between 8 H 30 and 17 H 15. Thirty-seven percent of the cases were sent between 12 H and 14 H. Response time was 15 minutes (3 to 57 minutes). Rate of differed diagnoses was 2%. Rate of discordant diagnoses was 3.4%.

CONCLUSION

Frozen section is a rapid and accurate tool in digestive surgery. Local adjustment of the organization of the Pathology Department could enhance the rapidity and the quality of pathology diagnoses.

The method and accuracy of documentation of intraoperative fluids management in liver transplantation recipients

BACKGROUND

In liver transplantation, blood loss can be massive, requiring timely and rapid fluid resuscitation. Maintaining proper documentation of fluids during such situations can be difficult and may often lead to counting errors. We report our method of documentation of fluid management during liver transplantation.

MATERIAL/METHODS

Each unit of red blood cells (125 cc) that comes from the blood bank had a serial number of 10 Arabic numbers which were verified and double-checked. Each unit was then numbered and labeled as encircled absolute numbers (e.g., 1, 2, 3). Both the encircled number and the serial number of the bag were recorded in the anesthesia chart. Each liter of crystalloids and colloids were similarly numbered and labeled in sequence for ease of calculation. At the end of the operation, the nurse anesthetist ascertains that the number of units of blood products used matched with the number of units supplied by the blood bank. The total amounts of crystalloids and colloids given during the operation was also calculated, rechecked and written in a tabulated form.

RESULTS

Since the introduction of this method, we have detected and readily corrected 3 incidences of counting discrepancy in the total units of blood products transfused and the products supplied by the blood bank. Moreover, our records have now become transparent data that are easily retrievable for future scientific research.

CONCLUSIONS

Our method of documentation of fluid management during liver transplantation is easy, accurate and effective.

Inflammation affects sufentanil consumption in ulcerative colitis

BACKGROUND

Previous studies have demonstrated an increased perioperative opioid requirement during inflammatory disease. To evaluate the influence of the inflammatory process, we studied in the same patient the sufentanil requirement during procedures that occur during two distinct phases of ulcerative colitis with different inflammatory profiles: (1) left colectomy for major colitis unresponsive to medical treatment during acute inflammation and (2) coloprotectomy with ileoanal anastomosis, three months after recovery of the acute inflammatory episode.

METHODS

Sixteen patients with clinical and histological evidence of ulcerative colitis scheduled for colectomy with ileoanal anastomosis were included. For each surgical procedure, anaesthesia was induced with sufentanil 0.5 microg kg(-1) and propofol 2 mg kg(-1). Patients were ventilated with 50% nitrous oxide and oxygen, and tidal volume was adjusted to keep end-tidal CO2 at 30 mmHg. Anaesthesia was maintained with end-tidal isoflurane at 0.5%. Analgesia was achieved with continuous infusion of sufentanil at 0.3 microg kg(-1) h(-1). Additional boluses of sufentanil and increases in infusion rates were used when haemodynamic variables increased to more than 20% of preoperative values. Sufentanil consumption during surgery was analysed by Wilcoxon signed rank sum test. P < 0.05 was considered significant.

RESULTS

Total intra-operative sufentanil requirement was significantly larger during colectomy performed for acute inflammatory colitis than during ileoanal anastomosis performed after the inflammatory process (1.24 +/- 0.48 microg kg(-1) h(-1) vs. 0.62 +/- 0.3 microg kg(-1) h(-1); P < 0.05).

CONCLUSION

For the same patient, inflammatory status influences opioid requirements during surgery for ulcerative colitis.

Sentinel node and vulvar cancer: a series of 47 patients

BACKGROUND

There is growing interest to apply the sentinel node technique in the treatment of vulvar cancer.

METHODS

All charts of the patients operated on for vulvar cancer at Tampere University Hospital from January 1, 2001 through June 30, 2005 were retrospectively reviewed. Demographic, clinical, and histopathological information was collected from each patient. The sentinel lymph node mapping was done intraoperatively either with a combination of the radioisotope and dye techniques (40 patients) or with the dye technique alone (7 patients). The sentinel lymph node was dissected separately for histopathological evaluation, and then a routine inguinal lymphadenectomy was performed.

