Prediction of hematocrit decline and the impact of peri-operative fluid use in lumbar spinal fusion surgery.

PURPOSE: Peri-operative blood loss unaccounted for and post-operative hematocrit decline could have a significant impact on the outcome of elective spinal surgery patients. The study assesses the accuracy of predictive models of hematocrit decline and blood loss in spinal surgery and determines the impact of peri-operative fluid administration on hematocrit levels of patients undergoing first-time single level lumbar fusion surgery for degenerative spine disease and the trend thereof in the first 24 h post-operatively. METHODS: Clinical and biochemical parameters were prospectively collected in patients undergoing single level lumbar spinal surgery. Predictive models were applied to assess their accuracy in intra-operative blood loss and post-operative hematocrit decline. RESULTS: High correlation (0.98 Pearson correlation coefficient) occurred between calculated (predicted) and recorded hematocrit from hours 2 to 6 post-operatively. Predictive accuracy declined thereafter yet remained moderate. Patients received an average intra-operative fluid volume of 545.45 ml per hour (47% of estimated total blood volume). A significant hematocrit decline occurred post-induction (43.47-39.78%, p < 0.001) with total fluid volume received being the significant contributing variable (p < 0.001). Hypertensive patients were the only subgroup to drop below the safe hematocrit threshold of 30%. CONCLUSION: Iatrogenic hemodilution can accurately be predicted for the first six hours post-operatively, with high risk patients identifiable. Fluid therapy should be goal directed rather than generic, and good communication between the surgeon and anesthesiologist remains the cornerstone to manage physiological changes secondary to blood loss. Although helpful, predictive formulas are not universally applicable to all phenotypes.

Measured performance of filtration and ventilation systems for fine and ultrafine particles and ozone in an unoccupied modern California house.

This study evaluated nine ventilation and filtration systems in an unoccupied 2006 house located 250 m downwind of the I-80 freeway in Sacramento, California. Systems were evaluated for reducing indoor concentrations of outdoor particles in summer and fall/winter, ozone in summer, and particles from stir-fry cooking. Air exchange rate was measured continuously. Energy use was estimated for year-round operation in California. Exhaust ventilation without enhanced filtration provided indoor PM2.5 that was 70% lower than outdoors. Supply ventilation with MERV13 filtration provided slightly less protection, whereas supply MERV16 filtration reduced PM2.5 by 97-98% relative to outdoors. Supply filtration systems used little energy but provided no benefits for indoor-generated particles. Systems with MERV13-16 filter in the recirculating heating and cooling unit (FAU) operating continuously or 20 min/h reduced PM2.5 by 93-98%. Across all systems, removal percentages were higher for ultrafine particles and lower for black carbon, relative to PM2.5 . Indoor ozone was 3-4% of outdoors for all systems except an electronic air cleaner that produced ozone. Filtration via the FAU or portable filtration units lowered PM2.5 by 25-75% when operated over the hour following cooking. The energy for year-round operation of FAU filtration with an efficient blower motor was estimated at 600 kWh/year.