Preoperative Fluid Fasting Times and Postinduction Low Blood Pressure in Children: A Retrospective Analysis.

BACKGROUND: Children are required to fast before elective general anesthesia. This study hypothesized that prolonged fasting causes volume depletion that manifests as low blood pressure. This study aimed to assess the association between fluid fasting duration and postinduction low blood pressure. METHODS: A retrospective cohort study was performed of 15,543 anesthetized children without preinduction venous access who underwent elective surgery from 2016 to 2017 at Children's Hospital of Philadelphia. Low blood pressure was defined as systolic blood pressure lower than 2 standard deviations below the mean (approximately the 2.5th percentile) for sex- and age-specific reference values. Two epochs were assessed: epoch 1 was from induction to completion of anesthesia preparation, and epoch 2 was during surgical preparation. RESULTS: In epoch 1, the incidence of low systolic blood pressure was 5.2% (697 of 13,497), and no association was observed with the fluid fasting time groups: less than 4 h (4.6%, 141 of 3,081), 4 to 8 h (6.0%, 219 of 3,652), 8 to 12 h (4.9%, 124 of 2,526), and more than 12 h (5.0%, 213 of 4,238). In epoch 2, the incidence of low systolic blood pressure was 6.9% (889 of 12,917) and varied across the fasting groups: less than 4 h (5.6%, 162 of 2,918), 4 to 8 h (8.1%, 285 of 3,531), 8 to 12 h (5.9%, 143 of 2,423), and more than 12 h (7.4%, 299 of 4,045); after adjusting for confounders, fasting 4 to 8 h (adjusted odds ratio, 1.33; 95% CI, 1.07 to 1.64; P = 0.009) and greater than 12 h (adjusted odds ratio, 1.28; 95% CI, 1.04 to 1.57; P = 0.018) were associated with significantly higher odds of low systolic blood pressure compared with the group who fasted less than 4 h, whereas the increased odds of low systolic blood pressure associated with fasting 8 to 12 h (adjusted odds ratio, 1.11; 95% CI, 0.87 to 1.42; P = 0.391) was nonsignificant. CONCLUSIONS: Longer durations of clear fluid fasting in anesthetized children were associated with increased risk of postinduction low blood pressure during surgical preparation, although this association appeared nonlinear.

Duration of preoperative clear fluid fasting and peripheral intravenous catheterization in children: A single-center observational cohort study of 9693 patients.

BACKGROUND: Children routinely undergo inhalational induction of general anesthesia. Intravenous line placement typically occurs after induction of anesthesia and can be challenging, particularly in infants and young children. AIMS: We conducted a retrospective observational study to determine whether there was an association between clear liquid fasting time and the number of peripheral intravenous catheter insertion attempts in anesthetized children. The secondary aim was to identify factors associated with multiple attempts to insert intravenous lines. METHODS: After institutional research board approval, we retrieved a data set of all children between 0 months and 18 years who received general anesthesia at our hospital between January 1, 2016, and September 30, 2017. Data included age, gender, weight, race, ASA status, gestational age, number of peripheral intravenous catheter insertion attempts, any assistive device for insertion, and insertion site. Inclusion criteria were mask induction, ASA status 1 or 2, nonemergency, ambulatory surgical procedures, and placement of a single intravenous line during the anesthetic. RESULTS: A total of 9693 patients were included in the study. Of which 8869 patients required one insertion attempt and 824 underwent multiple insertion attempts. 50% of patients in the single insertion attempt group had clear liquid fasting time <6.9 hours compared to 51.8% of patients requiring multiple attempts. Logistic regression model adjusted for age, ASA status, gender, and BMI did not find an association between duration of clear liquid fasting time and rate of multiple insertion attempts for intravenous catheters (OR: 0.99, 95% CI: 0.98-1.01, P = .47). CONCLUSION: Clear liquid fasting time was not associated with multiple insertion attempts for intravenous line insertion in children receiving general anesthesia. Factors such as patient age, ethnicity, time of day of induction of anesthesia, and American Society of Anesthesiologists Physical Status classification show a greater association with the risk of multiple intravenous line insertion attempts.

STBUR: Sleep trouble breathing and unrefreshed questionnaire: Evaluation of screening tool for postanesthesia care and disposition.

