Massive hemorrhage protocol activation in obstetrics: a 5-year quality performance review.

BACKGROUND: A structured approach to hemorrhagic emergencies in obstetrics has gained popularity with the implementation of massive hemorrhage protocols. The trauma literature suggests that routine quality reviews should be in place to improve patient outcomes. The aim of this study was to develop quality indicators and assess compliance by the clinical team. METHODS: A multidisciplinary team set the institutional quality indicators for the massive hemorrhage protocol review. A retrospective review of all obstetrical massive hemorrhage protocol activation events from September 2010 to January 2015 was performed. All protocol events occurred before the creation of the quality indicators. Data were retrieved from patient records. RESULTS: There were 17 (0.09%) protocol activations for 19 790 deliveries during the study period. All 17 (100%) patients received at least one unit of red blood cells. Overactivation, defined as the transfusion of <2 units of red blood cells, occurred in two cases (12%). Common causes of non-compliance were: 24% (4/17) temperature monitoring, 18% (3/17) lactate measurement, 41% (7/17) arterial blood gas sampling, and 18% (3/17) hemoglobin maintenance within the target range of 55-95 g/L. Admission to intensive care and peripartum hysterectomy occurred in 12 and 5 cases (71% and 29%), respectively. CONCLUSIONS: Suboptimal compliance was found in multiple areas, which may be attributable to the low frequency of activation of our massive haemorrhage protocol in obstetrics. The quality targets identified in this report can act as a basis for other institutions developing quality indicators to evaluate performance.

Spontaneous tension pneumothorax: what is it and does it exist?

Tension pneumothorax is variously defined but is generally thought of as a pneumothorax in which the pressure of intrapleural gas exceeds atmospheric pressure, producing adverse effects, including mediastinal shift associated with cardiovascular collapse, often attributed to reduced venous return and kinking of the great vessels. The mechanism of tension pneumothorax is said to be a valvular defect in the visceral pleura such that air enters the pleural space in inspiration but cannot exit in expiration, leading to a progressive increase in pressure. However, as the driving pressure forcing air into the pleura in inspiration is atmospheric pressure, the pleural pressure can never exceed 1 atm during inspiration in a spontaneously breathing subject. Furthermore, all pneumothoraces must have pressures greater than atmospheric during expiration, or conventional treatment with intercostal tube drainage would not work. Pilot experiments have failed to show any re-entry of pleural gas into the lung in patients with persistent air leaks but no evidence of tension, suggesting these behave as valvular pneumothoraces. Case reports of tension pneumothorax in spontaneously breathing patients are rare, and most patients have other explanations for clinical deterioration. Although a large and rapidly expanding pneumothorax may require urgent intervention, it is unlikely that the effects are mediated by high intrapleural pressures. The term tension pneumothorax in spontaneously breathing patients should be reconsidered.

Evaluation of a patient with left ventricular assist device dysfunction.

With the increasing number of LVAD recipients due to lack of donor availability and use of an LVAD as destination therapy, there will be a significant proportion of this population presenting with device related complications. Initial evaluation should be with TEE because conduit obstruction would be a significant complication, among others. As observed in this case report, it is sometimes difficult to noninvasively detect device malfunction, and even surgical exploration left questions unanswered. Echocardiography has been the principal modality used so far to assess the LVAD cannulas. More reliance on Doppler velocities and establishment of a normal range of values and flow profiles of the inflow and outflow cannulas are necessary. Baseline echocardiographic studies could be used for future comparisons. Fluoroscopy and selective angiography have also been reported to be helpful. We would also recommend measuring LV hemodynamics, which have not been previously described, as an additional mode of evaluation of this emerging problem. This case report demonstrates the need for additional noninvasive modalities for diagnosis of ventricular assist device malfunction.

Non-Hodgkin's lymphomas in U.S. Navy personnel.

Non-Hodgkin's lymphomas are one of the most commonly occurring cancers in the age groups heavily represented in the U.S. Navy. The Navy has a wide range of potential occupational exposures. This study was initiated to identify any occupational associations of non-Hodgkin's lymphomas that may adversely affect naval readiness. The objective of this study was to compare the incidence of non-Hodgkin's lymphomas in U.S. Navy active duty enlisted personnel during the period 1974-1983 with the general U.S. population, and to assess if risk varied by naval occupation or length of service. The Naval Health Research Center's computer-based disease registry was used to conduct a prospective study of all white U.S. Navy enlisted men during 1974-1983 to test for the existence of any short-term risk possibly due to occupation. Men in 80 occupations, ranging from clerk to journalist to machinist and boiler operator were observed for 3,704,864 person-years; mean length of service was 5.1 yr, but 19% of person-years were contributed by men who had served at least 11 yr. Incident cases of non-Hodgkin's lymphomas were identified and verified using Medical Board findings or review of original medical records. Average annual age-specific and age-adjusted incidence rates were calculated. Examination of pathology records and medical review boards confirmed 68 cases of non-Hodgkin's lymphomas. The annual age-adjusted incidence rate per 100,000 person-years in Navy men was significantly lower than in the U.S. Surveillance, Epidemiology, and End Results (SEER) population, probably due to screening and other selection factors associated with Navy service that result in a healthy worker effect.(ABSTRACT TRUNCATED AT 250 WORDS)