The enhanced recovery after surgery (ERAS) Greenie Board: a Navy-inspired quality improvement tool.

The United States Navy uses a visual feedback system for pilots, named 'the Greenie Board', to improve flight manoeuvres on aircraft carriers. Given that increased compliance with enhanced recovery after surgery protocols reduces postoperative complications, we decided to apply a similar feedback system to our institutional enhanced recovery programme. We undertook a prospective 12-month audit of 194 patients assigned to our enhanced recovery programme and evaluated adherence to the anaesthesia-related components of our protocol, before and after implementing a Greenie Board. A compliance score was calculated by summing points for adherence to: intra-operative antibiotic prophylaxis; temperature management; goal-directed intravenous fluid therapy; postoperative nausea and vomiting prophylaxis; and postoperative fluid restriction. The score for each patient was then colour-coded and anonymously displayed for each anaesthetist on a Greenie Board within the operating theatre suite. Protocol adherence improved significantly following introduction, with 'Green' scores (acceptable compliance) increasing from 33% to 72% of patients (p < 0.0001). The greatest improvement was seen with anti-emetic prophylaxis (49% to 70%, p = 0.004) with a consequent reduction in postoperative nausea and vomiting (OR 0.42, 95% CI 0.19-0.88, p = 0.021). We did not observe a decrease in other postoperative complications nor hospital length of stay. We conclude that this US Navy-inspired feedback system is an easily implemented, low-cost quality improvement tool that significantly improved adherence to intra-operative components of our enhanced recovery protocol. The system lends itself to global scaling to drive quality improvement in healthcare delivery and would be suited to institutions without electronic medical records, including low-resource countries.

Effect of probe design on accuracy and reliability of pulse oximetry in pediatric patients.

STUDY OBJECTIVE: To determine if the traditional band-wrap disposable pulse oximeter probe is more accurate or reliable for oxygen monitoring in children than the reusable clip-type probe. DESIGN: Prospective, observational clinical study. SETTING: Operating room of a large university hospital. PATIENTS: 18 children 11 years of age or younger, who were scheduled for general anesthesia with placement of an intraarterial catheter. INTERVENTIONS: Pulse oximetry values were obtained using both band and clip probes of three pulse oximeters (Nellcor, Hayward CA; Novametrix, Wallingford, CT; Ohmeda, Boulder, CO) and compared with simultaneous hemoximetry values. Dropout rate (percent of down time) also was recorded for each probe-machine combination. MEASUREMENTS AND MAIN RESULTS: Data were analyzed using bias and precision and t-test. p < 0.05 is considered significant. Bias (mean SpO2-SaO2) is less than 2% for all probe-machine combinations. The range of error observed between SpO2 and SaO2 for all data points was greatest using the Nellcor band (27.8%) and least using the Ohmeda band (11.4%). In cyanotic children, the greatest bias and precision were observed with Nellcor band (N = 11, -5.12 +/- 9.74) and the best agreement with Novametrix band (N = 17, 0.08 +/- 4.21). The difference in bias for any test units above or below the median weight of 13.75 kg did not vary by more than 1%. Dropout rate was minimal for all units in nonbypass situations. After cardiopulmonary bypass, no data dropout was observed with Ohmeda band; observed down time with the other units varied between 34% and 55%. CONCLUSIONS: The type of probe selected has little effect on accuracy of pulse oximetry in children. After cardiopulmonary bypass, using the Ohmeda band combination may improve the likelihood of obtaining consistent readings and decreasing down time.

Coculture system to assess biocompatibility of candidate orthopaedic materials.

When examining the biocompatibility of materials for orthopaedic use, it is important to examine the in vitro response of osteoblasts and macrophages to the material. The purpose of the current study was to develop an in vitro system that more accurately models the dynamic macrophage and osteoblast interactive response to biomaterials. A filter coculture system was designed that enables two cell types to be separated, while permitting cellular mediators to diffuse through its porous membrane. Using the filter coculture system, macrophage and osteoblast interaction in response to polymethylmethacrylate particle exposure was examined. As a marker of bone resorption potential, the level of prostaglandin E2 released from the macrophage and osteoblast coculture was compared with traditionally used in vitro culture systems. Cells interacting in the filter coculture system were found to produce prostaglandin E2 levels significantly greater than those of traditional conditioned media transfer systems. This filter coculture system offers an in vitro model that accounts for the continual cell to cell mediator interaction of two cell types simultaneously exposed to an implant material. This system may be useful in examining the biocompatibility of candidate materials at the bone interface, and thus elucidating the mechanisms of material induced bone resorption.