RESULTS

The final FIGO surgical Stage distribution was: Stage I, 11 (23%); Stage II, 14 (30%); Stage III, 21 (45%); and Stage IV, 1 (2%). Sentinel lymph node was identified in 46 (98%) women with either one or both of the methods. In Stage I-II, the sentinel lymph node identification rate was 25/25 (100%) with the combined method. The only patient with unidentified sentinel lymph node had lymphatic spread beyond inguinal area or Stage IV disease. Eighteen of the sentinel lymph nodes (39%) were positive for tumor cells, and in 5 cases additional metastatic nodes were found. One patient with macroscopically enlarged metastatic inguinal nodes and Stage III disease had a negative sentinel lymph node. In the 25 patients with Stage I-II disease, the false-negative rate of the sentinel lymph node method was 0/4, giving a negative predictive value of 1.00.

CONCLUSIONS

A sentinel node identification rate of 98% with a false-negative rate of 0% in the patients with Stage I-II disease is an encouraging finding.

Long-term results of intraoperative presacral electron boost radiotherapy (IOERT) in combination with total mesorectal excision (TME) and chemoradiation in patients with locally advanced rectal cancer

BACKGROUND

We analyzed the long-term results of patients with locally advanced rectal cancer using a multimodal approach consisting of total mesorectal excision (TME), intraoperative electron-beam radiation therapy (IOERT), and pre- or postoperative chemoradiation (CRT).

PATIENTS AND METHODS

Between 1991 and 2003, 210 patients with locally advanced rectal cancer (65 International Union Against Cancer [UICC] Stage II, 116 UICC Stage III, and 29 UICC Stage IV cancers) were treated with TME, IOERT, and preoperative or postoperative CHT. A total of 122 patients were treated postoperatively; 88 patients preoperatively. Preoperative or postoperative fluoropyrimidine-based CRT was applied in 93% of these patients.

RESULTS

Median age was 61 years (range, 26-81). Median follow-up was 61 months. The 5-year actuarial overall survival (OS), disease-free survival (DFS), local control rate (LC), and distant relapse free survival (DRS) of all patients was 69%, 66%, 93%, and 67%, respectively. Multivariate analysis revealed that UICC stage and resection status were the most important independent prognostic factors for OS, DFS, and DRS. The resection status was the only significant factor for local control. T-stage, tumor localization, type of resection, and type of chemotherapy had no significant impact on OS, DFS, DRS, and LC. Acute and late complications > or =Grade 3 were seen in 17% and 13% of patients, respectively.

CONCLUSION

Multimodality treatment with TME and IOERT boost in combination with moderate dose pre- or postoperative CRT is feasible and results in excellent long-term local control rates in patients with intermediate to high-risk locally advanced rectal cancer.

Development of an Objective Scoring System for Measurement of Resident Performance on the Human Patient Simulator

Background

The decrease in the percentage of patients having cesarean delivery during general anesthesia has led some educators to advocate the increased use of simulation-based training for this anesthetic. The authors developed a scoring system to measure resident performance of this anesthetic on the human patient simulator and subjected the system to tests of validity and reliability.

Methods

A modified Delphi technique was used to achieve a consensus among several experts regarding a standardized scoring system for evaluating resident performance of general anesthesia for emergency cesarean delivery on the human patient simulator. Eight third-year and eight first-year anesthesiology residents performed the scenario and were videotaped and scored by four attending obstetric anesthesiologists.

Results

Third-year residents scored an average of 150.5 points, whereas first-year residents scored an average of 128 points (P = 0.004). The scoring instrument demonstrated high interrater reliability with an intraclass correlation coefficient of 0.97 (95% confidence interval, 0.94-0.99) compared with the average score.

Conclusions

The developed scoring tool to measure resident performance of general anesthesia for emergency cesarean delivery on the patient simulator seems both valid and reliable in the context in which it was tested. This scoring system may prove useful for future studies such as those investigating the effect of simulator training on objective assessment of resident performance.

Anesthesia monitoring by registered nurses during cataract surgery: Assessment of need for intraoperative anesthesia consultation

PURPOSE

To assess the frequency and risk factors for intraoperative anesthesia consultation when performing cataract surgery monitored by registered nurses.

SETTING

Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA.

METHODS

This retrospective review was of 270 cataract surgeries performed under local anesthesia from April 1, 2002, to April 1, 2003.

