A cross-sectional investigation of communication in Do-Not-Resuscitate orders in Dutch hospitals.

BACKGROUND: The decision to attempt or refrain from resuscitation is preferably based on prognostic factors for outcome and subsequently communicated with patients. Both patients and physicians consider good communication important, however little is known about patient involvement in and understanding of cardiopulmonary resuscitation (CPR) directives. AIM: To determine the prevalence of Do Not Resuscitate (DNR)-orders, to describe recollection of CPR-directive conversations and factors associated with patient recollection and understanding. METHODS: This was a two-week nationwide multicentre cross-sectional observational study using a study-specific survey. The study population consisted of patients admitted to non-monitored wards in 13 hospitals. Data were collected from the electronic medical record (EMR) concerning CPR-directive, comorbidity and at-home medication. Patients reported their perception and expectations about CPR-counselling through a questionnaire. RESULTS: A total of 1136 patients completed the questionnaire. Patients' CPR-directives were documented in the EMR as follows: 63.7% full code, 27.5% DNR and in 8.8% no directive was documented. DNR was most often documented for patients >80 years (66.4%) and in patients using >10 medications (45.3%). Overall, 55.8% of patients recalled having had a conversation about their CPR-directive and 48.1% patients reported the same CPR-directive as the EMR. Most patients had a good experience with the CPR-directive conversation in general (66.1%), as well as its timing (84%) and location (94%) specifically. CONCLUSIONS: The average DNR-prevalence is 27.5%. Correct understanding of their CPR-directive is lowest in patients aged ≥80 years and multimorbid patients. CPR-directive counselling should focus more on patient involvement and their correct understanding.

The role of fibrinogen in massive postpartum haemorrhage, a case report.

•A G2P1 with a complicated obstetric history of massive postpartum haemorrhage (7 L)•Monitoring of fibrinogen levels during pregnancy and labour•Fibrinogen suppletion resulted in only 2 L blood loss during the third stage of labour.•This case report and literature show that fibrinogen levels might play a role in massive postpartum hemorrhage.

Patient acceptable symptom states after totalhip or knee replacement at mid-term follow-up: Thresholds of the Oxford hip and knee scores.

OBJECTIVES: To define Patient Acceptable Symptom State (PASS) thresholds for the Oxford hip score (OHS) and Oxford knee score (OKS) at mid-term follow-up. METHODS: In a prospective multicentre cohort study, OHS and OKS were collected at a mean follow-up of three years (1.5 to 6.0), combined with a numeric rating scale (NRS) for satisfaction and an external validation question assessing the patient's willingness to undergo surgery again. A total of 550 patients underwent total hip replacement (THR) and 367 underwent total knee replacement (TKR). RESULTS: Receiver operating characteristic (ROC) curves identified a PASS threshold of 42 for the OHS after THR and 37 for the OKS after TKR. THR patients with an OHS ≥ 42 and TKR patients with an OKS ≥ 37 had a higher NRS for satisfaction and a greater likelihood of being willing to undergo surgery again. CONCLUSIONS: PASS thresholds appear larger at mid-term follow-up than at six months after surgery. With- out external validation, we would advise against using these PASS thresholds as absolute thresholds in defining whether or not a patient has attained an acceptable symptom state after THR or TKR. Cite this article: Bone Joint Res 2014;3:7-13.

Hip and knee replacement patients prefer pen-and-paper questionnaires: Implications for future patient-reported outcome measure studies.

OBJECTIVES: Electronic forms of data collection have gained interest in recent years. In orthopaedics, little is known about patient preference regarding pen-and-paper or electronic questionnaires. We aimed to determine whether patients undergoing total hip (THR) or total knee replacement (TKR) prefer pen-and-paper or electronic questionnaires and to identify variables that predict preference for electronic questionnaires. METHODS: We asked patients who participated in a multi-centre cohort study investigating improvement in health-related quality of life (HRQoL) after THR and TKR using pen-and-paper questionnaires, which mode of questionnaire they preferred. Patient age, gender, highest completed level of schooling, body mass index (BMI), comorbidities, indication for joint replacement and pre-operative HRQoL were compared between the groups preferring different modes of questionnaire. We then performed logistic regression analyses to investigate which variables independently predicted preference of electronic questionnaires. RESULTS: A total of 565 THR patients and 387 TKR patients completed the preference question. Of the THR patients, 81.8% (95% confidence interval (CI) 78.4 to 84.7) preferred pen-and-paper questionnaires to electronic questionnaires, as did 86.8% (95% CI 83.1 to 89.8) of TKR patients. Younger age, male gender, higher completed level of schooling and higher BMI independently predicted preference of electronic questionnaires in THR patients. Younger age and higher completed level of schooling independently predicted preference of electronic questionnaires in TKR patients. CONCLUSIONS: The majority of THR and TKR patients prefer pen-and-paper questionnaires. Patients who preferred electronic questionnaires differed from patients who preferred pen-and-paper questionnaires. Restricting the mode of patient-reported outcome measures to electronic questionnaires might introduce selection bias. Cite this article: Bone Joint Res 2013;2:238-44.

A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopedic surgery. International Study of Perioperative Transfusion (ISPOT) Investigators.