Silicone gel and octamethylcyclotetrasiloxane (D4) enhances antibody production to bovine serum albumin in mice.

The purpose of the present study was to determine whether components of silicone breast implants [silicon (polydimethylsiloxane) oil, silicone gel, and octamethylcyclotetrasiloxane (D4)] potentiate the antibody response to bovine serum albumin (BSA) in mice. Seventy A/J mice were divided into seven groups which received the following: group I--phosphate buffer solution (PBS); group II--20 centistoke (cs) silicone oil; group III--50% silicone gel homogenized in silicone oil; group IV--incomplete Freunds' adjuvant (IFA); group V--IFA mixed with an equal volume of silicone oil; group VI--D4; and group VII--IFA mixed with an equal volume of DA. Each 0.1 mL of treatment material(s) was mixed or emulsified with an equal 0.1-mL volume of 250 micrograms/mL BSA in PBS solution. Antibodies to BSA were measured using an enzyme-linked immunosorbent assay. Our study demonstrates for the first time that both D4 and the silicone gel potentiate antibody production to BSA in mice. Histopathologic evaluation of the injection sites reveals granulomas for mice injected with IFA and D4 preparations. Whether D4 or silicone gel acts as an adjuvant against self-antigens has yet to be determined.

Production of an extracellular polysaccharide by Agrobacterium sp DS3 NRRL B-14297 isolated from soil.

A bacterium isolated from soil and identified as Agrobacterium sp produced a water-soluble extracellular polysaccharide capable of producing highly viscous solutions. Gas chromatographic analysis revealed a sugar composition of glucose, galactose and mannose in the molar ratio of 7.5:2.4:1, together with 3.7% (w/w) pyruvic acid. Methylation analyses showed the presence of (1-->3)-, (1-->4)- and (1-->6)-linked glucose, (1-->3)- and (1-->4, 1-->6)-linked galactose and a small portion of (1-->3)-linked mannose residues. Succinic acid was not present. The molecular weight of the polysaccharide was estimated by light scattering to be 2 x 10(6) Da. The viscosity of solutions containing the polysaccharide remained constant from pH 3 to 11, and decreased by 50% when heated from 5 to 55 degrees C. Maximum yield of the polysaccharide, 20 g L-1, was reached in 48 h at 30 degrees C incubation.

Silicone gel and octamethylcyclotetrasiloxane potentiate antibody production to bovine serum albumin in mice.

Earlier studies, in the rat, have shown that silicone gel acts as a potent adjuvant for antibody production against bovine serum albumin (BSA). The purpose of the present study is to determine whether components of the silicone breast implant (silicone oil, silicone gel, and octamethylcyclotetrasiloxane [D4]) potentiate the antibody response to BSA in mice. Groups of ten A/J mice received a single subcutaneous injection of 0.1 ml of BSA emulsified with the following: a) silicone preparations, b) incomplete Freund's adjuvant, or c) saline alone. Antibodies to BSA were measured using an enzyme-linked immunosorbant assay. The results indicate that both D4 and the silicone gel potentiate antibody production to BSA in mice. Known adjuvants have been shown to induce autoimmune syndromes in animal models. Whether silicones can act in a similar mechanism is still unclear.

Wood burning related injuries.

During the past two years, 80 patients were seen in the emergency department of The Mary Imogene Bassett Hospital (Cooperstown, NY) for injuries related to the use of wood burning stoves. The types of injuries included 25 lacerations, 19 crush injuries, 10 fractures, 7 eye injuries and 7 burns. Seven of these patients required hospitalization, and five required operative procedures. There was no mortality. Physician and patient education about the potential dangers of wood stove use may help prevent these injuries.