RESULTS

The American Society of Anesthesiologists (ASA) classification of each patient was determined: 1 patient was classified as ASA 1. One hundred fifty patients were classified as ASA 2. One hundred nineteen patients were classified as ASA 3. The anesthesiology department was consulted 24 times. Nineteen consultations involved patients who were ASA 3, and 5 consultations involved patients who were ASA 2 (P<.001). In most cases (23 of 24), the anesthesia service provided a consultation (eg, increase oxygen flow rate, clarification of electrocardiogram, start intravenous line, equipment repair) and left the nurses to continue to monitor the patient. In only 1 case (ASA 3), the anesthesia service converted the case to monitored anesthesia care and relieved the nurse to monitor the patient.

CONCLUSIONS

In this study, monitoring of routine cataract surgery by registered nurses was associated with a low rate of intraoperative anesthesia consultation. Most consultations resulted in little intervention. The ASA classification appears predictive of the need for intraoperative anesthesia consultation.

[Decreased number of R1-resections in radical retropubic prostatectomy. Use of a newly developed fast sectioning technique]

Therapeutic success and prognosis in RRP is determined by negative surgical margins. In order to minimize the proportion of positive surgical margins in the final histological evaluation, valid intraoperative control by means of frozen margin analysis is indispensable. We have developed and evaluated a new frozen margin procedure based on the Stanford method with transverse and sagittal cut directions. This technique facilitates comprehensive intraoperative evaluation of curved margin areas for the first time. Retrospective analysis of the results of the new frozen section technique revealed positive surgical margins in 2.7% of patients. The results obtained with this new technique were significantly superior to those obtained with two established techniques (10.3%, P < or =0.001; 17.2%, P < or =0.001). Our results demonstrate that the new frozen margin technique is clearly more sensitive for intraoperative detection of positive margins and thus leads to substantially higher rates of negative surgical margins.

Influence of head position on the effectiveness of twist drill craniostomy for chronic subdural hematoma

BACKGROUND

Twist drill craniostomy with closed system drainage (TDC-CSD) is a well-accepted treatment of chronic subdural hematomas (CSDH). Although this intervention has a long track record of effectiveness, little is known of its relationship with the head position of the patient (flat vs elevated). This study evaluated if the position of the patient's head influences outcome.

METHODS

The database of a University Hospital Center was queried for patients who had CSDH treated by TDC-CSD between January 1997 and March 2001. Identified patients were grouped into 2 categories: head of bed (HOB) at 30% and HOB flat while undergoing treatment. Outcomes were then evaluated with regard to amount of drainage, complications, recurrence, and length of hospital stay (LOS).

RESULTS

Forty-four patients were identified who received TDC-CSD treatment of CSDH. Of these, 24 patients had flat HOB and 20 had HOB elevated to 30 degrees . Although patients with elevated HOB had higher amounts of drainage (239 vs 166 mL), this figure did not reach statistical significance (P = .23). The number of recurrences and complications likewise did not reach statistical significance. Despite these findings, a statistically significant difference in LOS was found between the groups (flat = 5.5 days, elevated = 8.1 days, P = .03). This was believed secondary to bias resulting from placing the HOB of healthier patients (based on Glasgow Coma Scale) flat.

CONCLUSIONS

Elevation of the patient's head during TDC-CSD treatment of CSDH does not seem to impact the amount of drainage, recurrence frequency, or complication rate. Although a statistically significant difference in LOS was observed based on this variable, it appeared to be the result of bias in patient selection for HOB elevation.

[Suitability of intraoperative autotransfusion]

This work presents the procedure applied by our hospital to assess the quality and security of intra operative autotransfusion. The suitability of the three following variables has to be constantly assessed: performance of the machines to concentrate and wash collected blood, bacterial contamination of processed blood and rate of adverse events. We note that the procedure is applied with participation of medical and nursing staff. Since its setting-up, we note an amelioration of suitable variables.

Effects of Intraoperative Blood Salvage on Leukocyte Recruitment to the Endothelium

Background

The contamination of salvaged wound blood with activated leukocytes has been suspected to play a role in leukocyte-mediated tissue injury by increased adhesion to the endothelium. To verify this hypothesis, the authors performed a clinical study to examine the effects of blood salvage on leukocyte-endothelial interactions.

