ABSTRACT
Introduction: The implementation of Patient Blood Management (PBM) in cardiac surgery has been shown to be effective in reducing blood transfusions and associated complications, as well as improving patient outcomes. Despite the potential benefits of PBM in cardiac surgery, there are several barriers to its successful implementation. Objectives: The main objectives of this study were to ascertain the impact of the national Romanian PBM recommendations on allogeneic blood product transfusion in cardiac surgery and identify predictors of perioperative packed red blood cell transfusion. Methods: As part of the Romanian national pilot programme of PBM, we performed a single-centre, retrospective study in a tertiary centre of cardiovascular surgery, including patients from two time periods, before and after the implementation of the national recommendations. Using coarsened exact matching, from a total of 1174 patients, 157 patients from the before group were matched to 169 patients in the after group. Finally, we built a multivariate regression model from the entire cohort to analyse independent predictors of PRBC transfusion in the perioperative period. Results: Although there was a trend towards a lower proportion of patients requiring PRBC transfusion in the "after" group compared to the "before" group (44.9%vs. 50.3%), it was not statistically significant. There was a significant difference between the "after" group and the "before" group in terms of fresh-frozen plasma (FFP) transfusion rates, with a lower percentage of patients requiring FFP transfusion in the "after" group compared to "before" (14.2%, vs. 22.9%, p = 0.04). This difference was also seen in the total perioperative FFP transfusion (mean transfusion 0.7 units in the "before" group, SD 1.73 vs. 0.38 units in the "after" group, SD 1.05, p = 0.04). In the multivariate regression analysis, age > 64 years (OR 1.652, 95% CI 1.17-2.331, p = 0.004), female sex (OR 2.404, 95% CI 1.655-3.492, p < 0.001), surgery time (OR 1.295, 95% CI 1.126-1.488, p < 0.001), Hb < 13 g/dl (OR 3.611, 95% CI 2.528-5.158, p < 0.001), re-exploration for bleeding (OR 3.988, 95% CI 1.248-12.738, p = 0.020), viscoelastic test use (OR 2.18, 95% CI 1.34-3.544, p < 0.001), FFP transfusion (OR 4.023, 95% CI 2.426-6.671, p < 0.001), and use of a standardized pretransfusion checklist (OR 8.875, 95% CI 5.496-14.332, p < 0.001) remained significantly associated with PRBC transfusion. The use of a preoperative standardized haemostasis questionnaire was independently associated with a decreased risk of perioperative PRBC transfusion (0.565, 95% CI 0.371-0.861, p = 0.008). Conclusions: Implementation of national PBM recommendations led to a reduction in FFP transfusion in a cardiac surgery centre. The use of a preoperative standardized haemostasis questionnaire is an independent predictor of a lower risk for PRBC transfusion in this setting.
ABSTRACT
Robotic assisted surgery (RAS) represents a great challenge for anesthesiology due to the increased intraabdomial pressures required for surgical optimal approach. The changes in lung physiology are difficult to predict and require fast decision making in order to prevent altered gas exchange. The aim of this study was to document the combined effect of patient physical status, medical history and intraoperative position during RAS on lung physiology and to determine perioperative risk factors for hypercapnia. We prospectively analyzed 62 patients who underwent elective RAS. Age, co-morbidities and body mass index (BMI) were recorded before surgery. Ventilatory parameters and arterial blood gas analysis were determined before induction of anesthesia, after tracheal intubation and on an hourly basis until the end of surgery. In RAS, the induction of pneumoperitoneum was associated with a significant decrease in lung compliance from a mean of 42.5-26.7 ml cm H2O-1 (p = 0.001) and an increase in plateau pressure from a mean of 16.1 mmHg to a mean of 23.6 mmHg (p = 0.001). Obesity, demonstrated by a BMI over 30, significantly correlates with a decrease in lung compliance after induction of anesthesia (p = 0.001). A significant higher increase in arterial CO2 tension was registered in patients undergoing RAS in steep Trendelenburg position (p = 0.05), but no significant changes in end-tidal CO2 were recorded. A higher arterial to end-tidal CO2 tension gradient was observed in patients with a BMI > 30 (p < 0.001). In conclusion, patients' physical status, especially obesity, represents the main risk factor for decreased lung compliance during RAS and patient positioning in either Trendelenburg or steep Trendelenburg during surgery has limited effects on respiratory physiology.
