Nicole R. Guinn

Local anesthetics and mode of delivery: bupivacaine versus ropivacaine versus levobupivacaine.

BACKGROUND:The influence of the labor epidural local anesthetic (LA) on mode of delivery has not been adequately studied. In this study, we sought to determine if there is a difference in mode of delivery among parturients who receive epidural bupivacaine, ropivacaine, or levobupivacaine. METHODS:Nulliparous women at term requesting labor analgesia with a cervical dilation <5 cm were randomized to receive epidural bupivacaine, ropivacaine, or levobupivacaine. Analgesia was initiated with a bolus of 15 mL of 0.0625% of the assigned LA with fentanyl 2 &mgr;g/mL. Analgesia was maintained with an infusion of the same solution at 10 mL/h. The primary endpoint was the operative delivery rate (instrumental assisted vaginal delivery plus cesarean delivery). RESULTS:Ninety-eight women received bupivacaine, 90 ropivacaine, and 34 levobupivacaine (before it was removed from the US market). There was no significant difference in the operative delivery rate (bupivacaine = 46%, ropivacaine = 39%, and levobupivacaine = 32%, P = 0.35) among groups. There was less motor block in the levobupivacaine group when compared with the ropivacaine and bupivacaine groups, P < 0.05. There was no significant difference in the duration of the first or second stage of labor, the total dose of LA received per hour of labor, or neonatal outcome among groups. CONCLUSIONS:Bupivacaine, ropivacaine, and levobupivacaine all confer adequate labor epidural analgesia, with no significant influence on mode of delivery, duration of labor, or neonatal outcome.

Adenosine-induced transient asystole for intracranial aneurysm surgery: a retrospective review.

Brief Summary We describe the use of adenosine-induced cardiac arrest to facilitate intracranial aneurysm clip ligation. Background Cerebral aneurysms are highly variable which may result in difficult surgical exposure for clip ligation in select cases. Secure clip placement is often not feasible without temporarily decompressing the aneurysm. This can be accomplished with temporary clip ligation of proximal vessels, or with deep hypothermic circulatory arrest on cardiopulmonary bypass, although these methods have their own inherent risks. Here we describe an alternate method of decompressing the aneurysm via adenosine-induced transient asystole. Methods We examined the records of 27 patients who underwent craniotomy for cerebral aneurysm clipping in which adenosine was used to induce transient asystole to facilitate clip ligation. Duration of adenosine-induced bradycardia (heart rate <40) and hypotension (SBP<60) recorded on the electronic anesthesia record and outcome data including incidence of successful clipping, intraoperative and postoperative complications, and mortality were recorded. Results Satisfactory aneurysm decompression was achieved in all cases, and all aneurysms were clipped successfully. The median dose of intravenous adenosine resulting in bradycardia greater than 30 seconds was 30 mg. The median dose of adenosine resulting in hypotension greater than 30 seconds was 15 mg, and greater than 60 seconds was 30 mg. One case of prolonged hypotension after rapid redosing of adenosine required brief closed chest compressions before circulation was spontaneously restored. No other adverse events were observed. Conclusions Adenosine cardiac arrest is a relatively novel method for decompression of intracranial aneurysms to facilitate clip application. With appropriate safety precautions, it is a reasonable alternative method when temporary clipping of proximal vessels is not desirable or not possible.

Comparison of visually estimated blood loss with direct hemoglobin measurement in multilevel spine surgery.

Estimates of blood loss in the operating room are typically performed as a visual assessment by providers, despite multiple studies showing this to be inaccurate. Use of a less subjective measurement of blood loss such as direct measurement of the hemoglobin (Hb) mass lost from the surgical field may better quantify surgical bleeding. The objective of this investigation was to compare anesthesiologist estimates of intraoperative blood loss with measured Hb loss.

Jehovah's Witnesses and cardiac surgery: A single institution's experience

Based on biblical doctrines, patients of the Jehovahs Witness faith refuse allogeneic blood transfusion. Cardiac surgery carries a high risk of blood transfusion, but has been performed in Jehovahs Witnesses for many years. The literature contains information on the outcomes of this cohort, but does not detail the perioperative care of these patients. This article describes a single institutions experience in perioperative care of Jehovahs Witnesses undergoing cardiac surgery.

How do we develop and implement a preoperative anemia clinic designed to improve perioperative outcomes and reduce cost

Treatment of anemia is one of the four pillars of patient blood management programs. Preoperative anemia is common and associated with increased perioperative morbidity after surgery and increased rates of blood transfusion. Effective treatment of preoperative anemia, however, requires advanced screening, diagnosis, and initiation of therapy weeks before elective surgery. Here we describe the development and implementation of a preoperative anemia screening and treatment program at Duke University Hospital.