BACKGROUND: The Snoring, Trouble Breathing, and Un-Refreshed (STBUR) questionnaire is a five-question screening tool for pediatric sleep-disordered breathing and risk for perioperative respiratory adverse events in children. The utility of this questionnaire as a preoperative risk-stratification tool has not been investigated. In view of limited availability of screening tools for preoperative pediatric sleep-disordered breathing, we evaluated the questionnaire's performance for postanesthesia adverse events that can impact postanesthesia care and disposition. METHODS: The retrospective study protocol was approved by the institutional research board. The data were analyzed using two different definitions for a positive screening based on a five-point scale: low threshold (scores 1 to 5) and high threshold (score of 5). The primary outcome was based on the following criteria: (a) supplemental oxygen therapy following postanesthesia care unit (PACU) stay until hospital discharge, (b) greater than two hours during phase 1 recovery, (c) anesthesia emergency activation in the PACU, and (d) unplanned hospital admission. RESULTS: About 6025 patients completed the questionnaire during the preoperative evaluation. And 1522 patients had a low threshold score and 270 had a high-threshold score. We found statistically significant associations in three outcomes based on the low threshold score: supplemental oxygen therapy (negative-predictive value [NPV] 0.97, 95% CI 0.97-98), PACU recovery time (NPV 0.99, 95% CI 0.99-0.99) and escalation of care (NPV 0.98, 95% CI 0.97-0.98). Positive-predictive values were statistically significant for all outcomes except anesthesia emergency in the PACU. CONCLUSION: The Snoring, Trouble Breathing, and Un-Refreshed questionnaire identified patients at higher risk for prolonged phase 1 recovery, oxygen therapy requirement, and escalation of care. The questionnaire's high-negative predictive value and specificity may make it useful as a screening tool to identify patients at low risk for prolonged stay in PACU.

Age of Transfused Blood Impacts Perioperative Outcomes Among Patients Who Undergo Major Gastrointestinal Surgery.

OBJECTIVE: To evaluate the impact of transfused packed red blood cell (PRBC) age on perioperative morbidity among patients undergoing major gastrointestinal surgery. BACKGROUND: Patients undergoing major surgery often receive PRBC transfusions. The effect of PRBC age (ie, storage duration before transfusion) on perioperative surgical outcomes remains poorly defined. METHODS: In this study, 1365 patients were identified who underwent a hepato-pancreatic or colorectal resection and received ≥1 unit of PRBCs between 2009 and 2014 at the Johns Hopkins Hospital. Data regarding the storage duration of PRBCs, clinicopathologic characteristics, and perioperative outcomes were obtained and analyzed. Multivariable modified Poisson regression analyses were performed to assess the effect of PRBC age on perioperative morbidity. RESULTS: A total of 5901 PRBC units were transfused for a median of 2 (interquartile range 2-4) units transfused per patient. In all, 936 (68.6%) patients received only units of blood that had been stored for less than 35 days ("fresh" blood), whereas 429 (31.4%) patients received at least 1 unit of PRBC that had been stored for ≥35 days ("older" blood). Overall postoperative morbidity was 32.8%. The incidence of postoperative complications (42.7% vs 28.3%) was higher among patients who received "older" vs "fresh" blood (P < 0.001). After adjusting for confounders on multivariable analysis, transfusion of "older" blood remained independently associated with an increased risk of perioperative morbidity (Relative Risk 1.20, P = 0.03). CONCLUSIONS: The use of "older" blood was an independent predictor of postoperative morbidity among patients undergoing hepato-pancreatic or colorectal procedures. Transfusion of "older" blood products may contribute to a higher risk of postoperative complications.

Morbidity and Mortality after High-dose Transfusion.

