John E. Forestner

Allogeneic blood transfusion increases the risk of postoperative bacterial infection: A meta-analysis

Background: Immunosuppression is a consequence of allogeneic (homologous) blood transfusion (ABT) in humans and is associated with an increased risk in cancer recurrence rates after potentially curative surgery as well as an increase in the frequency of postoperative bacterial infections. Although a meta-analysis has been reported demonstrating the relationship between ABT and colon cancer recurrence, no meta-analysis has been reported demonstrating the relationship of ABT to postoperative bacterial infection. Methods: Twenty peer-reviewed articles published from 1986 to 2000 were included in a meta-analysis. Criteria for inclusion included a clearly defined control group (nontransfused) compared with a treated (transfused) group and statistical analysis of accumulated data that included stepwise multivariate logistic regression analysis. In addition, a subgroup of publications that included only the traumatically injured patient was included in a separate meta-analysis. A fixed effects analysis was conducted with odds ratios obtained by using the conditional maximum likelihood method and 95% confidence intervals on the obtained odds ratios were determined using the mid-p technique. Results: The total number of subjects included in this meta-analysis was 13,152 (5,215 in the transfused group and 7,937 in the nontransfused group). The common odds ratio for all articles included in this meta-analysis evaluating the association of ABT to the incidence of postoperative bacterial infection was 3.45 (range, 1.43-15.15), with 17 of the 20 studies demonstrating a value of p < or = 0.05. These results provide overwhelming evidence that ABT is associated with a significantly increased risk of postoperative bacterial infection in the surgical patient. The common odds ratio of the subgroup of trauma patients was 5.263 (range, 5.03-5.43), with all studies showing a value of p < 0.05 (0.005-0.0001). These results demonstrate that ABT is associated with a greater risk of postoperative bacterial infection in the trauma patient when compared with those patients receiving ABT during or after elective surgery. Conclusion: These results demonstrate that ABT is an associated and apparently significant and frequently overlooked risk factor for the development of postoperative bacterial infection in the surgical patient. Allogeneic blood transfusion is a greater risk factor in the traumatically injured patient when compared with the elective surgical patient for the development of postoperative bacterial infection.

A Massive Transfusion Protocol to Decrease Blood Component Use and Costs

HYPOTHESIS A massive transfusion protocol (MTP) decreases the use of blood components, as well as turnaround times, costs, and mortality. DESIGN Retrospective before-and-after cohort study. SETTING Academic level I urban trauma center. PATIENTS AND METHODS Blood component use was compared in 132 patients during a 2-year period following the implementation of an MTP; 46 patients who were treated the previous year served as historical control subjects. INTERVENTION Introduction of an MTP that included recombinant factor VIIa for patients with exsanguinating hemorrhage. MAIN OUTCOME MEASURES The amount of each blood component transfused, turnaround times, blood bank and hospital charges, and mortality rates. RESULTS After introduction of the MTP, there was a significant decrease in packed red blood cells, plasma, and platelet use. The turnaround time for the first shipment was less than 10 minutes, and the time between the first and second shipments was reduced from 42 to 18 minutes, compared with historical controls. The decreased use of blood products represented a savings of

Fast-tracking after outpatient laparoscopy: Reasons for failure after propofol, sevoflurane, and desflurane anesthesia

2270 per patient or an annual savings of

Technics for Fiberoptic Laryngoscopy in Anesthesia

200, 000, despite increased costs for recombinant factor VIIa. There was no difference in mortality in either group; it remained around 50%. Thromboembolic complications did not increase, despite a significant increase in the use of recombinant factor VIIa. CONCLUSIONS The MTP resulted in a reduction in the use of blood components with improved turnaround times and significant savings. Mortality was unaffected. The use of recombinant factor VIIa did not increase thromboembolic complications in these patients.

Inadvertent epidural injection of thiopental: a case report.

IMPLICATIONS In this study, although 41%-94% of the patients were fast-track eligible after laparoscopic surgery, only 35%-53% of the patients actually bypassed the postanesthesia care unit (PACU) because of anesthetic-related factors and surgical complications. Residual sedation was the most common anesthetic-related cause of failure to bypass thePACU.

Effects of Halothane on Intraocular Pressure in Anesthetized Children

A new era in the use of laryngoscopy has been opened with the development of the fiberscope. As modifications and improvements in instrumentation are advanced, technics of fiberoptic laryngoscopy must be re-evaluated, as presented in this study.