Subject(s)
Hypercapnia/physiopathology , Lung Compliance/physiology , Obesity/physiopathology , Robotic Surgical Procedures , Aged , Anesthetics/therapeutic use , Blood Gas Analysis , Body Mass Index , Comorbidity , Elective Surgical Procedures , Female , Hemodynamics/physiology , Humans , Intraoperative Period , Male , Middle Aged , Monitoring, Intraoperative/methods , Prospective Studies , Respiration, Artificial , Respiratory Mechanics/physiology , Risk FactorsABSTRACT
Con la hipótesis que el uso de soluciones dextrosadas e hidroeléctricas preparadas mediante técnica industrial no utiliza tiempo de enfermería para su preparación, disminuye la incidencia de contaminación microbiana accidental y aumenta la exactitud de su composición química, llevamos a cabo un trabajo de investigación con los siguientes objetivos: 1) determinar si la composición de las fórmulas propuestas para la PI es apropiada para la hidratación en el período neonatal, 2) comparar dos técnicas de preparación : preparación por enfermería (PE) y preparación industrial (PI). Propusimos 4 fórmulas; N§ 1 y N§ 2 conteniendo dextrosa al 5 por ciento y al 10 por ciento respectivamente y 40 mEq/1 de Na y 20 mEq/1 de K en ambas; N§ 3 dextrosa al 10 por ciento, 20 mEq/1 sin K. Los objetivos se cumplieron en tres etapas. Etapa 1: soluciones PE con enfermeras dedicadas al mismo tiempo al cuidado de recien nacidos en terapia intensiva. Etapa 2: soluciones PI. Etapa 3: soluciones PE con enfermeras dedicadas exclusivamente a la preparación de la solución sin tarea asistencial. Las fórmulas propuestas cubrieron el 80 por ciento de las soluciones indicadas en la unidad de cuidado intensivo neonatal. El tiempo utilizado por enfermería para la preparación de las soluciones PE fue mayor en la etapa 1 que en la 3: X 5,22 minutos vs. 3,98 min. (p<.0005). Se detectó contaminación microbiana en 2/57 (3,5 por ciento) de soluciones PE de la etapa 1 vs 0 por ciento en soluciones PE de etapa 3 y soluciones PI. Se encontraron diferencias significativas en la composición química de Na (p<.01) y K (p<.05) entre las soluciones PE 1§ etapa y PI; en las soluciones PE 3§ etapa persistió una mayor variabilidad con respecto a soluciones PI y una diferencia significativa para el K (p<0.05) pero no se observó diferencias significativas en la composición de Na. En conclusión las soluciones PI presentan mayor exactitud y precisión en su composición química, menor riesgo de contaminación microbiana y no se utiliza tiempo de enfermería para la preparación. Persiste la necesidad de las soluciones PE en 20 por ciento; de los casos; dichas soluciones deberían ser preparadas por enfermeras dedicadas exclusivamente a esta tarea dado que se observó menor variabilidad en la composición química, menor tiempo requerido para su preparación y menor riesgo de contaminación microbiana comparándolas con soluciones preparadas por enfemeras dedicadas a la tarea asistencial.
Subject(s)
Humans , Male , Female , Infant, Newborn , Electrolytes/therapeutic use , Glucose/therapeutic use , Industry , Intensive Care, Neonatal , Neonatal Nursing , Water/administration & dosage , Bacterial Infections , Biological ContaminationABSTRACT
Con la hipótesis que el uso de soluciones dextrosadas e hidroeléctricas preparadas mediante técnica industrial no utiliza tiempo de enfermería para su preparación, disminuye la incidencia de contaminación microbiana accidental y aumenta la exactitud de su composición química, llevamos a cabo un trabajo de investigación con los siguientes objetivos: 1) determinar si la composición de las fórmulas propuestas para la PI es apropiada para la hidratación en el período neonatal, 2) comparar dos técnicas de preparación : preparación por enfermería (PE) y preparación industrial (PI). Propusimos 4 fórmulas; Nº 1 y Nº 2 conteniendo dextrosa al 5 por ciento y al 10 por ciento respectivamente y 40 mEq/1 de Na y 20 mEq/1 de K en ambas; Nº 3 dextrosa al 10 por ciento, 20 mEq/1 sin K. Los objetivos se cumplieron en tres etapas. Etapa 1: soluciones PE con enfermeras
