Paul St. Jacques

Damage control hematology: The impact of a trauma exsanguination protocol on survival and blood product utilization

BACKGROUND The importance of early and aggressive management of trauma- related coagulopathy remains poorly understood. We hypothesized that a trauma exsanguination protocol (TEP) that systematically provides specified numbers and types of blood components immediately upon initiation of resuscitation would improve survival and reduce overall blood product consumption among the most severely injured patients. METHODS We recently implemented a TEP, which involves the immediate and continued release of blood products from the blood bank in a predefined ratio of 10 units of packed red blood cells (PRBC) to 4 units of fresh frozen plasma to 2 units of platelets. All TEP activations from February 1, 2006 to July 31, 2007 were retrospectively evaluated. A comparison cohort (pre-TEP) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. Multivariable analysis was performed to compare mortality and overall blood product consumption between the two groups. RESULTS Two hundred eleven patients met inclusion criteria (117 pre-TEP, 94 TEP). Age, sex, and Injury Severity Score were similar between the groups, whereas physiologic severity (by weighted Revised Trauma Score) and predicted survival (by trauma-related Injury Severity Score, TRISS) were worse in the TEP group (p values of 0.037 and 0.028, respectively). After controlling for age, sex, mechanism of injury, TRISS and 24-hour blood product usage, there was a 74% reduction in the odds of mortality among patients in the TEP group (p = 0.001). Overall blood product consumption adjusted for age, sex, mechanism of injury, and TRISS was also significantly reduced in the TEP group (p = 0.015). CONCLUSIONS We have demonstrated that an exsanguination protocol, delivered in an aggressive and predefined manner, significantly reduces the odds of mortality as well as overall blood product consumption.

Derivation and validation of Spo2/fio2 ratio to impute for Pao2/fio2 ratio in the respiratory component of the Sequential Organ Failure Assessment score*

Objective: The Sequential Organ Failure Assessment (SOFA) score is validated to measure severity of organ dysfunction in critically ill patients. However, in some practice settings, daily arterial blood gas data required to calculate the respiratory component of the SOFA score are often unavailable. The objectives of this study were to derive Spo2/Fio2 (SF) ratio correlations with the Pao2/Fio2 (PF) ratio to calculate the respiratory parameter of the SOFA score, and to validate the respiratory SOFA obtained using SF ratios against clinical outcomes. Patients and Measurements: We obtained matched measurements of Spo2 and Pao2 from two populations: group 1—patients undergoing general anesthesia and group 2—patients from the acute respiratory distress syndrome network—low-vs. high-tidal volume for the acute respiratory management of acute respiratory distress syndrome database. Using a linear regression model, we first determined SF ratios corresponding to PF ratios of 100, 200, 300, and 400. Second, we evaluated the contribution of positive end-expiratory pressure (PEEP) on the relationship between SF and PF, for patients on PEEP in centimeters of water (cm H2O) of <8, 8-12, and >12. Third, we calculated the SOFA scores in a separate cohort of intensive care unit patients using the derived SF ratios and validated them against clinical outcomes. Results: The total SOFA scores calculated using SF ratios and PF ratios were highly correlated (Spearman’s rho 0.85, p < 0.001) in all patients and in the three stratified PEEP categories (<8 cm H2O, Spearman’s rho 0.87, p < 0.001; PEEP 8-12 cm H20, Spearman’s rho 0.85, p < 0.001; PEEP >12 cm H2O, Spearman’s rho 0.85, p < 0.001). The respiratory SOFA scores based on SF ratios and PF ratios correlated similarly with intensive care unit length of stay and ventilator-free days, when validated in a cohort of critically ill patients. Conclusion: The total and respiratory SOFA scores obtained with imputed SF values correlate with the corresponding SOFA score using PF ratios. Both the derived and original respiratory SOFA scores similarly predict outcomes.

The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes Group Research Consortium.

BACKGROUND:In this study, we sought to determine the frequency and outcomes of epidural hematomas after epidural catheterization. METHODS:Eleven centers participating in the Multicenter Perioperative Outcomes Group used electronic anesthesia information systems and quality assurance databases to identify patients who had epidural catheters inserted for either obstetrical or surgical indications. From this cohort, patients undergoing laminectomy for the evacuation of hematoma within 6 weeks of epidural placement were identified. RESULTS:Seven of 62,450 patients undergoing perioperative epidural catheterizations developed hematoma requiring surgical evacuation. The event rate was 11.2 × 10−5 (95% confidence interval [CI], 4.5 × 10−5 to 23.1 × 10−5). Four of the 7 had anticoagulation/antiplatelet therapy that deviated from American Society of Regional Anesthesia guidelines. None of 79,837 obstetric patients with epidural catheterizations developed hematoma (upper limit of the 95% CI, 4.6 × 10−5). The hematoma rate in obstetric epidural catheterizations was significantly lower than in perioperative epidural catheterizations (P = 0.003). CONCLUSIONS:In this series, the 95% CI for the frequency of epidural hematoma requiring laminectomy after epidural catheter placement for perioperative anesthesia/analgesia was 1 event per 22,189 placements to 1 event per 4330 placements. Risk was significantly lower in obstetric epidurals.

Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices

BACKGROUND Despite evidence that use of a checklist during the pre-incision time out improves patient morbidity and mortality, compliance with performing the required elements of the checklist has been low. In an effort to improve compliance, a standardized time out interactive Electronic Checklist System [iECS] was implemented in all hospital operating room (OR) suites at 1 institution. The purpose of this 12-month prospective observational study was to assess whether an iECS in the OR improves and sustains improved surgical team compliance with the pre-incision time out. METHODS Direct observational analyses of preprocedural time outs were performed on 80 cases 1 month before, and 1 and 9 months after implementation of the iECS, for a total of 240 observed cases. Three observers, who achieved high interrater reliability (kappa = 0.83), recorded a compliance score (yes, 1; no, 0) on each element of the time out. An element was scored as compliant if it was clearly verbalized by the surgical team. RESULTS Pre-intervention observations indicated that surgical staff verbally communicated the core elements of the time out procedure 49.7 ± 12.9% of the time. After implementation of the iECS, direct observation of 80 surgical cases at 1 and 9 months indicated that surgical staff verbally communicated the core elements of the time out procedure 81.6 ± 11.4% and 85.8 ± 6.8% of the time, respectively, resulting in a statistically significant (P < .0001) increase in time out procedural compliance. CONCLUSION Implementation of a standardized, iECS can dramatically increase compliance with preprocedural time outs in the OR, an important and necessary step in improving patient outcomes and reducing preventable complications and deaths.

An analysis of risk factors for patient complaints about ambulatory anesthesiology care.

BACKGROUND:Anesthesiology groups continually seek data sources and evaluation metrics for ongoing professional practice evaluation, credentialing, and other quality initiatives. The analysis of patient complaints associated with physicians has been previously shown to be a marker for patient dissatisfaction and a predictor of malpractice claims. Additionally, previous studies in other specialties have revealed a nonuniform distribution of complaints among professionals. In this study, we describe the distribution of complaints among anesthesia providers and identify factors associated with complaint risk in pediatric and adult populations. METHODS:We performed an analysis of a complaint database for an academic medical center. Complaints were recorded as comments during postoperative telephone calls to ambulatory surgery patients regarding the quality of their anesthesiology care. Calls between July 1, 2006 and June 30, 2010 were included. Risk factors were grouped into 3 categories: patient demographics, procedural, and provider characteristics. RESULTS:A total of 22,871 calls placed on behalf of 120 anesthesiologists were evaluated, of which 307 yielded a complaint. There was no evidence of provider-to-provider heterogeneity in complaint risk in the pediatric population. In the adult population, an unadjusted test for the random intercept variance component in the mixed effects model pointed toward significant heterogeneity (P = 0.01); however, after adjusting for a prespecified set of risk factors, provider-to-provider heterogeneity was no longer observed (P = 0.20). Several risk factors exhibited evidence for complaint risk. In the pediatric patient model, risk factors associated with complaint risk included a 10-year change in age, the use of general anesthesia (versus not), and a 1-hour change in the actual minus scheduled start times. Odds ratios were 1.47 (95% confidence interval (CI), 1.04–2.08), 0.22 (95% CI, 0.07–0.62), and 1.27 (95% CI, 1.10–1.47), respectively. In the adult patient model, risk factors associated with complaint risk included male gender, general anesthesia, a 10-year change in provider experience, and speaking with the patient (rather than a family member). Odd ratios were 0.66 (95% CI, 0.47–0.92), 0.67 (95% CI, 0.47–0.95), 1.18 (95% CI, 1.01–1.38), and 1.96 (95% CI, 1.17–3.29), respectively. CONCLUSIONS:There was apparent evidence in adult patients to suggest heterogeneity in provider risk for a patient complaint. However, once patient, procedural, and provider factors were acknowledged in analyses, such evidence for heterogeneity is diminished substantially. Further study into how and why these factors are associated with greater complaint risk may reveal potential interventions to decrease complaints.