BACKGROUND: It is well recognized that increased transfusion volumes are associated with increased morbidity and mortality, but dose-response relations between high- and very-high-dose transfusion and clinical outcomes have not been described previously. In this study, the authors assessed (1) the dose-response relation over a wide range of transfusion volumes for morbidity and mortality and (2) other clinical predictors of adverse outcomes. METHODS: The authors retrospectively analyzed electronic medical records for 272,592 medical and surgical patients (excluding those with hematologic malignancies), 3,523 of whom received transfusion (10 or greater erythrocyte units throughout the hospital stay), to create dose-response curves for transfusion volumes and in-hospital morbidity and mortality. Prehospital comorbidities were assessed in a risk-adjusted manner to identify the correlation with clinical outcomes. RESULTS: For patients receiving high- or very-high-dose transfusion, infections and thrombotic events were four to five times more prevalent than renal, respiratory, and ischemic events. Mortality increased linearly over the entire dose range, with a 10% increase for each 10 units of erythrocytes transfused and 50% mortality after 50 erythrocyte units. Independent predictors of mortality were transfusion dose (odds ratio [OR], 1.037; 95% CI, 1.029 to 1.044), the Charlson comorbidity index (OR, 1.209; 95% CI, 1.141 to 1.276), and a history of congestive heart failure (OR, 1.482; 95% CI, 1.062 to 2.063). CONCLUSIONS: Patients receiving high- or very-high-dose transfusion are at especially high risk for hospital-acquired infections and thrombotic events. Mortality increased linearly over the entire dose range and exceeded 50% after 50 erythrocyte units.

Variation in crystalloid administration: an analysis of 6248 patients undergoing major elective surgery.

BACKGROUND: Large variations exist regarding the type and volume of fluid to be administered to patients. This study aimed to quantitate variations in the administration of crystalloid fluids at the level of the patient, provider, and procedure at a large, tertiary care center. METHOD: Patients who underwent major cardiac, thoracic, or abdominal procedures between 2011 and 2014 were identified. Variations in crystalloid administration were compared by procedure and provider using a coefficient of variation (CV). Multivariable hierarchical linear modeling was performed to identify factors predictive of fluid administration and quantitate variation at the level of the patient and provider. RESULTS: Among 6248 patients who met inclusion criteria, the average crystalloid volume was 25.8 mL kg(-1) m(2) h(-1), corresponding to a CV of 55%. Patients who underwent pancreatectomy received the highest corrected crystalloid volume (32.7 mL kg(-1) m(2) h(-1)), whereas those who underwent coronary artery bypass grafting received the lowest corrected crystalloid volume (14.7 mL kg(-1) m(2) h(-1)). Variations in fluid practices were noted between providers (corrected CV; 14.7%-97.1%) and within the practices of the same provider (corrected CV range; 24.1%-87.9%). On multivariable analysis, age and changes in hemoglobin concentration were associated with a higher crystalloid volume (both P < 0.05). Although over 90% of the variation was attributed to patient-level factors, approximately 10% was due to factors at level of the provider (surgeon: 5.8% versus anesthesiologist: 3.4%). CONCLUSIONS: Wide variations were noted in crystalloid administration between procedures, providers, and within providers. Evidence-based practices and goal-directed therapies should be incorporated to avoid unwanted variations.

Effect of surgeon and anesthesiologist volume on surgical outcomes.

BACKGROUND: Little is known regarding the effects of caseload volume of other relevant members of the "surgical team." The present study sought to report variations in health care utilization and outcomes relative to surgeon and anesthesiologist volume among patients undergoing pancreatic surgery. METHODS: A total of 969 patients undergoing pancreatic surgery from 2011-2013 were identified at a large, tertiary care center. Multivariable regression analyses explored the effects of provider volume on crystalloid administration, blood transfusions, mortality, length of stay, and hospital charges. RESULTS: A total of 11 surgeons were identified while 100 anesthesiologists were involved in providing care to all patients. Annual case volume for surgeons ranged from 5-101 pancreatic resections per year; each anesthesiologist was involved in a fewer number of cases per year with a maximum of 15 patients treated by the same anesthesiologist. Higher volume surgeons had higher transfusions (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.38-2.47; P < 0.001), greater crystalloid administration (OR, 1.62; 95% CI, 1.24-2.12; P < 0.001), and longer length of stay (OR, 1.74; 95% CI, 1.20-2.53; P = 0.003). In contrast, 30-d readmission was lower among higher volume surgeons (low volume versus high volume; 23.1% versus 11.6%; P < 0.001). Variations in patient-related outcomes were not associated with anesthesia provider volume (all P > 0.05). Similarly, total hospital charges and mortality were not associated with provider volumes (both P > 0.05). CONCLUSIONS: Although variability exists in health care practices among providers at the surgeon level, less is observed among anesthesiologists. Although a proportion of this variability can be explained by provider volumes, a significant proportion remains unexplained possibly due to nonmodifiable factors such as patient case mix.