Addressing the unmet need of life-threatening anemia with hemoglobin-based oxygen carriers

S evere life-threatening acute anemia is a peril for tissue and major organ damage and mortality owing to inadequate oxygen delivery with consequent tissue and organ hypoxia. Human response to acute normovolemic anemia includes increased heart rate, stroke volume, decreased systemic vascular resistance, and consequently increased cardiac output resulting in some compensatory oxygen delivery, as well as increased oxygen extraction. However, if the anemia becomes sufficiently severe, the response is inadequate; when the hemoglobin (Hb) concentration continues to decrease to less than 7 g/dL the immediate result is decreased oxygen delivery, placing specific organs at risk for dysfunction and damage. The human brain is very sensitive to acute anemia, and a Hb concentration of less than 7 g/dL results in a cerebral electrophysiologic finding (increased P300 latency) that is associated with impaired cognitive function and is a measure of “how well the CNS can process and incorporate incoming information” as well as measured neurocognitive deficits that are reversible when the arterial blood partial pressure of oxygen is increased or red blood cells (RBCs) are transfused shortly thereafter. Once moderate-to-severe anemia has developed, as Hb concentration decreases further there is a substantial increase in morbidity (organ damage) and mortality. Clinical trials have tested liberal versus conservative transfusion strategies, but the lower limits for transfusion in the conservatively transfused patients were 7 to 9.7 g/dL and therefore did not address morbidity and mortality outcomes associated with more severe anemia. None of the four recent meta-analyses identified a trial with a “restrictive” transfusion arm threshold of less than 7 g/dL Hb. Furthermore, patients in these studies likely remained at the “trigger” Hb concentration for a relatively brief period, and in the two large studies reporting such data patients in the restrictive arms were transfused for symptoms more frequently than those in the liberal arm. There is a relatively small population of patients for whom RBC transfusion is not an option, who then, at times, are confronted with severe life-threatening anemia. Data from this population, such as untransfused Jehovah’s Witness patients, treated with contemporary standard of care procedures and interventions provide the best source of information for outcomes associated with progressive life-threatening severe, acute anemia. In 2013 we reviewed the published information from patients with untransfused, severe, life-threatening anemia (most commonly owing to patient refusal of transfusion) in the context of assessing the balance of benefit:risk of Hb-based oxygen carriers (HBOCs). Since then, important additional information has been accrued, enabling a better assessment of the mortality of severe anemia and a comparison with patients treated with an HBOC. To provide a more

Costs and outcomes after cardiac surgery in patients refusing transfusion compared with those who do not: a case-matched study.

Although numerous studies have demonstrated the feasibility of cardiac surgery for blood refusal patients, few studies match to controls, and fewer examine cost. This historical cohort study aims to compare costs and outcomes after cardiac surgery in Jehovahs Witness patients who refuse blood transfusion with a group of matched patients accepting transfusion.

Bloodless Orthotopic Heart Transplantation in a Jehovah's Witness.

We present the case of a 53-year-old female Jehovahs Witness with nonischemic cardiomyopathy who successfully underwent a bloodless heart transplantation using fibrinogen concentrate (RiaSTAP; CSL Behring, King of Prussia, PA) and other blood-conservation methods. With a multidisciplinary team and the use of preoperative erythropoietin-stimulating drugs, normovolemic hemodilution, cell salvage, and pharmacotherapy to prevent and treat coagulopathy, we were able to maintain hemoglobin levels greater than 11 g/dL without the need for blood transfusion. We conclude that orthotopic heart transplants may be performed successfully in select Jehovahs Witness patients using standard and novel blood conservation methods.

Encouraging single-unit transfusions: a superior patient blood management strategy?

S ince the Transfusion Requirements in Critical Care (TRICC) trial published in 1999 demonstrated equivalent or improved outcomes when using a restrictive versus a liberal transfusion threshold in critically ill patients, providers and institutions have sought to decrease utilization of allogeneic red blood cells by promoting restrictive transfusion practices. Since that landmark trial, multiple other studies in different populations, including patients undergoing cardiac surgery, elderly patients undergoing hip replacement, medical patients with gastrointestinal bleeds, and patients with traumatic brain injury, have redemonstrated the equivalence or superiority of restrictive over liberal transfusion thresholds with regard to patient outcomes. However, despite a growing body of evidence supporting this practice, individuals and institutions have found it surprisingly difficult to adhere to these guidelines. Nonetheless, there remain multiple motivations for reducing superfluous transfusion; blood products are a finite resource subject to shortage, there are numerous risks associated with transfusion, and transfusion is an expensive endeavor from both direct (acquisition) and indirect (materials, labor, administration) costs. With the rising costs of health care, particular attention has been paid to areas of potential waste, including unnecessary transfusion. Blood transfusion remains one of the most common procedures performed in hospitals, with nearly 21 million blood components transfused in the United States each year. At the Joint Commission’s National Summit on Overuse in 2012, blood transfusion was listed as the number one most overused procedure; and, although it is difficult to retrospectively determine the appropriateness of all transfusions, studies have demonstrated significant variability in the transfusion practices of different providers, suggesting the potential for substantial waste. One single-institution study found that nearly half (47.8%) of transfusions had an inadequate indication, leading to a direct, five-figure cost to the center. With an acquisition cost of approximately

Outcomes in Patients Undergoing Cardiac Surgery Who Decline Transfusion and Received Erythropoietin Compared to Patients Who Did Not: A Matched Cohort Study.

300 per unit of red blood cells and greater than 10 million units transfused in the United States alone, the economic impact of transfusions with questionable indications may be greater than