UNLABELLED: Concern about risks of allogeneic transfusion has led to an interest in methods for decreasing perioperative transfusion. To determine whether cell salvage reduces patient exposure to allogeneic blood, we performed meta-analyses of randomized trials, evaluating the effectiveness and safety of cell salvage in cardiac or orthopedic elective surgery. The primary outcome was the proportion of patients who received at least one perioperative allogeneic red cell transfusion. Twenty-seven studies were included in the meta-analyses. Cell salvage devices that do not wash salvaged blood were marginally effective in cardiac surgery patients when used postoperatively (relative risk [RR] = 0.85, 95% confidence interval [CI] = 0.79-0.92). Devices that wash or do not wash salvaged blood considerably decreased the proportion of orthopedic surgery patients who received allogeneic transfusion (RR = 0.39, 95% CI = 0.30-0.51 and RR = 0.35, 95% CI 0.26-0.46, respectively). No studies of cell savers that wash salvaged blood during cardiac surgery were included. Cell salvage did not appear to increase the frequency of adverse events. We conclude that cell salvage in orthopedic surgery decreases the risk of patients' exposure to allogeneic blood transfusion perioperatively. Postoperative cell salvage in cardiac surgery, with devices that do not wash the salvaged blood, is only marginally effective. IMPLICATIONS: This meta-analysis of all published randomized trials provides the best current estimate of the effectiveness of cell salvage and is useful in guiding clinical practice. We conclude that cell salvage in orthopedic surgery decreases the proportion of patients requiring allogeneic blood transfusion perioperatively, but postoperative cell salvage is only marginally effective in cardiac surgery.

Technologies to minimize blood transfusion in cardiac and orthopedic surgery. Results of a practice variation survey in nine countries. International Study of Peri-operative Transfusion (ISPOT) Investigators.

OBJECTIVES: Due to the discovery in the 1980s that blood transfusion can transmit HIV, there has been increased interest in technologies that reduce the amount of allogeneic blood used during and after surgery. These technologies include drugs (aprotinin, tranexamic acid, epsilon-aminocaproic acid, erythropoietin), devices (cell salvage), and techniques (acute hemodilution, predeposited autologous donation). The purpose of this study was to ascertain the degree of practice variation, if any, that exists for eight technologies in nine countries in orthopedic and cardiac surgery. METHODS: In each country, either all hospitals or a random sample of hospitals with medical/surgical beds were surveyed between 1995 and 1997. Two instruments were used. The first instrument was a postcard that asked recipients whether the technologies were currently being used in their hospital for orthopedic and/or cardiac surgery to reduce perioperative allogeneic transfusion. The second questionnaire elicited information regarding the degree of use both in qualitative and quantitative terms. Data were collected, entered, and analyzed in each country, with summary results submitted to the Canadian coordinating center on a standardized data collection form. RESULTS: Pharmaceuticals were generally used in a much smaller proportion of hospitals in orthopedic than in cardiac surgery. Aprotinin and tranexamic acid were the drugs most frequently used in cardiac surgery. Nonpharmacological technologies were used to a greater degree than drugs in orthopedic surgery, although there was wide variation among technologies and countries. Acute hemodilution and cell salvage were used in a greater proportion of hospitals for cardiac surgery than orthopedic surgery. CONCLUSIONS: The results of this survey indicate that there is considerable practice variation in the use of technologies to minimize exposure to perioperative allogeneic transfusion within and between countries.

Effect of perioperative blood transfusion and cell saver on the incidence of postoperative infective complications in patients with an aneurysm of the abdominal aorta.

OBJECTIVE: To find out if there was an association between perioperative blood transfusion and the development of infective complications, and whether the use of the cell saver for autologous transfusion had any influence. DESIGN: Retrospective study. SETTING: University Hospital. SUBJECTS: 102 consecutive patients who had been operated on for aneurysms of the abdominal aorta. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: 32 of the 102 patients developed infective complications. Thirteen patients died (six after emergency and seven after elective operations). Nine died as a direct result of infection, one of intra-abdominal bleeding, one of necrosis of the colon, and two of cardiopulmonary complications. The incidence of infective complications was directly related to the number of units of blood transfused, being 0 when 0 or 1 was given; 11 (20%) when 2-4 units were given; 12 (55%) when 5-8 units were given; and 9 (69%) when the number was 9 or more. The cell saver had no influence on the incidence. Other factors associated with higher rates of infective complications were the insertion of a bifurcated prosthesis (p = 0.03), and emergency operation (p < 0.001). CONCLUSION: These results confirm the association between blood transfusion and the incidence of infective complications. It may be that more intensive use of the cell saver and preoperatively saved autologous blood could reduce the rate of infective complications.

Spinal monitoring during vertebral column surgery under continuous alfentanil infusion.

An anaesthetic technique for surgical procedures on the vertebral column is described consisting of a continuous infusion of a short acting opioid, alfentanil, and a muscle relaxant, vecuronium, in combination with positive pressure ventilation using a nitrous oxide/oxygen mixture. It is shown that the two standard forms of spinal monitoring, wake-up testing and somatosensory cortical evoked potentials, can be employed effectively using this anaesthetic technique. Wake-up testing was performed in 23 patients. Average wake-up time was 10 min (SD 3.7 min). Evoked responses suitable for spinal monitoring could be obtained in 60 of 61 patients.

[Peroperative transfusion of autologous blood; experiences with a blood cell separator]. / Peroperatieve transfusie van autoloog bloed; ervaringen met een bloedcelscheider.

Technical progress in the last decade has made intraoperative autotransfusion of shed blood by means of a blood cell separator a safe method of blood transfusion. Complications may now be prevented by removing potentially harmful substances such as debris from the wound, heparin, activated clotting factors and free haemoglobin. The Red Cross Blood Bank in Nijmegen has performed 80 intraoperative autotransfusions. An average of 4 litres of blood was processed and 1.2 litres of red cell suspension were prepared, with a haematocrit of 0.47 l/l. This means saving about 3 donor units of packed cells during operation. Recovery of the erythrocytes was 61.9%; of the heparin and haemoglobin 95.3 and 95%, respectively, were removed. Almost all platelets were removed. No complications were noted. This technique can reduce intraoperative blood loss and use of donor blood.