Methods

Expression of L-selectin, CD18, and CD11b and leukocyte adhesion to activated endothelium from human umbilical veins were measured in 25 patients undergoing major orthopedic surgery. Adhesion of fluorescently labeled leukocytes was examined in a flow chamber at shear rates of 50-1,600 s. Comparisons were made between samples from venous blood and from processed salvaged wound blood (SWB).

Results

At 30% hematocrit, SWB contained 2,162 +/- 147 leukocytes/microl. In comparison with venous blood, CD11b was up-regulated in SWB 1.3- to 3.6-fold on monocytes and neutrophils, whereas L-selectin and CD18 decreased on monocytes by 53% and 15%, respectively (P &lt; 0.05). Despite up-regulation of CD11b, firm adhesion was significantly reduced by 74-76% in SWB. Rolling fractions and rolling velocities were significantly higher in SWB, and their relation to shear rate was markedly altered (P &lt; 0.01). In addition, adherent leukocytes from SWB were significantly less resistant to increments of shear rate than leukocytes from venous blood (P &lt; 0.01).

Conclusions

Despite up-regulated CD11b, integrin-mediated adhesion is markedly impaired in salvaged blood. Therefore, the effect of blood salvage cannot be predicted from cell surface expression but rather from functional assays. The former hypothesis, that leukocytes from SWB aggravate leukocyte-mediated tissue injury by increased adhesion, may not be as great a concern as previously suggested.

Intraoperative single fraction high-dose-rate brachytherapy for head and neck cancers

PURPOSE

To report on the use of single fraction high-dose-rate brachytherapy in delivering localized intraoperative radiation therapy to sites in the head and neck region inaccessible to intraoperative electron beam radiotherapy (IOERT).

METHODS AND MATERIALS

After maximal surgical resection, 7.5-20 Gy intraoperative high-dose-rate brachytherapy (IOHDR) was delivered to 65 patients using custom-made surface applicators.

RESULTS

The 1-, 3-, and 5-year local control rates for the entire group were 77%, 69%, and 59%, respectively. The 1-, 3-, and 5-year overall survival rates were 83%, 63%, and 42%, respectively, with a median overall survival of 50 months. There were no major intraoperative or postoperative complications.

CONCLUSIONS

IOHDR can be used to treat selected locally advanced head and neck tumors arising at sites inaccessible to IOERT or at institutions not using IOERT. A prospective multi-institutional study with a larger number of patients treated with IOHDR is needed to firmly establish the efficacy of IOHDR in this population group.

Pathological approach to breast conserving therapy

There is no uniformly accepted definition of a positive margin in breast conserving surgery. In 1999, the Japanese Breast Cancer Society created the Guidelines for Breast-Conserving Treatment (GBCT). At that time, we did a questionnaire survey about the definition of margin status. Although 57.1% of hospitals/institutes used the definition of cancer cells present at the surface, the GBCT adopted the definition of cancer cells present within 5 mm of the surface. Moreover, the GBCT required that the distance between the edge of the cancer cells and the surface be recorded in millimeters when cancer cells were present within 5 mm of the surface. The risk factors for local recurrence after breast-conserving treatment were studied. From 1986 to 1995, 391 patients were treated with breast-conserving surgery at Osaka Medical Center for Cancer and Cardiovascular Diseases. Of these, 35 patients developed local recurrence. Multivariate analysis showed that positive margin (p=0.0002), high degree of ductal proliferative change around the tumor (p=0.0035) and high histological grade (p=0.0041) were significant independent risk factors for local recurrence, while radiation therapy (p=0.0327) significantly reduced local recurrence. There was no significant difference in the risk of local recurrence between the two different definitions of positive margin (tumor present at the surface and tumor present within 5 mm from the surface). It is hoped that more hospitals/institutes will adopt the definition of margin positivity presented by the GBCT and that a practical definition of margin positivity will be established.

