Outcomes associated with absent blood product utilization in Jehovah's witness patients compared to the standard of care in cardiac surgery: A ten-year experience.

INTRODUCTION: For Jehovah's Witness (JW) patients requiring cardiac surgery, various strategies such as preoperative use of erythropoietin stimulating agents (ESAs), intravenous iron (IVI), and non-pharmacologic interventions have emerged to prevent complications from blood loss given transfusion is not acceptable in this population. METHODS: Retrospective case-control of cardiac surgeries performed by the same surgeon between 1/1/2011 and 8/30/2021. JW patients were matched to non-JW who received blood products and non-JW who did not receive blood products on a 1:2:2 basis. Patients were matched on procedure, age, gender, and Society of Thoracic Surgeons morbidity score. Eligible patients were aged >18 years and had a sternotomy procedure. The primary efficacy and safety outcomes included mean hematocrit values perioperatively and thrombotic events. RESULTS: A total of 27 JW, 52 non-JW transfused, and 53 non-JW not transfused patients were included in the analysis. JW patients had significantly higher mean hematocrits at every time point when compared to non-JW transfused patients and at all time points except clinic and the last recorded operating room value when compared to non-JW not transfused patients. No significant differences in thrombotic rates were found between groups, however there was a numerically higher incidence in the JW population (JW: 7.4%; non-JW transfused: 0%; non-JW not transfused: 1.9%; p = .106). CONCLUSION: A blood conservation protocol in a JW population was associated with higher perioperative hematocrit values when compared to matched controls. Further prospective study is warranted before applying similar protocols to other populations given the possibility for an increased rate of venous thromboembolism.

T-cell suppression by red blood cells is dependent on intact cells and is a consequence of blood bank processing.

BACKGROUND: Red blood cells (RBCs) suppress T-cell responsiveness through a mechanism requiring cell-cell contact. Questions remain as to whether this effect is an allogeneic response, related to cell death, or dependent on particular components of the RBCs. STUDY DESIGN AND METHODS: Peripheral T cells were isolated from healthy donors and exposed to stored allogeneic RBCs or autologous RBCs after processing. RBCs were lysed by hypotonic solvent to produce cellular ghosts. Tritiated thymidine proliferation assays were utilized. Cultures were saturated with interleukin (IL)-2 to determine whether impaired IL-2 synthesis played a role. RESULTS: T-cell proliferation was suppressed by both autologous and allogeneic RBCs. RBC membrane integrity does enhance T-cell suppression. T-cell death is not responsible for the suppressive changes. IL-2 synthesis is suppressed in RBC-exposed T cells but addition of exogenous IL-2 does not rescue proliferative capabilities. Proliferation of T cells was inhibited with RBC exposure but mitigated with the addition of fresh RBCs. CONCLUSIONS: T-cell suppression is enhanced by intact RBCs but this effect is unrelated solely to alloantigens. Neither apoptosis nor necrosis of T cells contributes to this phenomenon. IL-2 synthesis is suppressed after RBC exposure as a consequence of T-cell inhibition, but is not the primary cause of suppression. Fresh RBCs do not mediate T-cell suppression, indicating that changes in the RBC and development of the storage lesion may occur during initial blood bank processing.

Evaluation of Antibiotic Duration after Surgical Debridement of Necrotizing Soft Tissue Infection.

Background: Necrotizing soft tissue infection (NSTI) is known to be a medical emergency with high morbidity and mortality. Guidelines do not specify the optimal duration of antibiotic agents after completion of surgical debridements of NSTI, which has created variable practice. It was hypothesized that patients with NSTI who receive 48 hours or less of post-operative antibiotic agents after final debridement have similar rates of subsequent intervention or infection recurrence, suggesting that a shorter duration of antibiotic agents may treat NSTI adequately after final surgical debridement. Patients and Methods: This was a retrospective study including adults with NSTI identified through International Classification of Diseases, Ninth Revision (ICD-9), International Classification of Diseases, Tenth Revision (ICD-10), and Current Procedural Terminology (CPT) codes admitted to one academic institution between January 1, 2010 and July 31, 2020. Demographics, surgical practices, antibiotic practices, and clinical outcomes including inpatient mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, total antibiotic days, necrotizing infection clinical composite end point (NICCE) success, and infection recurrence were compared based on the duration of antibiotic agents after final debridement. Results: Three hundred twenty-two patients with NSTI were included and baseline characteristics and clinical severity markers were well balanced between the two groups. In 71 patients (22%) who received less than 48 hours of antibiotic agents after final debridement there was no difference in recurrence (1.4% vs. 3.6%; p = 0.697), mortality (1.4% vs. 4.4%; p = 0.476), or ICU LOS (1 vs. 2 days; p = 0.300], but they did have a shorter hospital LOS (7 vs. 10 days; p = 0.011). Conclusions: Shorter duration of antibiotic therapy after final surgical debridement of NSTI may be appropriate in patients without another indication for antibiotic agents.

Variations in early outcomes of endovascular aneurysm repair with alternate endograft configurations.