Efficacy of education followed by computerized provider order entry with clinician decision support to reduce red blood cell utilization.

BACKGROUND: Two necessary components of a patient blood management program are education regarding evidence-based transfusion guidelines and computerized provider order entry (CPOE) with clinician decision support (CDS). This study examines changes in red blood cell (RBC) utilization associated with each of these two interventions. STUDY DESIGN AND METHODS: We reviewed 5 years of blood utilization data (2009-2013) for 70,118 surgical patients from 10 different specialty services at a tertiary care academic medical center. Three distinct periods were compared: 1) before blood management, 2) education alone, and 3) education plus CPOE. Changes in RBC unit utilization were assessed over the three periods stratified by surgical service. Cost savings were estimated based on RBC acquisition costs. RESULTS: For all surgical services combined, RBC utilization decreased by 16.4% with education alone (p = 0.001) and then changed very little (2.5% increase) after subsequent addition of CPOE (p = 0.64). When we compared the period of education plus CPOE to the pre-blood management period, the overall decrease was 14.3% (p = 0.008; 2102 fewer RBC units/year, or a cost avoidance of $462,440/year). Services with the highest massive transfusion rates (≥10 RBC units) exhibited the least reduction in RBC utilization. CONCLUSIONS: Adding CPOE with CDS after a successful education effort to promote evidence-based transfusion practice did not further reduce RBC utilization. These findings suggest that education is an important and effective component of a patient blood management program and that CPOE algorithms may serve to maintain compliance with evidence-based transfusion guidelines.

Compliance with Surgical Care Improvement Project for Body Temperature Management (SCIP Inf-10) Is Associated with Improved Clinical Outcomes.

BACKGROUND: In an effort to measure and improve the quality of perioperative care, the Surgical Care Improvement Project (SCIP) was introduced in 2003. The SCIP guidelines are evidence-based process measures designed to reduce preventable morbidity, but it remains to be determined whether SCIP-measure compliance is associated with improved outcomes. METHODS: The authors retrospectively analyzed the electronic medical record data from 45,304 inpatients at a single institution to assess whether compliance with SCIP Inf-10 (body temperature management) was associated with a reduced incidence of morbidity and mortality. The primary outcomes were hospital-acquired infection and ischemic cardiovascular events. Secondary outcomes were mortality and hospital length of stay. RESULTS: Body temperature on admission to the postoperative care unit was higher in the SCIP-compliant group (36.6° ± 0.5°C; n = 44,064) compared with the SCIP-noncompliant group (35.5° ± 0.5°C; n = 1,240) (P < 0.0001). SCIP compliance was associated with improved outcomes in both nonadjusted and risk-adjusted analyses. SCIP compliance was associated with a reduced incidence of hospital-acquired infection (3,312 [7.5%] vs.160 [12.9%] events; risk-adjusted odds ratio [OR], 0.68; 95% CI, 0.54 to 0.85), ischemic cardiovascular events (602 [1.4%] vs. 38 [3.1%] events; risk-adjusted OR, 0.60; 95% CI, 0.41 to 0.92), and mortality (617 [1.4%] vs. 60 [4.8%] events; risk-adjusted OR, 0.41; 95% CI, 0.29 to 0.58). Median (interquartile range) hospital length of stay was also decreased: 4 (2 to 8) versus 5 (2 to 14) days; P < 0.0001. CONCLUSION: Compliance with SCIP Inf-10 body temperature management guidelines during surgery is associated with improved clinical outcomes and can be used as a quality measure.

Risk-adjusted clinical outcomes in patients enrolled in a bloodless program.

