Impact of a Hemoglobin Trigger Communication Tool on Perioperative Transfusion in Cardiac Surgery.

OBJECTIVES: Blood transfusion represents an important and potentially modifiable risk in the daily practice of cardiac surgery. The risk profile and increasing cost of transfusion led us to study the effect of different maneuvers, interventions, or surgical techniques to minimize transfusion while maintaining patient safety. This study compares postoperative outcomes before and after incorporating a verbal hemoglobin (Hb) trigger during the surgical timeout in which the surgeon and anesthesiologist preemptively agree on a threshold for packed red blood cell (PRBC) administration in the perioperative period. METHODS: The authors performed a chart review of patients who underwent cardiac surgery from July 2013 through June 2014 at our institution. Patients who underwent surgery from July 2013 through December 2013 served as the pre-Hb trigger group, and patients who underwent surgery from January 2014 through June 2014 served as the post-Hb trigger group. Information collected included patient demographics, type of cardiac surgery, preoperative Hb, Hb trigger, and intraoperative and postoperative variables. The primary outcome was the incidence of PRBC transfusions. Secondary outcomes included the incidence of frozen plasma (FP) transfusion, mechanical ventilation beyond postoperative day 1, and 30-day mortality. RESULTS: The study included 191 patients, with 84 in the pre-Hb trigger group and 107 in the post-Hb trigger group. Intraoperative PRBC transfusions did not decrease in the posttrigger group compared with the pretrigger group (pretrigger 51.4% vs posttrigger 52.4%, P = 1.0); however, intraoperative FP administration was lower in the posttrigger group (65.4% vs 50.0%, P = 0.038). Postoperative mechanical ventilation beyond postoperative day 1 also was significantly lower in the posttrigger group compared with the pretrigger group (27.1% vs 14.3%, P = 0.035). CONCLUSIONS: Implementation of a verbal Hb trigger during the surgical timeout was associated with a reduction in FP administration and duration of mechanical ventilation, but not a decrease in PRBC transfusion and mortality.

Induction of General Anesthesia and Mask Ventilation With a Full-Face Continuous Positive Airway Pressure Mask in a Patient With a Nose Deformity.

Mask ventilation (MV) is an essential component of airway management and can be lifesaving in situations where the placement of a secure airway device proves challenging. Effective MV requires a seal to be created between the mask and the face to maintain patency of the external airway structures and can be difficult in the setting of facial abnormalities or facial trauma. Here we describe a case in which a continuous positive airway pressure (CPAP) mask was used for anesthesia induction and MV in an 85-year-old man who underwent a plastic surgery reconstruction of the left nasal dorsum and ala following a Mohs surgery, which had prevented the use of conventional face mask. An effective seal was achieved, and anesthesia was successfully induced with the mask. We reviewed the literature and discussed alternative approaches for face mask use in the setting of facial abnormalities where the use of a conventional mask is unfeasible.

La2O3 Nanoparticles: Study of Uptake and Distribution in Pfaffia glomerata (Spreng.) Pedersen by LA-ICP-MS and µ-XRF.

The production and use of nanoparticles (NPs) in different fields increased in the last years. However, some NPs have toxicological properties, making these materials potential emerging pollutants. Therefore, it is important to investigate the uptake, transformation, translocation, and deposition of NPs in plants. In this work, laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) and micro X-ray fluorescence (µ-XRF) were used to investigate the uptake and translocation of La2O3 NPs to stem and leaves of Pfaffia glomerata (Spreng.) Pedersen after in vitro cultivation of plants in the presence of 400 mg L-1 of La2O3 NPs. By using LA-ICP-MS and µ-XRF, image of the spatial distribution of La in the leaves was obtained, where higher concentration of La was observed in the main veins. Differences in the signal profile of La in leaves of plants cultivated in the presence of bulk La2O3 (b-La2O3) and La2O3 NPs were observed. Sharp peaks of La indicated that NPs were transported to the stems and leaves of plants treated with La2O3 NPs. Both LA-ICP-MS and µ-XRF techniques have shown to be useful for detecting NPs in plants, but LA-ICP-MS is more sensitive than µ-XRF and allowed better detection and visualization of La distribution in the whole leaf.

Robotic mitral valve repair: a review of anesthetic management of the first 200 patients.

OBJECTIVE: The aim of this study was to describe the evolution in anesthetic technique used for the first 200 patients undergoing robotic mitral valve surgery. DESIGN: A retrospective review. SETTING: A single tertiary referral academic hospital. PARTICIPANTS: Two hundred consecutive patients undergoing robotic mitral valve surgery using the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) at Mayo Clinic Rochester. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After obtaining institutional review board approval, surgical and anesthetic data were recorded. For analysis, patients were placed in 4 groups, each containing 50 consecutive patients, labeled Quartiles 1 to 4. Over time, there were statistically significant decreases in cardiopulmonary bypass and aortic cross-clamp times. Significant differences in the anesthetic management were shown, with a reduction of intraoperative fentanyl and midazolam doses, and the introduction of paravertebral blockade in Quartile 2. There was a reduction of time between incision closure and extubation, and nearly 90% of patients were extubated in the operating room in Quartiles 3 and 4. Despite changes to the intraoperative analgesic management, and focus on earlier extubation, there were no differences seen in visual analog scale (VAS) pain scores over the 4 quartiles. Reductions were seen in total intensive care unit and hospital length of stay during the study period. CONCLUSIONS: Changes to the practice, including efforts to limit intraoperative opioid administration and the addition of preoperative paravertebral blockade, helped facilitate earlier extubation. In the second half of the study period, close to 90% of patients were extubated in the operating room safely and without delaying patient transition to the intensive care unit.

Sacral tumor resection: the effect of surgical staging on patient outcomes, resource management, and hospital cost.

STUDY DESIGN: Single-institution retrospective study. OBJECTIVE: To assess the effect surgical staging (i.e., sequencing) has on clinical and economic outcomes for patients undergoing sacropelvic tumor resection requiring lumbopelvic stabilization. SUMMARY OF BACKGROUND DATA: Sacral corpectomy with lumbopelvic stabilization is an extensive surgical procedure that can be performed in either a single episode or multiple episodes of care on different days. The impact of varied sequencing of surgical episodes of care on patient, resource, and financial outcomes is unknown. METHODS: This single-center retrospective case series identified all cases of sacropelvic tumor resection requiring lumbopelvic stabilization over an 8-year period. We assessed and compared clinical and economic outcomes for patients whose anterior exposure and posterior resection were separated into two distinct surgical episodes of care (staged) versus patients whose anterior exposure and posterior resection occurred in a single encounter (nonstaged procedures). Primary endpoints included procedural outcomes (operative and after-hours surgical time), resuscitative requirements, adverse perioperative events, mortality, and direct medical costs (hospital and physician) associated with the surgical episodes of interest. RESULTS: From January 1, 2000, to July 15, 2008, a total of 25 patients were identified. Eight patients had their procedure staged. Surgical staging was associated with a significant increase in intensive care unit free days (P = 0.03), ventilator free days (P < 0.01), and reduced morbidity (P < 0.01). Surgical staging significantly reduced postoperative red blood cell (P = 0.03), and after-hours red blood cell (P < 0.01) and component requirements (P = 0.04). Mean total inpatient costs were $89,132 lower for patients undergoing the staged procedure (95% confidence interval of mean cost difference = -$178,899 to -$4661). CONCLUSION: Separating the anterior exposure and posterior resection phases of complex sacral tumor resection into two separate surgical episodes of care is associated with improved clinical outcomes and reduced inpatient cost.