Clinical Outcome of Perioperative Airway and Ventilatory Management in Children Undergoing Craniofacial Surgery

Data on the management of perioperative airway and ventilatory support in children undergoing craniofacial surgery are limited. The purpose of this study was to review the authors' experience with airway management and ventilatory support during the perioperative period in children undergoing craniofacial surgery. Ninety-five consecutive children underwent 99 craniofacial procedures from July 1, 1999, through June 30, 2002. Direct laryngoscopy was successfully used to establish an airway in 86 (86.8%) cases, whereas 13 (13.1%) cases required the use of fiberoptic bronchoscopy to establish an airway before surgery. The oral route was used in 82 (83%) cases, and the nasal route was used in 17 (17%) cases. Length of anesthesia was 330 +/- 160 minutes, and the actual surgical time was 246 +/- 151 minutes. The volume of crystalloids infused during surgery was 87 +/- 78 mL/kg body weight (BW), and the volume of packed red blood cells infused during surgery was 10 +/- 14 mL/kg BW (range, 0-60 mL/kg BW). Tracheal extubation was successfully accomplished in the postanesthesia recovery unit (PACU) in 57 (58%) patients, whereas 42 patients were admitted to the pediatric intensive care unit (PICU) and received mechanical ventilation for 10 +/- 9 hours (range, 1-60 hours). Of these, 37 (37%) were extubated in the PICU, whereas 5 patients were extubated in the operating room with the craniofacial surgeon in attendance in the event an emergency tracheostomy was needed. However, none of these patients required tracheostomy to maintain a secure airway. Three patients required reintubation after the first attempt at tracheal extubation in the PICU. All three of those patients subsequently were extubated without the need for tracheostomy. The length of tracheal intubation and mechanical ventilation was longer (24 +/- 13 hours versus 8.6 +/- 7 hours, P < 0.001) in patients who required bronchoscopic intubation than in those who were intubated using direct laryngoscopy. The length of hospital stay, although clinically relevant, did not reach statistical significance between the two groups (5 +/- 7 days versus 3.7 +/- 2.7 days, P = 0.5). A positive correlation was observed between the duration of tracheal intubation and mechanical ventilation and the following perioperative factors: anesthesia time (rho = 0.6, P < 0.01), surgical time (rho = 0.55, P < 0.01), volume of crystalloids (rho = 0.5, P < 0.01), and the volume of packed red blood cells infused (rho = 0.55, P < 0.01) during surgery. No episodes of cardiorespiratory arrest or death occurred in any of the patients. This study demonstrates that when performing complex craniofacial procedures in children, a thorough evaluation of the airway before surgery and continuous communication between specialists during the perioperative period is imperative for a successful outcome. Furthermore, most pediatric patients who require mechanical ventilation during the postoperative period do so for a short period of time following surgery.

Achieving vascular access success in the quality outcomes era

BACKGROUND

In 1997 the National Kidney Foundation put forth guidelines for hemoaccess through its Dialysis Outcomes Quality Initiative (DOQI). Some centers have been able to meet these standards; most have not.

METHODS

A retrospective review was made of our database of more than 3,500 hemoaccess procedures from 1986 to 2003.

RESULTS

Our approach, increased use of transposed fistulas and preoperative duplex mapping, has led to a fistula incidence (84%) and prevalence (54%) exceeding DOQI criteria. Meeting the DOQI guideline for thrombectomy rate (0.5 per year) is mostly achieved by increased use of fistulas. Additionally, access monitoring, as well as intraoperative angiography, angioplasty, stenting, and surgical revision, can aid in decreasing the frequency of occlusions (0.45 per year). This operative approach has led to a 98% success rate for surgical thrombectomy, exceeding the DOQI guideline of 85%. Earlier referrals from nephrologists have lowered the catheter use prevalence to 9%.

CONCLUSIONS

An aggressive approach to placing fistulas, maintaining the access, and receiving prompt referrals can lead to success in meeting DOQI criteria.

Is male gender a risk factor for bile duct injury during laparoscopic cholecystectomy?

BACKGROUND

Since its introduction in the late 1980s laparoscopic cholecystectomy has become the treatment of choice for gallstone disease. Unfortunately, the rate of iatrogenic biliary duct injuries (BDIs) has at least doubled after the adoption of the laparoscopic method. Population-based studies reporting the distribution of laparoscopic BDI patients according to gender and the severity of the BDI are mostly lacking. The purpose of the present study was to analyze the BDIs sustained during laparoscopic cholecystectomy in and around Turku University Central Hospital, with a special reference to the distribution of patients according to gender and the severity of the BDI.

PATIENTS AND METHODS

A total of 3,736 laparoscopic cholecystectomies (2,627 female patients, 1,109 male) was performed in and around Turku University Central Hospital from 1995 to 2002 (by the end of April). The number and severity of BDIs and the gender of BDI patients were recorded, and the risk of BDI during laparoscopic cholecystectomy was calculated for the total patient population and for both genders separately.

