Jeffrey A. Green

Developing a blood conservation program in cardiac surgery

The beneficial effects of blood transfusions have been described and widely accepted. Multiple factors, including shortages, costs, infectious risks, immunologic risks, and the risk/benefit ratio to the patient, have made the medical community reassess the guidelines for transfusion. Cardiac surgery presents a unique subset of patients, because intervention at multiple stages in the care of these patients is possible to decrease the need for transfusion. An algorithm for a cardiac surgery program was developed and a reassessment performed. Once it was seen that no detrimental effect on patient care occurred, the program was expanded, was enhanced, and subsequently has been offered to the rest of the health care system. This program has resulted in a decrease in cost while maintaining patient outcomes. The success of the program is believed to be a result of the multidisciplinary approach taken, with a commitment from all members of the blood reduction team being the key component of this success.

Current status of antifibrinolytics in cardiopulmonary bypass and elective deep hypothermic circulatory arrest

Cardiopulmonary bypass (CPB) results in many physiologic derangements, including activation of the hemostatic and fibrinolytic pathways. Deep hypothermic circulatory arrest (DHCA) adds a further insult to the coagulation systems because it involves more extreme hypothermia and organ ischemia related to blood stasis. The abnormalities induced by CPB disrupt the checks and balances in the hemostatic and fibrinolytic systems, resulting in a pathologic state that leads to excessive bleeding and other perioperative complications. Prophylactic antifibrinolytic therapy can attenuate the response to this insult by restoring the delicate balance within these systems, potentially reducing the complication rate and improving patient outcomes.

Shortcomings and Challenges of Information System Adoption

The number of institutions implementing AIMS is increasing. Shortcomings in the design and implementation of EMRs have been associated with unanticipated consequences, including changes in workflow. These have often resulted from the carryover of paper-based documentation practices into an electronic environment. The new generation of mobile devices allows providers to have situational awareness of multiple care sites simultaneously, possibly allowing for improved proactive decision making. Although potentially facilitating safer anesthetic supervision, technologic and cultural barriers remain. Security, quality of information delivery, regulatory issues, and return on investment will continue as challenges in implementing and maintaining this new technology.

Anesthesia Recordkeeping: Accuracy of Recall with Computerized and Manual Entry Recordkeeping

Anesthesia information management systems (AIMS) are rapidly gaining widespread acceptance. Aggressively promoted as an improvement to manual-entry recordkeeping systems (MERS) in the areas of accuracy, quality improvement, billing and vigilance, these systems record all patient vital signs and parameters, providing a legible hard copy and permanent electronic record. Concern exists that the practitioner may be less vigilant unless this data is recorded manually. This study’s purpose was to determine if vigilance, as measured by the ability to recall important data, is influenced by the method of recordkeeping. This study analyzed differences in the accuracy of Certified Registered Nurse Anesthetists’ (CRNAs) recall of specific patient variables during the course of an actual anesthetic case. CRNAs using AIMS were compared to CRNAs using MERS. Accuracy of recalled values of 10 patient variables was measured: highest and lowest values for heart rate, systolic blood pressure, inspiratory pressure, and end-tidal carbon dioxide levels, lowest oxygen saturation and total fluid volume. Four tertiary care facilities participated in this research; two of which used MERS, two utilized AIMS. A total of 214 subjects participated in this study; 106 in the computerized recordkeeping group, and 108 in the manual entry recordkeeping group. Demographic covariates were analyzed to ensure homogeneity between groups and facilities. No significant statistical differences were identified between the accuracy of recall among the groups. There was no difference in the accuracy of practitioners’ recall of patient variables when using computerized or manual entry recordkeeping systems, suggesting little impact on vigilance.