BACKGROUND: Most endovascular abdomincal aortic aneurysm (AAA) repairs (EVARs) performed in the United States utilize a bifurcated configuration. The purpose of this study was to examine the effect of alternate graft configurations on early outcomes during EVAR. METHODS: Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective EVAR for AAA from 2005 to 2007 were stratified by configuration using CPT codes. Bifurcated configurations (CPT 34802, 34803, 34804) were compared to straight configurations such as tube or aortouni-iliac grafts (CPT 34800, 34805). Preoperative risk factors, intraoperative variables, 30-day outcome measures, and length of stay were compared. Composite morbidity included patients experiencing one or more of 21 complications defined by NSQIP protocol. Student's t-test and analyses of variance were used to compare variables. RESULTS: There were 3,264 patients who underwent EVAR, including 2,864 bifurcated endografts and 400 straight endografts. Composite morbidity was greater in patients receiving straight endografts compared to those receiving bifurcated endografts (15.2% vs. 9.3%, p < 0.001). Length of stay was greater in the "straight" cohort as well (4.9 + or - 6.9 vs. 3.3 + or - 5.6, p < 0.001). There was a trend toward increased mortality in the "straight" cohort, but it did not reach statistical significance (2% vs. 0.9%, p = 0.054). After controlling for the top 11 NSQIP predictors of mortality in vascular patients, graft configuration remained significant in the multivariable analysis for morbidity (odds ratio [OR] = 1.55, 95% confidence interval [CI[ 1.13-2.12, p = 0.006) and length of stay but not mortality (OR = 1.63, 95% CI 0.70-3.80, p = 0.263). CONCLUSION: EVAR using a tube or aortouni configuration is associated with increased complications and length of stay. These poorer outcomes may be related to factors that lead surgeons to choose these approaches.

Maintaining an open trauma intensive care unit bed for rapid admission can be cost-effective.

BACKGROUND: In 2012, we implemented a ready open trauma intensive care unit (TICU) bed process. Our hypothesis was that this process would decrease emergency department (ED) length of stay (LOS) in a cost-effective manner without worsening clinical outcomes. METHODS: We developed a charge nurse without a patient assignment to facilitate this open bed. We also provided team training for early ICU resuscitation. All Level 1 activations admitted directly to the TICU before and after the implementation were examined. Patients taken directly to the operating room from the ED, deaths within 24 hours of admission, and patients with nonsurvivable head injuries were excluded. Cost-effectiveness of the position was examined. RESULTS: Age (mean [SD], 45.78 [18.71] years), sex (74.7% male), and Injury Severity Score (ISS) (mean [SD], 17.27 [9.26]) were not significantly different. Median ED LOS for the postimplementation group decreased from 230 minutes to 66 minutes (p < 0.001). Median ICU LOS (from 3.29 to 2.98 days, p = 0.13) and total median hospital LOS (from 10.71 to 7.98 days, p = 0.06) decreased but were not statistically significant. Controlling for age, ISS, sex, and mechanism of injury the postimplementation group had a 29% reduction in ICU LOS (2.12 days), a 28% reduction in hospital LOS (4.34), and a 54% reduction in ED LOS (154 minutes). The LOS decreased despite a small increase in ISS (from 15.89 to 18.37). Observed/expected mortality did not differ between the groups, preimplementation/postimplementation of 0.87 and 0.92. Nursing productivity increased one nurse after implementation at a cost of $624 per day. The ICU LOS decrease of 1.6 days at a rate of $1,144 average ICU daily cost of room and board totaled $1,830 per patient. The decreased ICU LOS dollars minus the increase nurse pay resulted in an overall savings of $1,206 per patient. CONCLUSION: Rapid access to the TICU made possible by the charge nurse without a direct assignment and team training has a potential cost savings without adversely affecting patient outcomes. LEVEL OF EVIDENCE: Cost analysis, level III.

A middle fidelity model is effective in teaching and retaining skill set needed to perform a laparoscopic pyloromyotomy.

INTRODUCTION: An inanimate technical skills trainer for laparoscopic pyloromyotomy (LP) has not been described. A middle fidelity model, reproducing the three consistent steps in LP, was developed as a component of a teaching module for surgical residents, and tested on medical students, residents, and pediatric surgeons. MATERIALS AND METHODS: In the first phase of the study, a cohort of 29 pediatric surgeons used the LP model and completed questionnaires about the model's realism and accuracy. Descriptive statistics were used to analyze questionnaire responses. Chi-square tests were performed to determine if level of experience influenced responses. For the second phase of the study, medical students and surgical residents individually participated in the training of cognitive knowledge about hypertrophic pyloric stenosis and skills acquisition for LP. Subject testing consisted of simulator task performance and multiple-choice quiz administration immediately after training and repeated at 8 weeks after training. Data were analyzed by using paired sample t-tests and one-way analyses of variance (ANOVA). RESULTS: The pediatric surgeons agreed that the model accurately simulated essential components of the pyloromyotomy, and that the model would be an excellent tool to introduce surgeons to LP. A total of 26 students and early surgical residents completed the training and testing. Knowledge-based test performance improved from pre- to postinstruction by 17.45 [standard error of the mean (SEM) + 3.5] (P < 0.001) and from preinstruction to 8 weeks by 4.54 (SEM = 3.2) (P = 0.17). Mean improvement in time of simulator task performance was 85.2 +/- 75.4 seconds. Based on a one-way ANOVA, higher level of training was associated with decreased mean times (P = 0.04). CONCLUSIONS: Face and content validities of the simulation were demonstrated by the pediatric surgeons. An effective training experience was demonstrated with medical students and residents. At 2 months, simulator task-completion rates and task-performance times showed technical skills were retained, whereas, based on test scores, cognitive knowledge was not as well retained.