RESULTS

The risk of BDI was 0.86% for the total patient population, 0.95% for female and 0.63% for male. The most conspicuous finding was that the female gender was predominant in the severe types of BDI. However, the risk of mild BDI seemed to be fairly equal in both genders.

CONCLUSION

We conclude that female gender seems to be a risk factor for severe iatrogenic BDI during laparoscopic cholecystectomy.

Intraoperative lymphatic mapping and sentinel lymph node biopsy in patients with papillary carcinoma of the thyroid gland

We examined the feasibility of sentinel lymph node biopsy for thyroid cancer. Thirty-eight patients with papillary thyroid carcinoma underwent intraoperative lymphatic mapping and sentinel lymph node biopsy. At surgery, we exposed the thyroid gland and used a tuberculin syringe to inject 0.2 ml of 1% patent blue dye directly into the thyroid mass. The lymphatics and the lymph node dyed with blue dyes, was excised as a sentinel lymph node. Modified radical neck dissection was performed following sentinel lymph node biopsy and the diagnostic ability of sentinel lymph node biopsy was examined. A sentinel lymph node was identified successfully in 27 (71%) of 38 patients. Sentinel lymph node biopsy removed one to three lymph nodes (median, two nodes). Eighteen patients had paratracheal sentinel lymph nodes, five patients had jugular sentinel lymph nodes, and four patients had both. Histological nodal metastasis was recognized in 16 of 27 cases. The positive rate of cancer metastases in sentinel lymph nodes was 58%, which was significantly higher than 11% in non-sentinel lymph nodes. Diagnostic ability of sentinel lymph node biopsy showed that accuracy was 89%, sensitivity was 84%, and specificity was 100%. Our preliminary study indicated that sentinel lymph node biopsy was available on detection of non-palpable nodal metastasis in the patients with thyroid cancer; however, further experience and refinement are needed.

[An analysis on blood transfusion for hepatic resection]

BACKGROUND

Hepatic resection is prone to significant blood loss. Adverse effects of blood loss and transfusion mandate improvements in surgical techniques to reduce blood loss and transfusion.

METHODS

We retrospectively analyzed the present status of intraoperative blood transfusion practice of 42 hepatic resections in National Kure Medical Center for the year of 2000.

RESULTS

Median values for blood loss were 1355, 1708, 1415, and 2298 ml for nonanatomic, subsegmental, segmental and extended right resections, respectively. Crossmatched to transfused blood (C/T) ratios were 1.76, 1.19, 2.31, and 0.90 for nonanatomic, subsegmental, segmental and extended right resections, respectively.

CONCLUSION

In general, C/T ratio of 1.5 to 2.5 has been recommended but own C/T ratios are 1.19 and 0.9 for subsegmental and extended right hepatic resection, which are lower than recommended values. It was estimated that inappropriate prediction of blood loss by several surgeons and unused maximum surgical blood order schedule (MSBOS) or type and screen (T&S) decreased these values of C/T ratio in the present analysis. We therefore conclude that MSBOS and T&S could be improved by avoiding such in appropriate prediction.

Tranexamic acid given intraoperatively reduces blood loss after total knee replacement: a randomized, controlled study

BACKGROUND

Extensive blood loss in total knee replacement (TKR) surgery is well known and is associated with a high transfusion rate of allogenic blood. Tranexamic acid (TXA) has been shown to reduce blood loss by 50% in this patient group, but only in cases with a perioperative loss of 1400-1800 ml. This study was performed to see if TXA offers any advantages in knee replacement surgery with blood loss at 800 ml.

METHODS

Thirty consecutive patients scheduled for TKR in spinal anesthesia with the use of a tourniquet, were randomized to TXA or non-TXA. Tranexamic acid 10 mg kg-1 was given at conclusion of surgery and again 3 h later. Blood loss was registered.

RESULTS

Total blood loss was at all times significantly lower in the TXA group compared to the non-TXA group (409.7+/-174.9 ml vs. 761.7+/-313.1 ml; P<0.001). There were no differences in coagulation parameters. No patients in the TXA group had a blood transfusion vs. 13% in the non-TXA group (NS). No complications were registered in the two groups.

CONCLUSION

We conclude that TXA significantly reduces blood loss after total knee replacement surgery.

