Compliance Is Contagious: Using Informatics Methods to Measure the Spread of a Documentation Standard From a Preoperative Clinic.

PURPOSE: Preoperative documentation is essential to coordinated care and has the potential for standardization, which may facilitate downstream clinical management. DESIGN: An observational pre/post standardization design was used. METHODS: We analyzed the implementation of a preoperative documentation standardization intervention in Vanderbilt's Preoperative Evaluation Clinic (VPEC) and its impact outside VPEC. A phased intervention consisted of clinician education with monthly feedback, followed by the development of a compliance dashboard and inclusion in Ongoing Professional Performance Evaluation system by VPEC. A follow-up survey was administered to measure the impact on clinical management. FINDINGS: Adherence to standardization was improved with the addition of electronic feedback. Implementation of this system in the preoperative clinic had significant impact outside VPEC. Trainee status was a significant predictor of adoption of the standardized format. CONCLUSIONS: Adoption of a preoperative documentation standard in a clinic had a positive impact on standardization practices in a perioperative system.

The Effects of Dexmedetomidine on Microelectrode Recordings of the Subthalamic Nucleus during Deep Brain Stimulation Surgery: A Retrospective Analysis.

BACKGROUND: The placement of subthalamic nucleus (STN) deep brain stimulation (DBS) electrodes can be facilitated by intraoperative microelectrode recording (MER) of the STN. OBJECTIVES: Optimal anesthetic management during surgery remains unclear because of a lack of quantitative data of the effect of anesthetics on MER. Therefore, we measured the effects of dexmedetomidine (DEX) on MER measures of the STN commonly taken intraoperatively. METHODS: MER from 45 patients was retrospectively compared between patients treated with remifentanil (REMI) alone or both REMI and DEX, which are the 2 main standards of care at our center. The measures examined were population activity, such as root mean square, STN length, and number of passes yielding STN, and the single-neuron measures of firing rate and variability. RESULTS: The addition of DEX does not affect population measures (number of passes: DEX+REMI, n = 68, REMI only, n = 154), or neuronal firing rates (number of neurons: DEX+REMI, n = 64, REMI only, n = 72), but firing rate variability was reduced. CONCLUSIONS: In this cohort, population-based measures routinely used for electrode placement in the STN were unaffected by DEX when added to REMI. Neuronal firing rates were also unaffected, but their variability was reduced, even beyond 20 min after cessation.

Perioperative visual loss.

Perioperative visual loss is an infrequent, devastating complication associated with spine surgery, most commonly from ischemic optic neuropathy. Current research and expert opinion indicate that it is associated with procedures that create elevated venous pressure in the head for prolonged periods of time. The largest case-control study on ischemic optic neuropathy associated with spine surgery found six independent and significant risk factors including male sex, obesity, Wilson frame use, longer operative times, greater blood loss, and a lower colloid to crystalloid ratio in the non-blood fluid administration. The American Society of Anesthesiologists developed a practice advisory for the prevention of this complication. In this setting, it is advisable to avoid significant physiologic and hemodynamic perturbations as much as possible, given the uncertainty of the pathophysiology. Because prevention of this complication cannot be guaranteed, consent for perioperative visual loss should be strongly considered in patients at high risk for this complication.

Measuring and Improving First Case On-Time Starts and Analysis of Factors Predicting Delay in Neurosurgical Operating Rooms.

BACKGROUND: We undertook an operating room (OR) process improvement project to increase first case on-time starts (FCOTS) in the neurosurgical ORs at a tertiary care academic medical center. We engaged the neurosurgical perioperative team which included neurosurgeons, neuroanesthesiologists, and nurses in a shared goal of improving FCOTS. METHODS: Our project involved hiring a new service manager and a focused shared effort on improving FCOTS. After project completion, we conducted a retrospective analysis of FCOTS in 6 neurosurgical ORs. If patients were not in the OR within 5 minutes of scheduled start time, it was considered a late start. Factors predicting delayed start were also identified. During the same period, first cases performed outside the neurosurgical ORs served as a control group. RESULTS: A total of 2328 elective neurosurgical cases were evaluated. The baseline FCOTS from November 2009 to March 2010 was 33%. The first performance shift occurred during March 2010 to January 2011 when FCOTS increased to 44%. In the second performance shift between January 2011 and November 2011 during the implementation phase of this quality improvement project, FCOTS rose to 68% and has continued to increase. Multivariate logistic regression analysis identified the following as significant predictors of delayed start: female sex (odds ratio [OR]=0.771; 95% confidence interval [CI], 0.599-0.943), certified registered nurse anesthetists on the case (OR=0.750; 95% CI, 0.576-0.924), cases done on Friday (OR=0.551; 95% CI, 0.312-0.791), and American Society of Anesthesiologists status IV (OR=0.530; 95% CI, 0.157-0.903). CONCLUSION: The quality improvement project, which was implemented in 2 phases, successfully increased the FCOTS rate in our neurosurgical ORs from 33% to 68%.

Kinetic parameters and lactate dehydrogenase isozyme activities support possible lactate utilization by neurons.

Lactate is potentially a major energy source in brain, particularly following hypoxia/ischemia; however, the regulation of brain lactate metabolism is not well understood. Lactate dehydrogenase (LDH) isozymes in cytosol from primary cultures of neurons and astrocytes, and freshly isolated synaptic terminals (synaptosomes) from adult rat brain were separated by electrophoresis, visualized with an activity-based stain, and quantified. The activity and kinetics of LDH were determined in the same preparations. In synaptosomes, the forward reaction (pyruvate + NADH + H(+ )--> lactate + NAD(+)), which had a V (max) of 1,163 micromol/min/mg protein was 62% of the rate in astrocyte cytoplasm. In contrast, the reverse reaction (lactate + NAD(+ )--> pyruvate + NADH + H(+)), which had a V (max) of 268 micromol/min/mg protein was 237% of the rate in astrocytes. Although the relative distribution was different, all five isozymes of LDH were present in synaptosomes and primary cultures of cortical neurons and astrocytes from rat brain. LDH1 was 14.1% of the isozyme in synaptic terminals, but only 2.6% and 2.4% in neurons and astrocytes, respectively. LDH5 was considerably lower in synaptic terminals than in neurons and astrocytes, representing 20.4%, 37.3% and 34.8% of the isozyme in these preparations, respectively. The distribution of LDH isozymes in primary cultures of cortical neurons does not directly reflect the kinetics of LDH and the capacity for lactate oxidation. However, the kinetics of LDH in brain are consistent with the possible release of lactate by astrocytes and oxidative use of lactate for energy in synaptic terminals.