Effects of rotational thromboelastometry-guided transfusion management in patients undergoing surgical intervention for postpartum hemorrhage: An observational study.

BACKGROUND: Postpartum hemorrhage (PPH) can be associated with coagulopathy, which may be difficult to rapidly assess and may exacerbate blood loss. Rotational thromboelastometry (ROTEM) at the point of care can guide clinician choice of blood products and has been shown in some settings to reduce transfusions and improve outcomes. This hospital-based observational study aims to measure effects of a ROTEM-guided transfusion protocol on transfusion practice and clinical outcomes in patients with PPH managed in the operating theater. STUDY DESIGN AND METHODS: We compared a retrospective cohort of 450 consecutive patients with PPH treated in the operating theater before the introduction of a ROTEM-guided transfusion algorithm in June 2016, with 450 patients treated after its introduction. Multivariate regression was used to evaluate the effect of ROTEM introduction on the primary outcome, patients requiring a packed red blood cell (PRBC) transfusion and adjusting for demographic and obstetric confounders. Secondary outcomes included other blood product transfusions, hysterectomy, and intensive care unit admission. RESULTS: A total of 90 (20%) of patients treated prior to ROTEM introduction received a PRBC transfusion, compared with 102 (22.7%) of those treated after ROTEM introduction (95% confidence interval [CI] 1.0-2.0, p = .04). There was no difference in PRBC transfusion in patients undergoing caesarean section (95% CI 0.5-1.8, p = .99). There was a trend toward increased use of cryoprecipitate and reduced use of platelets and fresh frozen plasma after ROTEM introduction. CONCLUSION: In our institution, the introduction of ROTEM-guided transfusion did not reduce PRBC transfusion in patients with PPH treated in the operating theater.

Serial Observation of Blood Alcohol Concentration post Ethanol Pleurodesis (SOBER) Study: A Prospective Observational Study.

OBJECTIVES: To measure the blood alcohol concentration levels in patients after chemical pleurodesis with ethanol sclerosant via video-assisted thoracoscopic surgery. DESIGN: Prospective observational study. SETTING: Single tertiary university hospital. PARTICIPANTS: Eight patients undergoing chemical pleurodesis with ethanol sclerosant for management of recurrent pneumothoraces or pleural effusions. INTERVENTIONS: After ethics board approval, written informed consent was obtained from 8 patients undergoing chemical pleurodesis with ethanol sclerosant for management of recurrent pneumothoraces or pleural effusions. Five patients received a dose of 100 mL of 70% ethanol/1% iodine, and 3 patients received 30 mL. Blood alcohol concentration measurement was obtained at 30, 60, 90, and 120 minutes after the ethanol was instilled in the interpleural space. The postoperative quality of recovery scale was conducted preoperatively and then at 30 and 60 minutes postoperatively and on postoperative days 1 and 3. MEASUREMENTS AND MAIN RESULTS: The highest observed blood alcohol concentration was recorded at 30 minutes post-instillation of ethanol in all patients. The blood alcohol concentration peak for 75% of patients (6/8) was >0.05 g/dL at 30 minutes post-instillation of ethanol, and for 4 patients (50%), this remained >0.05 g/dL at 60 minutes. The median area under curve of ethanol absorbed was 5.66 g/dL/min (3.24-7.29). CONCLUSIONS: Significant systemic absorption of ethanol can occur after instillation of ethanol sclerosant, which potentially may affect the quality of recovery in patients. Postoperative management of these patients may need to be specifically tailored to take into account these observations.

Standard set of health outcome measures for older persons.

BACKGROUND: The International Consortium for Health Outcomes Measurement (ICHOM) was founded in 2012 to propose consensus-based measurement tools and documentation for different conditions and populations.This article describes how the ICHOM Older Person Working Group followed a consensus-driven modified Delphi technique to develop multiple global outcome measures in older persons. The standard set of outcome measures developed by this group will support the ability of healthcare systems to improve their care pathways and quality of care. An additional benefit will be the opportunity to compare variations in outcomes which encourages and supports learning between different health care systems that drives quality improvement. These outcome measures were not developed for use in research. They are aimed at non researchers in healthcare provision and those who pay for these services. METHODS: A modified Delphi technique utilising a value based healthcare framework was applied by an international panel to arrive at consensus decisions.To inform the panel meetings, information was sought from literature reviews, longitudinal ageing surveys and a focus group. RESULTS: The outcome measures developed and recommended were participation in decision making, autonomy and control, mood and emotional health, loneliness and isolation, pain, activities of daily living, frailty, time spent in hospital, overall survival, carer burden, polypharmacy, falls and place of death mapped to a three tier value based healthcare framework. CONCLUSIONS: The first global health standard set of outcome measures in older persons has been developed to enable health care systems improve the quality of care provided to older persons.

The WHO network of collaborating centres on standardization and regulatory evaluation of vaccines.