Influence of pre- or intraoperational use of tramadol (preemptive or preventive analgesia) on tramadol requirement in the early postoperative period

The aim of this study was to assess the influence of iv tramadol on opioid requirement in the early postoperative period. The subjects were 90 patients scheduled for colon surgery (hemicolectomy) who received general anesthesia using the (N2O/O2) isoflurane technique. Thirty patients (group I) were administered 100 mg of tramadol iv before induction of general anesthesia (preemptive analgesia). Group II (30 patients) was administered 100 mg of tramadol iv immediately after peritoneal closure (preventive analgesia) and control group (30 patients) received 100 mg of tramadol iv immediately after operation. Following the operation, all patients were administered tramadol in the PCA-iv mode in order to treat postoperative pain. In the postoperative period, the following parameters were measured: pain intensity (using VAS), total consumption of tramadol, time until the first PCA activation, and frequency of side effects (drowsiness, nausea, vomiting). In patients of groups I and II who had received preemptive or preventive analgesia, a significantly lower total consumption of tramadol, as compared with control group, was observed in the early postoperative period. However, the time until the first PCA activation was significantly shorter in group I as compared to the other two groups. No significant differences between the groups were found regarding pain intensity and frequency of side effects.

Preoperative blood volume deficit influences blood transfusion requirements in females and males undergoing coronary bypass graft surgery

STUDY OBJECTIVE

To evaluate whether preoperative blood volume and postoperative blood loss influence blood transfusion in females and males undergoing coronary artery bypass graft (CABG) surgery.

DESIGN

Prospective study.

SETTING

Anesthesiology department of a teaching hospital.

PATIENTS

57 CABG patients (21 females and 36 males).

MEASUREMENTS

Blood volume was determined using the radioactivity dilution method. Preoperatively, each patient received intravenous (IV) injection of 1 mL Albumin I(131) tracer having 25 microcuries of radioactivity. Five-milliliter blood samples were collected at different intervals. From these samples, hematocrit (Hct) value, preoperative total blood volume, red blood cell (RBC) volume, and plasma volume were determined. Postoperatively, some consenting patients received another 1 mL dose of the tracer, and the postoperative blood volumes were determined. If a patient received a blood transfusion, the units of packed red blood cells (PRBCs), platelets, or fresh frozen plasma (FFP) transfused were recorded. For each patient we recorded the gender, age, weight, height, body surface area (BSA), preoperative Hct, duration of surgery, and discharge Hct.

RESULTS

Preoperatively, the mean total blood volume, RBC volume, and plasma volume, respectively, were 2095 mL/m(2), 631 mL/m(2), and 1,465 mL/m(2) in females; and 2,580 mL/m(2), 878 mL/m(2), and 1,702 mL/m(2) in males. The preoperative blood volumes were significantly lower (p < 0.01) in females than in males. There was no significant difference between males and females in the extent of blood loss during CABG. Intraoperatively, females received PRBC transfusion of 1.38 units, significantly more (p < 0.01) than the 0.39 units received by males. During the entire hospital stay, females received 4.33 units of PRBC, significantly more than (p < 0.02) the 1.33 units received by males. Significantly more (p < 0.01) females (12 of 21) received intraoperative PRBC transfusion than did males (6 of 36). Multiple logistic regression analysis of the data showed that PRBC transfusion was significantly correlated with the preoperative total blood volume and RBC volume.

CONCLUSION

The greater need for blood transfusion in females than in males during CABG is primarily attributable to significantly lower preoperative total blood volume and RBC volume in females.

Survey on adoption of measures to prevent nosocomial infection by anaesthesia personnel

To assess the knowledge, attitudes and practices of anaesthesia personnel regarding infection control in hospitals, a questionnaire was distributed to anaesthesiology personnel of different educational levels in the hospitals of southern Islamic Republic of Iran. Chi-squared significance, Fisher exact and Spearman rho correlation coefficient tests were used to analyse the responses. The results suggest that measures to prevent infection transmission during anaesthesia are inadequate in our hospitals. The implementation of adequate measures to control infection was significantly associated with respondents' beliefs as to whether anaesthesia can cause infection in anaesthesia personnel and/or patients. Increasing the knowledge base of anaesthesia personnel and raising their awareness as to the risk of infection are necessary to improve infection control procedures by anaesthesia personnel.