Using Information Technology to Improve Quality in the OR

This article summarizes the current state of technology as it pertains to quality in the operating room, ties the current state back to its evolutionary pathway to understand how the current capabilities and their limitations came to pass, and elucidates how the overlay of information technology (IT) as a wrapper around current monitoring and device technology provides a significant advance in the ability of anesthesiologists to use technology to improve quality along many axes. The authors posit that IT will enable all the information about patients, perioperative systems, system capacity, and readiness to follow a development trajectory of increasing usefulness.

Automated identification of drug and food allergies entered using non-standard terminology

OBJECTIVE An accurate computable representation of food and drug allergy is essential for safe healthcare. Our goal was to develop a high-performance, easily maintained algorithm to identify medication and food allergies and sensitivities from unstructured allergy entries in electronic health record (EHR) systems. MATERIALS AND METHODS An algorithm was developed in Transact-SQL to identify ingredients to which patients had allergies in a perioperative information management system. The algorithm used RxNorm and natural language processing techniques developed on a training set of 24 599 entries from 9445 records. Accuracy, specificity, precision, recall, and F-measure were determined for the training dataset and repeated for the testing dataset (24 857 entries from 9430 records). RESULTS Accuracy, precision, recall, and F-measure for medication allergy matches were all above 98% in the training dataset and above 97% in the testing dataset for all allergy entries. Corresponding values for food allergy matches were above 97% and above 93%, respectively. Specificities of the algorithm were 90.3% and 85.0% for drug matches and 100% and 88.9% for food matches in the training and testing datasets, respectively. DISCUSSION The algorithm had high performance for identification of medication and food allergies. Maintenance is practical, as updates are managed through upload of new RxNorm versions and additions to companion database tables. However, direct entry of codified allergy information by providers (through autocompleters or drop lists) is still preferred to post-hoc encoding of the data. Data tables used in the algorithm are available for download. CONCLUSIONS A high performing, easily maintained algorithm can successfully identify medication and food allergies from free text entries in EHR systems.

Enhancing Point of Care Vigilance Using Computers

Information technology has the potential to provide a tremendous step forward in perioperative patient safety. Through automated delivery of information through fixed and portable computer resources, clinicians may achieve improved situational awareness of the overall operation of the operating room suite and the state of individual patients in various stages of surgical care. Coupling the raw, but integrated, information with decision support and alerting algorithms enables clinicians to achieve high reliability in documentation compliance and response to care protocols. Future studies and outcomes analysis are needed to quantify the degree of benefit of these new components of perioperative information systems.

Surgical Apgar score is associated with myocardial injury after noncardiac surgery

STUDY OBJECTIVE To assess the impact of intraoperative hemodynamics in the development of perioperative myocardial infarction (MI) and myocardial ischemia after noncardiac surgery. DESIGN Single-center retrospective cohort study of surgical patients from 2007 to 2012. SETTING Postanesthesia care unit, intensive care unit, and medical-surgical ward at an academic tertiary medical center. PATIENTS A total of 46,799 adult noncardiac, nonthoracic surgery patients, for which 2290 peak cardiac troponin (cTn) levels were available. MEASUREMENTS The 10-point Surgical Apgar Score (SAS) was calculated from intraoperative heart rate, blood pressure, and blood loss. Peak troponin (cTn) levels, hospital length of stay, 7- and 30-day postoperative mortality, patient demographics, and prior medical conditions were gathered. Troponin leak was defined as cTn-I 0.6 to 1.5 ng/mL or cTn-T 0.1 to 0.3 ng/mL; perioperative MI criteria were cTn-I greater than 1.5 ng/mL or cTn-T greater than 0.30 ng/mL. MAIN RESULTS Of 46,799 noncardiac surgical cases, 209 (0.4%) and 192 (0.4%) suffered cTn leak and MI, respectively. Low SAS (0-4) was associated with increased risk of cTn leak and perioperative MI (univariate odds ratio, 2.76 and 2.06; 95% confidence interval, 2.20-3.45 and 1.57-2.70, respectively). In multivariable analysis, Surgical Apgar Score, age 65 years or older, American Society of Anesthesiologists physical status greater than or equal to III, emergency surgery, history of MI or hypertension, prolonged intraoperative tachycardia (heart rate >100 beats/min for >59 minutes), and prolonged hypotension (mean arterial pressure <40 mm Hg for >2 minutes) were independently associated with cTn leak and perioperative MI. CONCLUSIONS Low SAS scores (0-4) may be associated with cTn elevation after noncardiac surgery. SAS-based risk stratification may guide perioperative cTn surveillance in lieu of routine postoperative screening.

