Tailoring the Blood Ordering Process for Cardiac Surgical Cases Using an Institution-Specific Version of the Maximum Surgical Blood Order Schedule.

BACKGROUND: Excess ordering of blood products for surgical cases is expensive and wasteful. Evidence has shown that institution-specific versions of the Maximum Surgical Blood Order Schedule (MSBOS) lead to better ordering practices. Most MSBOSs recommend a crossmatch for a minimum of 2 units of packed red blood cells (PRBCs) for cardiac surgical cases; however, studies have shown that >50% of these patients receive no transfusions. Our aim was to create a blood order algorithm for cardiac surgical cases that would decrease unnecessary crossmatching. METHODS: Retrospective data was collected for 264 patients from January 2011 through April 2012. The crossmatch-to-transfusion ratio (C:tx), transfusion probability (%T), and transfusion index (TI) were calculated for each type of procedure. RESULTS: All 264 patients were crossmatched and 98 patients were transfused, resulting in an overall transfusion probability (%T) of 37.12% (95% confidence interval 31.52-43.09). A total of 1175 units of blood were crossmatched, but only 370 units of blood were transfused, resulting in a C:tx of 3.17 (95% confidence interval 2.61-4.03). The average number of units transfused per procedure (transfusion index) was 1.40. C:tx was highest and TI was lowest for CABG, where approximately 11 units of blood were ordered for every 1 unit transfused (C:tx =11.70 ± 3.04), and the TI was 0.32. CONCLUSIONS: Using the gold standard C:tx of >2:1 as an indicator of inappropriate blood utilization, our analysis confirmed that excessive crossmatching occurred for several procedures. Now a subset of cardiac surgical cases only requires a type and screen order prior to surgery.

Analysis of orotracheal intubation techniques in the intensive care unit.

BACKGROUND: The development of specialised airway tools help laryngoscopists secure the airway in intensive care units. The use of videolaryngoscopy has been suggested in simulation studies, and human studies suggest that this advanced airway tool may have an advantage for difficult airways; however, less is known about its use in the ICU. OBJECTIVE: To compare orotracheal intubation before and after acquisition of an ICU-dedicated GlideScope (GS), and to determine the incidence of complications with orotracheal intubation in an ICU. METHODS: An observational study was conducted from October 2008 to April 2009 to record the use of advanced airway tools including videolaryngoscopy before ("pre-GS") and immediately after ("post-GS") the purchase of an ICUdedicated videolaryngoscope. Reasons for intubation, response time, type of intubation, number of attempts at intubation, reasons for delays in intubation, risk factors for difficult intubation and complications were compared between these groups. RESULTS: 56 patients were intubated pre-GS and 47 post- GS. Although a significant increase in videolaryngoscopy was observed in the ICU (P = 0.001), no significant reduction in total attempts at orotracheal intubation were observed (P = 0.66), and that the incidence of overall complications were not reduced (P = 0.21). CONCLUSIONS: The use of a new airway tool may not necessarily lead to immediate reduction in attempts at orotracheal intubation or in overall complication rates.

Evaluating safety of handoffs between anesthesia care providers.

BACKGROUND: Anesthesia care providers frequently exchange care of patients among one another. This daily process of information exchange could be a potential source for adverse events. OBJECTIVES: Our objectives were to determine if the current handoff system is ineffective and if more standardized methods available for the exchange of patient information could improve the effectiveness of handoffs. METHODS: We distributed a survey to all anesthesia staff, residents, and nurse anesthetists. The survey queried the following: handoff adequacy, location for best handoff, method for best handoff, and need for inclusion in the electronic medical record. RESULTS: We received 80 completed initial surveys from anesthesia staff, residents, and nurse anesthetists. Of those surveyed, 20% found the existing handoff process inadequate. Most reported both giving and receiving a poor or incomplete handoff within the previous year (84% and 57%, respectively), and 25% related an adverse outcome to a poor handoff. An overwhelming majority, 89%, felt that standardization of this process could improve patient care; 68% reported that ideal handoffs would occur in the record, as well as in person; and 62% believed that handoffs should be incorporated into the electronic medical record. CONCLUSIONS: These data will be used to improve the method of the patient care handoff and have assisted us in devising techniques that can be incorporated into daily practice, advancing the safety of handoffs and decreasing complications. A handoff screen has been included on the electronic anesthesia record, encouraging a more formalized procedure for handoffs, thereby promoting patient safety.

Intrathecal rosiglitazone acts at peroxisome proliferator-activated receptor-gamma to rapidly inhibit neuropathic pain in rats.

UNLABELLED: In this report, we demonstrate the transcription, expression, and DNA-binding properties of the peroxisome proliferator-activated receptor (PPAR)-gamma subtype of the peroxisome proliferator-activated nuclear receptor family to the spinal cord with real-time PCR, Western blot, and electrophoretic mobility shift assay. To test the hypothesis that activation of spinal PPAR-gamma decreases nerve injury-induced allodynia, we intrathecally administered PPAR-gamma agonists and/or antagonists in rats after transection of the tibial and common peroneal branches of the sciatic nerve. Single injection of either a natural (15-deoxy-prostaglandin J2, 15d-PGJ2) or synthetic (rosiglitazone) PPAR-gamma agonist dose-dependently decreased mechanical and cold hypersensitivity. These effects were maximal at a dose of 100 microg and peaked at approximately 60 minutes after injection, a rapid time course suggestive of transcription-independent mechanisms of action. Concurrent administration of a PPAR-gamma antagonist (bisphenol A diglycidyl ether, BADGE) reversed the effects of 15d-PGJ2 and rosiglitazone, further indicating a receptor-mediated effect. In animals without nerve injury, rosiglitazone did not alter motor coordination, von Frey threshold, or withdrawal response to a cool stimulus. Intraperitoneal and intracerebroventricular administration of PPAR-gamma agonists (100 microg) did not decrease mechanical and cold hypersensitivity, arguing against effects subsequent to diffusion from the intrathecal space. We conclude that ligand-induced activation of spinal PPAR-gamma rapidly reverses nerve injury-induced mechanical allodynia. New or currently available drugs targeted at spinal PPAR-gamma may yield important therapeutic effects for the management of neuropathic pain. PERSPECTIVE: PPAR-gamma receptor agonists such as rosiglitazone and pioglitazone are approved as insulin sensitizers by the United States Food and Drug Administration. We demonstrate PPAR-gamma expression in the spinal cord and report that activation of these receptors inhibits allodynia. BBB-permeant PPAR-gamma agonists may yield important therapeutic effects for the management of neuropathic pain.