Spontaneous Recovery Profile of Rapacuronium During Desflurane, Sevoflurane, or Propofol Anesthesia for Outpatient Laparoscopy

the foot-operated ARO valve was significantly less than with any of the hand-held devices tested. Therefore, this device is adequate for use with any of the currently-used systems that employ hand-held blowgun valves. The Whitey blowgun, which is admirably suited to the Sanders technic of ventilation for bronchoscopy,l or for microlaryngeal surgery,2 would be unsuitable for technics requiring jet flows greater than 100 L.lmin.3 One advantage of the foot pedal over handoperated systems is that the anesthesiologist has both hands free while he controls ventilation.

Reversal of rocuronium with edrophonium during propofol versus sevoflurane anesthesia

Intraocular pressure (IOP) measurements in children are usually performed under nitrous oxide and halothane anesthesia. We studied the effects of both time and end-tidal halothane concentration on IOP in 80 children (mean age ± SD = 4.5 ± 2.9 yr), to determine the most optimal time to make such measurements in anesthetized children. In 30 children the end-tidal halothane and nitrous oxide concentrations were kept constant while IOP was measured at 1-min intervals after the induction of anesthesia. Intraocular pressure did not change with time. In another 50 children 10P was measured immediately after induction, after 10 min of steady-state end-tidal halothane concentrations of both 0.5% and 1.0% in 66% nitrous oxide, and immediately after tracheal intubation. Intraocular pressure did not differ significantly at either halothane concentration but increased after tracheal intubation. We conclude that in patients anesthetized with halothane and nitrous oxide, IOP after induction remains constant over time and is not affected by end-tidal halothane concentrations up to 1.0% but is affected by tracheal intubation. Thus, the optimal time to measure IOP in children receiving up to 1% halothane in 66% nitrous oxide is during the first 10 min after induction, but before tracheal intubation.

Frank J. Murphy, M.D., C.M., 1900-1972: his life, career, and the Murphy eye.

UNLABELLED We evaluated the spontaneous recovery characteristics of rapacuronium during desflurane-, sevoflurane-, or propofol-based anesthesia in 51 consenting women undergoing laparoscopic tubal ligation procedures. After the induction of the anesthesia with standardized doses of propofol and fentanyl, 1.5 mg/kg IV rapacuronium was administered to facilitate tracheal intubation. Patients were randomized to receive either 1 minimum alveolar anesthetic concentration of desflurane, 1 minimum alveolar concentration of sevoflurane, or 100 microg. kg(-1). min(-1) propofol infusion in combination with 66% nitrous oxide in oxygen for maintenance of anesthesia. Neuromuscular blockade was monitored at the wrist by using electromyography. The degree of maximum blockade and the times for first twitch recovery (T(1)) to 5%, 25%, 50%, 75%, and 90%, as well as the recovery index, were similar in all three anesthetic groups. However, recovery times for the train-of-four ratio to achieve 0.7 and 0.8 were significantly longer with desflurane (44.4 +/- 18.9 and 53.5 +/- 22.4 min) and sevoflurane (44.8 +/- 15.1 and 53.2 +/- 15.8 min) compared with propofol (31.8 +/- 5.3 and 36.5 +/- 6.5 min). Eight patients (16%) required a maintenance dose of 0.5 mg/kg rapacuronium and reversal of rapacuronium residual block occurred in three (6%) patients. We conclude that spontaneous recovery after an intubating dose of 1.5 mg/kg rapacuronium was significantly prolonged by both desflurane and sevoflurane compared with propofol-based anesthesia. Routine monitoring of neuromuscular activity is recommended even when a single bolus dose of rapacuronium is administered during ambulatory anesthesia. IMPLICATIONS When administered for laparoscopic surgery, the duration of action of an intubating dose of rapacuronium was prolonged 40%-50% by desflurane and sevoflurane, respectively, (versus propofol). Monitoring recovery of neuromuscular blockade produced by rapacuronium is particularly important when desflurane or sevoflurane is administered to ensure that an adequate recovery (train-of-four > or = 0.8) is achieved by the end of anesthesia.

Advances in Transfusion Medicine

Background: The use of volatile anesthetics for maintenance of anesthesia can enhance the action of non‐depolarizing muscle relaxants and interfere with the reversal of neuromuscular blockade. In this study, we studied the antagonism of rocuronium with edrophonium‐atropine during propofol‐ versus sevoflurane‐based anesthesia.