Proceedings of the American Society for Enhanced Recovery/Evidence Based Peri-Operative Medicine 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine

Table of contentsA1 Effects of enhanced recovery pathways on renal functionCharles R. Horres, Mohamed A. Adam, Zhifei Sun, Julie K. Thacker, Timothy J. Miller, Stuart A. GrantA2 Economic outcomes of enhanced recovery after surgery (ERAS)Jeffrey HuangA3 What does eating, drinking and mobilizing after enhanced recovery surgery really mean?Kirstie McPherson, Sanjiv Patel, Su Cheen Ng, Denise Veelo, Bart Geerts, Monty MythenA4 Intra-operative fluid monitoring practicesSu Cheen Ng, Mark Foulger, Tim Collins, Kirstie McPherson, Michael MythenA5 Development of an integrated perioperative medicine care pathwayMark Edwards, Denny Levett, Tristan Chapman, Imogen Fecher – Jones, Julian Smith, John Knight, Michael GrocottA6 Cardiopulmonary exercise testing for collaborative decision making prior to major hepatobiliary surgeryMark Edwards, Thomas Sharp, Sandy Jack, Tom Armstrong, John Primrose, Michael Grocott, Denny LevettA7 Effect of an enhanced recovery program on length of stay for microvascular breast reconstruction patientsAdam B. King, Kye Higdon, Melissa Bellomy, Sandy An, Paul St. Jacques, Jon Wanderer, Matthew McEvoyA8 Addressing readmissions associated with an enhanced recovery pathway for colorectal surgeryAnne C. Fabrizio, Michael C. Grant, Deborah Hobson, Jonathan Efron, Susan Gearhart, Bashar Safar, Sandy Fang, Christopher Wu, Elizabeth WickA9 The Manchester surgical outcomes project: prevalence of pre operative anaemia and peri operative red cell transfusion ratesLeanne Darwin, John MooreA10 Preliminary results from a pilot study utilizing ears protocol in living donor nephrectomyAparna Rege, Jayanth Reddy, William Irish, Ahmad Zaaroura, Elizabeth Flores Vera, Deepak Vikraman, Todd Brennan, Debra Sudan, Kadiyala RavindraA11 Enhanced recovery after surgery: the role of the pathway coordinatorDeborah WatsonA12 Hospitalization costs for patients undergoing orthopedic surgery treated with intravenous acetaminophen (IV-APAP) + IV opioids or IV opioids alone for postoperative painManasee V. Shah, Brett A. Maiese, Michael T. Eaddy, Orsolya Lunacsek, An Pham, George J. WanA13 Development of an app for quality improvement in enhanced recoveryKirstie McPherson, Thomas Keen, Monty MythenA14 A clinical rotation in enhanced recovery pathways and evidence based perioperative medicine for medical studentsAlexander B Stone, Christopher L. Wu, Elizabeth C. WickA15 Enhanced recovery after surgery (ERAS) implementation in abdominal based free flap breast reconstructionRachel A. Anolik, Adam Glener, Thomas J. Hopkins, Scott T. Hollenbeck, Julie K. Marosky ThackerA16 How the implementation of an enhanced recovery after surgery (ERAS) protocol can improve outcomes for patients undergoing cystectomyTracey Hong, Andrea Bisaillon, Peter Black, Alan So, Associate Professor, Kelly MaysonA17 Use of an app to improve patient engagement with enhanced recovery pathwaysKirstie McPherson, Thomas Keen, Monty MythenA18 Effect of an enhanced recovery after surgery pathway for living donor nephrectomy patientsAdam B. King, Rachel Forbes, Brad Koss, Tracy McGrane, Warren S. Sandberg, Jonathan Wanderer, Matthew McEvoyA19 Introduction and implementation of an enhanced recovery program to a general surgery practice in a community hospitalPatrick Shanahan, John Rohan, Desirée Chappell, Carrie ChesherA20 “Get fit” for surgery: benefits of a prehabilitation clinic for an enhanced recovery program for colorectal surgical patientsSusan VanderBeek, Rebekah KellyA21 Evaluation of gastrointestinal complications following radical cystectomy using enhanced recovery protocolSiamak Daneshmand, Soroush T. Bazargani, Hamed Ahmadi, Gus Miranda, Jie Cai, Anne K. Schuckman, Hooman DjaladatA22 Impact of a novel diabetic management protocol for carbohydrate loaded patients within an orthopedic ERAS protocolVolz L, Milby JA23 Institution of a patient blood management program to decrease blood transfusions in elective knee and hip arthroplastyOpeyemi Popoola, Tanisha Reid, Luciana Mullan, Mehrdad Rafizadeh, Richard Pitera