ε-Aminocaproic acid and clinical value in cardiac anesthesia.

OBJECTIVE: The primary aim was to compare the "clinical value" of tranexamic acid (TXA) with ε-aminocaproic acid (EACA) when used for blood conservation during high-risk cardiac surgery. DESIGN: Data previously reported by the Blood Conservation Using Antifibrinolytics in a Randomized Trial (BART) study investigators were reanalyzed independently after appropriate statistical adjustment. The authors compared TXA with EACA for important primary and secondary outcomes and applied the "clinical value" equation to this comparison. SETTING: BART, the largest blinded multicenter study on this topic to date, compared all 3 commonly used antifibrinolytics head-to-head in a randomized dose-equivalent fashion during high-risk cardiac surgery. Comparisons of TXA with EACA with application of the clinical value equation was not performed specifically by the BART investigators. PARTICIPANTS: One thousand five hundred fifty patients enrolled in 2 of the 3 arms of the BART study were included in the analysis (TXA, n= 770 and EACA, n = 780, with data reported by the investigators in the New England Journal of Medicine). MAIN RESULTS: The major finding was that there were no significant differences in overall safety and clinically important efficacy between TXA and EACA. CONCLUSIONS: Considering the substantial difference in costs and with the increasing volume of high-risk cardiac surgery, EACA has increased "clinical value" when compared with TXA. EACA should be the antifibrinolytic medication of choice for high-risk cardiac surgery.

A surgical site infection cluster: the process and outcome of an investigation--the impact of an alcohol-based surgical antisepsis product and human behavior.

BACKGROUND: The institution of a process used to successfully execute a perioperative antibiotic administration system is but 1 component of preventing postoperative infections. Continued surveillance of infections is an important part of the process of decreasing postoperative infections. We recently experienced an increase in the number of postoperative infections in our patients. Using standard infection control methods of outbreak investigation, we tracked multiple variables to search for a common cause. We describe herein the process by which Quality Improvement methodology was used to investigate and manage this surgical site infection (SSI) cluster. METHODS: As part of routine surveillance for SSI, the infection control division seeks out evidence of postoperative infections. Patients were defined as having an SSI according to National Healthcare Safety Network SSI criteria. SSI data are reviewed monthly and aggregated on a quarterly basis. The SSI rate was above our usual level for 3 consecutive quarters of 2007. This increase in the infection rate led to an internal outbreak investigation, termed a "cluster investigation." This investigation comprised multiple concurrent methods including manual chart review of all cases; review of microbiological data; and inspection of operating rooms, instrument processing facilities, and storage areas. RESULTS: During 3 quarters, a trend emerged in our general surgical population that demonstrated that 4 surgical types had a sustained increase in SSI. The institutional antibiotic protocol was appropriate for prevention of the majority of these SSIs. As part of the investigation, direct observation of hand hygiene and surgical hand antisepsis technique was undertaken. At this time, there were 2 types of surgical hand preparation being used, at the discretion of the clinician: either a "standard" scrub with an antimicrobial soap or the application of a chlorhexidine gluconate and alcohol-based surgical hand antisepsis product. Observers noted improper use of this alcohol-based surgical hand antiseptic. This product was withdrawn from our operating rooms, and the SSI rate markedly decreased in the following 2 quarters. DISCUSSION: In conclusion, we report the results of a quality improvement process that investigated a 3-quarter increase in our SSI rate. An investigation was undertaken, and it was thought that the (mis)use of an alcohol-based hand antiseptic product was associated with the increased infection rate. Removing this product, along with reemphasizing the importance of infection control, was associated with a decrease in the infection rate to a level at or below our historical rate.

Effect of hormonal variation on Raman spectra for cervical disease detection.

OBJECTIVE: The objective of the study was to characterize the variations in normal cervical spectra because of menopausal status and location within the menstrual cycle. Using the information obtained, the accuracy of Raman spectroscopy to diagnose low-grade squamous intraepithelial lesion (LGSIL) will be improved. STUDY DESIGN: A total of 133 patients undergoing either colposcopy or Papanicolaou smear were recruited from either Vanderbilt University or Tri-State Women's Health. Raman spectra were collected from both normal and diseased areas. The data were processed and analyzed using a multiclass discrimination and classification algorithm to determine whether the spectra were correctly classified. RESULTS: Stratifying the data by menopausal state resulted in correctly classifying LGSIL 97% of the time (from 74%). CONCLUSION: This study brings Raman spectroscopy one step closer to clinical use by improving the sensitivity to differentiate LGSIL from normal.

Case study: preventing surgical complications at Baystate Medical Center.

An academic medical center's experience in a collaborative surgical infection prevention project may be instructive for other organizations.

A system and process redesign to improve perioperative antibiotic administration.

Surgical infection is a leading cause of patient injury, mortality, and excess health care costs. As part of a collaborative effort, we instituted three main focuses for perioperative antibiotic administration: appropriate selection of antibiotics, administration of antibiotics within 60 min before incision, and discontinuation of prophylactic antibiotics within 24 h of surgery. Anesthesiologists were identified as the practitioners most likely to accomplish the successful administration of antibiotics within 60 min before incision. Changes were made in ordering, documentation, and antibiotic preparation. Education was provided to all operating room staff at meetings and grand round presentations. Results were prominently displayed, and feedback was provided. The baseline appropriate antibiotic selection was 82% and is now 95%. The preintervention administration-incision time was 79 (range, 32-380) min, with 11% within the 60 min before incision. The administration-incision time is currently 19 (range, 0-95) min, and the number within 60 min is 95%. Before the institution of the process, the rate of surgical site infections was 3.8%, and is now approximately 1.4%. We describe our process used to improve antibiotic administration. During this time, the surgical site infection rate has been significantly reduced.

Unusual positioning of a central venous catheter.

Central venous cannulation, with or without a flow-directed pulmonary artery catheter, is commonly performed in patients undergoing cardiac surgery to measure central filling pressure and cardiac output, and to administer medications and fluids. The complications of central venous cannulation are numerous and include malposition, arterial puncture, pneumothorax, hemothorax, chylothorax, extravasation of infusate, thrombophlebitis, and infection. We describe a single-lumen catheter that was placed through the hemostatic valve of a 9F percutaneous introducer, which inadvertently entered the left internal mammary (internal thoracic) vein. The current case is unique in that it was diagnosed by visualization of the catheter during surgical dissection.

Multiclass discrimination of cervical precancers using Raman spectroscopy.

Raman spectroscopy has the potential to differentiate among the various stages leading to high-grade cervical cancer such as normal, squamous metaplasia, and low-grade cancer. For Raman spectroscopy to successfully differentiate among the stages, an applicable statistical method must be developed. Algorithms like linear discriminant analysis (LDA) are incapable of differentiating among three or more types of tissues. We developed a novel statistical method combining the method of maximum representation and discrimination feature (MRDF) to extract diagnostic information with sparse multinomial logistic regression (SMLR) to classify spectra based on nonlinear features for multiclass analysis of Raman spectra. We found that high-grade spectra classified correctly 95% of the time; low-grade data classified correctly 74% of the time, improving sensitivity from 92 to 98% and specificity from 81 to 96% suggesting that MRDF with SMLR is a more appropriate technique for categorizing Raman spectra. SMLR also outputs a posterior probability to evaluate the algorithm's accuracy. This combined method holds promise to diagnose subtle changes leading to cervical cancer.