BACKGROUND: Although clinical outcomes have been reported for patients who do not accept allogeneic blood transfusion (ABT), many previous studies lack a control group, fail to use risk adjustment, and focus exclusively on cardiac surgery. STUDY DESIGN AND METHODS: We report a risk-adjusted, propensity score-matched, retrospective case-control study of clinical outcomes for inpatients who did not accept ABT (bloodless, n = 294) and those who did accept ABT (control, n = 1157). Multidisciplinary specialized care was rendered to the bloodless patients to conserve blood and optimize clinical outcomes. Differences in hemoglobin (Hb), mortality, five morbid outcomes, and hospital charges and costs were compared. Subgroups of medical and surgical patients were analyzed, and independent predictors of outcome were determined by multivariate analysis. RESULTS: Overall, mortality was lower in the bloodless group (0.7%) than in the control group (2.7%; p = 0.046), primarily attributed to the surgical subgroup. After risk adjustment, bloodless care was not an independent predictor of the composite adverse outcome (death or any morbid event; p = 0.91; odds ratio, 1.02; 95% confidence interval, 0.68-1.53). Discharge Hb concentrations were similar in the bloodless (10.8 ± 2.7 g/dL) and control (10.9 ± 2.3 g/dL) groups (p = 0.42). Total and direct hospital costs were 12% (p = 0.02) and 18% (p = 0.02) less, respectively, in the bloodless patients, a difference attributed to the surgical subgroup. CONCLUSIONS: Using appropriate blood conservation measures for patients who do not accept ABT results in similar or better outcomes and is associated with equivalent or lower costs. This specialized care may be beneficial even for those patients who accept ABT.

Impaired red blood cell deformability after transfusion of stored allogeneic blood but not autologous salvaged blood in cardiac surgery patients.

BACKGROUND: Both cardiopulmonary bypass (CPB) and red blood cell (RBC) storage are associated with detrimental changes in RBC structure and function that may adversely affect tissue oxygen delivery. We tested the hypothesis that in cardiac surgery patients, RBC deformability and aggregation are minimally affected by CPB with autologous salvaged blood alone but are negatively affected by the addition of stored allogeneic blood. METHODS: In this prospective cohort study, 32 patients undergoing cardiac surgery with CPB were divided into 3 groups by transfusion status: autologous salvaged RBCs alone (Auto; n = 12), autologous salvaged RBCs + minimal (<5 units) stored allogeneic RBCs (Auto+Allo min; n = 10), and autologous salvaged RBCs + moderate (≥5 units) stored allogeneic RBCs (Auto+Allo mod; n = 10). Ektacytometry was used to measure RBC elongation index (deformability) and critical shear stress (aggregation) before, during, and for 3 days after surgery. RESULTS: In the Auto group, RBC elongation index did not change significantly from the preoperative baseline. In the Auto+Allo min group, mean elongation index decreased from 32.31 ± 0.02 (baseline) to 30.47 ± 0.02 (nadir on postoperative day 1) (P = 0.003, representing a 6% change). In the Auto+Allo mod group, mean elongation index decreased from 32.7 ± 0.02 (baseline) to 28.14 ± 0.01 (nadir on postoperative day 1) (P = 0.0001, representing a 14% change). Deformability then dose-dependently recovered toward baseline over the first 3 postoperative days. Changes in aggregation were unrelated to transfusion (no difference among groups). For the 3 groups combined, mean critical shear stress decreased from 359 ± 174 mPa to 170 ± 141 mPa (P = 0.01, representing a 54% change), with the nadir at the end of surgery and returned to baseline by postoperative day 1. CONCLUSIONS: In cardiac surgery patients, transfusion with stored allogeneic RBCs, but not autologous salvaged RBCs, is associated with a decrease in RBC cell membrane deformability that is dose-dependent and may persist beyond 3 postoperative days. These findings suggest that autologous salvaged RBCs may be of higher quality than stored RBCs, since the latter are subject to the so-called storage lesions.

Single dose oral diflunisal for acute postoperative pain in adults.