WHO Collaborating Centres (CCs) form part of an international collaborative network set up by WHO in support of its mandated programme at the country, intercountry, regional, interregional and global levels, as appropriate. As part of its mandate in the area of biologicals, WHO has broadened the scope of its work and has expanded the range of activities devoted to the establishment of international standards for vaccines. In line with global immunization goals, the need for standards for evaluation of quality, safety and efficacy of new vaccines, as well as those that have been in use for a long time, has significantly increased. Furthermore, complex issues related to new production methodologies, more sophisticated techniques for characterization and laboratory testing, and for nonclinical and clinical evaluation of vaccines have raised a number of regulatory challenges for WHO when requested to assist its Member States. In this context, CCs in the area of standardization of vaccines and biotherapeutics (excluding blood products) have provided technical assistance and have broadened the scope of their work over time. In the area of standardization and regulatory evaluation of vaccines, WHO currently has six CCs as well as one candidate centre for which the designation process has been initiated and a further three candidate centres with great potential. The purpose of the meeting held on 24-26 April 2012 was to improve understanding of WHO's priorities in setting standards, to facilitate their implementation, and to increase transparency of the roles and responsibilities of CCs. The meeting was also an excellent opportunity to explore possibilities for improving collaboration between WHO and CCs, as well as among CCs themselves by working as a CC network. All CCs expressed a wish for increased interaction, information-sharing, collaboration and other ways of working together that may lead to cross-fertilization between the CCs. Synergy was recognized as a significant mechanism for leveraging existing resources in responding to global public health challenges and in addressing WHO's priorities. Agreement was reached for operating as a network of CCs.

Long-term effectiveness of the preoperative smoking cessation programme at Western Health.

BACKGROUND: Smoking is associated with adverse effects in the perioperative period, including elevated risk of death. The perioperative period provides an opportunity to engage with patients who are smokers to encourage smoking cessation, often referred to as a 'teachable moment'. We developed a smoking intervention model for the pre-admission clinic (PAC) at Western Health, Victoria, Australia. This case series aimed to assess the impact of the smoking intervention model, which is standard of care, on the participant's smoking habits over four time points. METHODS: We enrolled 50 consecutive participants for elective surgery who were smokers and had attended PAC at Western Health, Footscray. All smokers were offered a standard intervention package to address their smoking. Participants underwent a brief interview to elicit their current smoking behaviour on their day of surgery, 3 and 12 months post-operatively. RESULTS: We found a reduction at each time point post-intervention in the average number of cigarettes smoked per day by all participants with a 43% reduction at 12 months compared with PAC. We found that the number of participants who had quit increased at each time point, with 29% abstinent at 12 months post-operatively. At 12 months, we found 71% of participants had either quit or reduced the number of cigarettes smoked compared with the amount reported at PAC. CONCLUSION: This study adds to the evidence that a simple intervention preoperatively can contribute to long-term changes in smoking behaviour.

HAN DOVER BETWEEN ANAESTHETISTS AND POST-ANAESTHETIC CARE UNIT NURSING STAFF USING ISBAR PRINCIPLES: A QUALITY IMPROVEMENT STUDY.

A structured approach to communication between health care professionals contains introduction/identification; situation; background; assessment and request/recommendation (ISBAR). ISBAR was introduced into the post anaesthetic care unit (PACU) of a large Victorian health service in 2013. The aim of this study was to measure the effect of an education program on ISBAR compliance. METHOD: A pre/post-test design using a 14-item audit tool was used to measure compliance to ISBAR before and after an education intervention in two acute hospitals in Melbourne, Victoria. The intervention consisted of one 30-minute education session to anaesthetists, and two 30-minute education sessions to PACU nurses, combined with visual cues using ISBAR wall posters. RESULTS: In Hospital A, significant improvement from pre- to post-audit was found in the items of cardiovascular assessment and actions (Fisher's exact test p < .05) and (X² (1) = 4.06, p < .05), respiratory assessment (X² (1) = 12.85, p < .01), analgesia assessment and responsibility + referral (X² (1) = 4.44, p < .05. For Hospital B significant improvement was found in communication difficulties (X² (2)= 13.55, p-< .01) and significant decreased performance was found in respiratory assessment (X² (1) = 8.98, p < .01) and responsibility + referral (X² (1) = 13.26, p < .01). IMPLICATION FOR PRACTICE: The results from this study cohort suggest an augmented education program may produce mixed results for ISBAR compliance. More than education and visual tools may be required to improve PACU ISBAR compliance.

Viscoelastic testing for hepatic surgery: a systematic review with meta-analysis-a protocol.

BACKGROUND: Viscoelastic tests, including thromboelastography (TEG) and rotational thromboelastometry (ROTEM), provide a global assessment of haemostatic function at the point of care. The use of a TEG or ROTEM system to guide blood product administration has been shown in some surgical settings to reduce transfusion requirements. The aim of this review is to evaluate all published evidence regarding viscoelastic testing in the setting of hepatic surgery. METHODS: We will search MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials databases to identify randomised controlled trials examining the use of viscoelastic testing for hepatic surgery. Two reviewers will independently screen titles and abstracts of studies identified and will independently extract data. Any disagreements will be resolved by discussion with a third reviewer. A meta-analysis will be conducted if feasible. DISCUSSION: Viscoelastic devices such as TEG and ROTEM are increasingly available to clinicians as a bedside test. Patients undergoing hepatic surgery have a significant risk of blood loss and coagulopathy requiring transfusion. Theoretical benefits of use of a TEG or ROTEM system in the hepatic surgical setting include a rationalisation of blood products, a reduction in transfusion-related side effects, an improvement in patient outcomes including mortality, and a reduction in cost. This systematic review will summarise the current evidence regarding the use of viscoelastic testing for hepatic surgery. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016036732.