Intraoperative blood collection without fluid replacement for cardiac surgery - A retrospective analysis.

Background: Transfusion rates in cardiac surgery are high. Aim: To determine if intraoperative autologous blood removal without volume replacement is associated with fewer homologous blood transfusions without increasing acute kidney injury. Setting and Design: Retrospective, comparative study. Materials and Methods: Adult patients undergoing cardiac surgery, excluding those who underwent ventricular assist device surgery, heart transplants, or cardiac surgery without cardiopulmonary bypass were excluded, who had 1-3 units of intraoperative autologous blood removal were compared to patients without blood removal for determination of volume replacement, vasopressor support, acute kidney injury, and transfusions. Results: Autologous blood removal was associated with fewer patients receiving homologous transfusions: intraoperative red cell transfusions fell from 75% (Control) to 48% (1 unit removed), 40% (2 units), and 30% (3 units), P < 0.001. Total intraoperative and postoperative homologous RBC units transfused were lower in the blood removal groups: median (interquartile range) 3 (1, 6) in Control patients and 0 (0, 2), 0 (0, 2) and 0 (0, 1) in the 1, 2, and 3 units removed groups, P < 0.001. Similarly, plasma, platelet, and cryoprecipitate transfusions decreased. After adjustment for confounders, increased amounts of autologous blood removal were associated with increased intravenous fluids, only when 2 units were removed, and trivially increased vasopressor use. However, it was not associated with acidosis or acute kidney injury. Conclusions: Intraoperative autologous blood removal without volume replacement of 1-3 units for later autologous transfusion is associated with decreased homologous transfusions without acidosis or acute kidney injury.

Modules for the Technical Skills Section of the OSCE Component of the American Board of Anesthesiology APPLIED Examination.

Introduction: To assess communication and professionalism, as well as technical skills related to patient care, the American Board of Anesthesiology (ABA) has begun administering an Objective Structured Clinical Examination (OSCE) portion of the APPLIED Examination in addition to the Standard Oral Examination component. Methods: We created video modules and a curriculum for anesthesiology resident OSCE preparation for the Interpretation of Monitors and Interpretation of Echocardiography components. The modules can be used individually by trainees or included as part of an OSCE workshop led by faculty educators with seven individual stations matching the content of the actual ABA examination. These modules are recommended for all levels of anesthesiology trainees so that they can gain exposure to the format and the fast pace of the examination. Results: Sixty-six junior and senior anesthesiology residents, fellows, and junior faculty successfully participated in these modules. Seventy-three percent of the participants agreed that after completing these modules, they now had a good understanding of the Interpretation of Monitors and Interpretation of Echocardiography technical skills stations. More than 90% of participants reported that the modules were useful, and more than 70% reported that they now felt prepared for these stations of the OSCE. Discussion: Developing technical skills stations for deliberate practice and preparation for the ABA OSCE is resource intensive. Finding time and faculty to facilitate OSCE preparation is also challenging. With the video modules and scripts included in this publication, residents can practice independently or as part of larger preparation course.

Intraoperative bispectral index monitoring and time to extubation after cardiac surgery: secondary analysis of a randomized controlled trial.

BACKGROUND: Fast track recovery is a care process goal after cardiac surgery. Intraoperative anesthetic depth may impact recovery, but the impact of brain monitoring on time to extubation and intensive care unit (ICU) length of stay after cardiac surgery has not been extensively studied. Our goal was to determine if BIS-guided anesthesia improves time to extubation compared to MAC-guided anesthesia in a cardiac surgery population. METHODS: In this secondary outcome analysis of a randomized controlled study, we analyzed 294 patients undergoing elective coronary bypass grafting, valve replacements, and bypass plus valve replacements at a single tertiary referral center between February 1, 2009 and April 30, 2010. We analyzed cardiac surgery patients that had been randomized to BIS-guided anesthesia alerts (n = 131) or MAC-guided anesthesia alerts (n = 163). The primary outcome measure was time to extubation in the BIS-guided and anesthetic concentration-guided groups. Secondary outcomes were length of stay in the ICU and total postoperative hospital length of stay. RESULTS: Valid extubation time data were available for 247 of 294 patients. The median [IQR] time to extubation was 307 [215 to 771] minutes in the BIS group and 323 [196 to 730] minutes in the anesthetic concentration group (p = 0.61). The median [IQR] ICU length of stay was 54 [29 to 97] hours versus 70 [44 to 99] hours (p = 0.11). In terms of postoperative hospital length of stay, there was no difference between the groups with median [IQR] times of 6 [5-8] days (p = 0.69) in each group. CONCLUSIONS: The use of intraoperative BIS monitoring during cardiac surgery did not change time to extubation, ICU length of stay or hospital length of stay. Data regarding BIS monitoring and recovery in an exclusively cardiac surgery population are consistent with recent effectiveness studies in the general surgical population. TRIAL REGISTRATION: ClinicalTrials.gov number NCT00689091.

The independent effects of anemia and transfusion on mortality after coronary artery bypass.

BACKGROUND: Both anemia and transfusions (Tx) are associated with mortality after cardiac operations. However, the relative contributions of anemia and Tx and their interaction on late mortality have not been determined. METHODS: 922 patients who underwent isolated coronary artery bypass grafting (CABG) were retrospectively studied. Anemia (A+) was defined as hemoglobin<12 g/dL for men and <11 g/dL for women. Patients who received (Tx+) and did not receive (Tx-) transfusions were compared; patient characteristics were controlled for by the use of Cox analysis and then by matching Tx+ to Tx- patients based on identical hemoglobin levels at admission and by propensity matching. RESULTS: 5.3% of Tx- patients died, compared with 11% of Tx+ patients (p=0.001). The interaction of anemia and Tx was associated with a greater hazard of dying. In particular, A+Tx+ (anemic, received transfusion) patients had a threefold hazard of death (2.918, 95% confidence interval=1.512-5.633, p=0.001) compared with A-Tx- (nonanemic, no transfusion) patients. A+Tx+ patients had twice the hazard of dying as did A+Tx- (anemic, no transfusion) (hazard ratio=2.087, 95% confidence interval=1.004-4.336, p=0.049). In populations matched by preoperative hemoglobin levels or by propensity scores, similar results were seen: a significant interaction between anemia and transfusion of red blood cells. A+Tx+ patients fared significantly worse than did the other three groups. Although there was no difference in mortality between A- patients who did or did not receive transfusions, A+T+ patients had triple the risk as A+T- patients, whereas A+Tx- patients had a similar risk of late mortality as A-Tx- patients. CONCLUSIONS: The anemia-transfusion interaction was associated with an increased hazard of late mortality.

To die, to sleep: US physicians' religious and other objections to physician-assisted suicide, terminal sedation, and withdrawal of life support.

This study analyzes data from a national survey to estimate the proportion of physicians who currently object to physician-assisted suicide (PAS), terminal sedation (TS), and withdrawal of artificial life support (WLS), and to examine associations between such objections and physician ethnicity, religious characteristics, and experience caring for dying patients. Overall, 69% of the US physicians object to PAS, 18% to TS, and 5% to WLS. Highly religious physicians are more likely than those with low religiosity to object to both PAS (84% vs 55%, P < .001) and TS (25% vs 12%, P < .001). Objection to PAS or TS is also associated with being of Asian ethnicity, of Hindu religious affiliation, and having more experience caring for dying patients. These findings suggest that, with respect to morally contested interventions at the end of life, the medical care patients receive will vary based on their physicians' religious characteristics, ethnicity, and experience caring for dying patients.