BACKGROUND: Diflunisal is a long-acting non-steroidal anti-inflammatory drug (NSAID) most commonly used to treat acute postoperative pain or chronic joint pain from osteoarthritis and rheumatoid arthritis. This review analyses the effectiveness and harm of different doses of diflunisal in the context of moderate to severe postoperative pain. OBJECTIVES: To assess efficacy, duration of action, and associated adverse events of single dose oral diflunisal in acute postoperative pain in adults. SEARCH STRATEGY: We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies to January 2010. SELECTION CRITERIA: Randomised, double blind, placebo-controlled trials of single dose orally administered diflunisal in adults with moderate to severe acute postoperative pain. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. Pain relief or pain intensity data were extracted and converted into the dichotomous outcome of number of participants with at least 50% pain relief over 4 to 6 hours, from which relative risk and number-needed-to-treat-to-benefit (NNT) were calculated. Numbers of participants using rescue medication over specified time periods, and time to use of rescue medication, were sought as additional measures of efficacy. Information on adverse events and withdrawals were collected. MAIN RESULTS: Nine studies in dental, orthopedic and gynaecological surgery met the inclusion criteria, testing doses of diflunisal from 125 mg to 1000 mg.For diflunisal 1000 mg, the NNT for at least 50% pain relief over 4 to 6 hours was 2.1 (1.8 to 2.6) (6 studies, 391 participants); the NNT to prevent remedication within 6 hours was 1.9 (1.7 to 2.3), and within 12 hours was 2.2 (1.9 to 2.7) (6 studies, 409 participants). More participants experienced adverse events with diflunisal 100 mg than with placebo, but none were serious or led to withdrawal.For diflunisal 500 mg, the NNT for at least 50% pain relief over 4 to 6 hours was 2.6 (2.1 to 3.3) (6 studies, 357 participants); the NNT to prevent remedication within 6 hours was 2.6 (2.1 to 3.4) (6 studies, 390 participants), and within 12 hours was 2.9 (2.3 to 4.0) (5 studies, 329 participants). Adverse events did not differ significantly from placebo. AUTHORS' CONCLUSIONS: Diflunisal has an analgesic effect similar to other NSAIDs in single dose, but benefits from providing significant analgesia for about twelve hours. This property may be useful when regular dosing is needed, or when taking several doses of a shorter acting analgesic is impractical.

A Visual Analytics Dashboard to Summarize Serial Anesthesia Records in Pediatric Radiation Treatment.

BACKGROUND: Young children who undergo radiation therapy may require general anesthesia to remain still during weeks of radiation sessions. On a typical day at our hospital, an anesthesia team will care for 10 patients in the radiation therapy suite, and each patient will have multiple prior anesthetic records. Daily review of prior anesthesia records is important to maintain anesthetic consistency and to identify potential improvement, yet our electronic health record (EHR) made such review time-consuming and cumbersome. OBJECTIVES: This article aims to design a visual analytics interface that simultaneously displays data from multiple anesthesia encounters to support clinical consistency in medications and airway management. METHODS: Documentation from the EHR is available in the clinical data warehouse following daily backups. A visual analytics interface was built to aggregate important components of multiple anesthesia encounters in pediatric radiation oncology on a single screen. The application was embedded in the EHR's anesthesia module and updated daily. RESULTS: Each anesthesia encounter was represented by a vertical line with the date at the bottom of the screen. Each vertical line was divided into sections corresponding to the medications, type of airway device, type of radiation oncology procedure, days between treatments, and recovery score and time. Information about the medications, airways, and procedures was shown with icon legends. This layout enabled users to quickly see the key components of multiple anesthetics and make inferences between, for example, the medications used and the recovery score. CONCLUSION: The dashboard provides a high-level summary of all radiation therapy anesthesia records for children receiving recurrent treatments. In this clinical scenario, it is desirable to replicate an optimal anesthetic approach for daily or near-daily treatments or adjust the anesthetic based on observed patterns.

One Laryngospasm, 2 Realities: A Case Report Highlighting the Impact of Data Granularity on Post Hoc Analysis of Perioperative Events.

We present the case of a laryngospasm event in a 21-month-old child in which the changes in pulse oximetry and end-tidal carbon dioxide were recorded by both our Anesthesia Information Management System and middleware medical device integration platform. When this case was analyzed retrospectively, we noted that the 2 systems recorded the event very differently with respect to pulse oximetry. This case report illustrates the impact of data sampling rates on post hoc analysis of perioperative events and highlights the importance of understanding data collection processes when using electronically recorded data.

Crystalloid administration among patients undergoing liver surgery: Defining patient- and provider-level variation.

BACKGROUND: Fluid administration among patients undergoing liver resection is a key aspect of perioperative care. We sought to examine practice patterns of crystalloid administration, as well as potential factors associated with receipt of crystalloid fluids. METHOD: Patients who underwent liver resection between 2010 and 2014 were identified. Data on clinicopathologic variables, operative details, and perioperative fluid administration were collected and analyzed using univariable and multivariable analyses; variation in practice of crystalloid administration was presented as coefficient of variation (COV). RESULTS: Among 487 patients, median crystalloid administered at the time of surgery was 4,000 mL. After adjusting for body size and operative duration, median corrected crystalloid was 30.0 mL kg(-1) m(2) h(-1), corresponding with a COV of 35%. Patients who received <30 mL kg(-1) m(2) h(-1) crystalloids were more likely to be younger (58 vs 60 years), white (79% vs 74%), and have a higher body mass index (BMI; 28.2 vs 25.4 kg/m(2); all P < .001). On multivariable analysis, increasing Charlson comorbidity index, BMI, estimated blood loss, and each additional hour of surgery were all associated with increased crystalloid administration (all P < .05). Corrected crystalloid administration varied among providers with a corrected COV ranging from 14% to 61%. When overall variation in crystalloid administration was assessed, 80% of the variation occurred at the patient level, and 20% occurred at the provider level (surgeon, 3% vs anesthesiologist, 17%). CONCLUSION: There was wide variability in crystalloid administration among patients undergoing liver resection. Although the majority of variation was attributable to patient factors, a large amount of residual variation was attributable to provider-level differences.

A novel means of assessing institutional adherence to blood transfusion guidelines.

Risk-adjusted institutional transfusion rates are not currently available on a national level. A surrogate means of benchmarking transfusion practices to use for internal quality improvement was studied. Blood utilization was prospectively studied among all colorectal surgery patients at the study institution (July 2010-November 2012), and these data were benchmarked with transfusion data from the National Surgical Quality Improvement Program (NSQIP) database by hospital type and size. Using NSQIP, the study institution's colorectal surgery transfusion rate was 16.3% (150/920 cases), which was slightly higher than the 14.3% national mean transfusion rate (12 191/85 507 cases; P = .08). When broken down by hospital type and size, the study hospital had a similar rate of blood transfusion compared with academic hospitals (P = .35) but a significantly higher rate than community hospitals, regardless of patient volume (P = .03). Benchmarking blood utilization compared with similar-type hospitals using NSQIP may be a surrogate method to assess adherence to evidence-based transfusion guidelines and identify areas for structured quality improvement initiatives.

Radiofrequency bipolar hemostatic sealer reduces blood loss, transfusion requirements, and cost for patients undergoing multilevel spinal fusion surgery: a case control study.

BACKGROUND: A relatively new method of electrocautery, the radiofrequency bipolar hemostatic sealer (RBHS), uses saline-cooled delivery of energy, which seals blood vessels rather than burning them. We assessed the benefits of RBHS as a blood conservation strategy in adult patients undergoing multilevel spinal fusion surgery. METHODS: In a retrospective cohort study, we compared blood utilization in 36 patients undergoing multilevel spinal fusion surgery with RBHS (Aquamantys, Medtronic, Minneapolis, MN, USA) to that of a historical control group (n = 38) matched for variables related to blood loss. Transfusion-related costs were calculated by two methods. RESULTS: Patient characteristics in the two groups were similar. Intraoperatively, blood loss was 55% less in the RBHS group than in the control group (810 ± 530 vs. 1,800 ± 1,600 mL; p = 0.002), and over the entire hospital stay, red cell utilization was 51% less (2.4 ± 3.4 vs. 4.9 ± 4.5 units/patient; p = 0.01) and plasma use was 56% less (1.1 ± 2.4 vs. 2.5 ± 3.4 units/patient; p = 0.03) in the RBHS group. Platelet use was 0.1 ± 0.5 and 0.3 ± 0.6 units/patient in the RBHS and control groups, respectively (p = 0.07). The perioperative decrease in hemoglobin was less in the RBHS group than in the control group (-2.0 ± 2.2 vs. -3.2 ± 2.1 g/dL; p = 0.04), and hemoglobin at discharge was higher in the RBHS group (10.5 ± 1.4 vs. 9.7 ± 0.9 g/dL; p = 0.01). The estimated transfusion-related cost savings were $745/case by acquisition cost and approximately 3- to 5-fold this amount by activity-based cost. CONCLUSIONS: The use of RBHS in patients undergoing multilevel spine fusion surgery can conserve blood, promote higher hemoglobin levels, and reduce transfusion-related costs.