Does the Implementation of a Quality Improvement Care Bundle Reduce the Incidence of Acute Kidney Injury in Patients Undergoing Emergency Laparotomy?

PURPOSE: Previous work has demonstrated a survival improvement following the introduction of an enhanced recovery protocol in patients undergoing emergency laparotomy (the emergency laparotomy pathway quality improvement care (ELPQuiC) bundle). Implementation of this bundle increased the use of intra-operative goal directed fluid therapy and ICU admission, both evidence-based strategies recommended to improve kidney outcomes. The aim of this study was to determine if the observed mortality benefit could be explained by a difference in the incidence of AKI pre- and post-implementation of the protocol. METHOD: The primary outcome was the incidence of AKI in the pre- and post-ELPQuiC bundle patient population in four acute trusts in the United Kingdom. Secondary outcomes included the KDIGO stage specific incidence of AKI. Serum creatinine values were obtained retrospectively at baseline, in the post-operative period and the maximum recorded creatinine between day 1 and day 30 were obtained. RESULTS: A total of 303 patients pre-ELPQuiC bundle and 426 patients post-ELPQuiC bundle implementation were identified across the four centres. The overall AKI incidence was 18.4% in the pre-bundle group versus 19.8% in the post bundle group p = 0.653. No significant differences were observed between the groups. CONCLUSIONS: Despite this multi-centre cohort study demonstrating an overall survival benefit, implementation of the quality improvement care bundle did not affect the incidence of AKI.

The R-value of global health (conserving energy to save lives).

The world health community has been rapidly expanding immunization programs with the intention of reducing and eliminating the most common controllable diseases. Many vaccines must be kept within the strict temperature range of 2 to 8°C. Temperature degradation and exposure to freezing temperatures will destroy the viability of these vaccines. The freezing problem of vaccines is often caused at the local level of distribution and can frequently be attributed to the methods and materials used to store the vaccines. PATH (Program for Applied Technology in Health) has issued a challenge to industry to address the problems of transporting and storing vaccines. In response to this challenge, SAVSU describes here calculated performance results for an advanced container design under development.

Topology-graph directed separating boundary surfaces approximation of nonmanifold neuroanatomical structures: application to mouse brain olfactory bulb.

Boundary surface approximation of 3-D neuroanatomical regions from sparse 2-D images (e.g., mouse brain olfactory bulb structures from a 2-D brain atlas) has proven to be difficult due to the presence of abutting, shared boundary surfaces that are not handled by traditional boundary-representation data structures and surfaces-from-contours algorithms. We describe a data structure and an algorithm to reconstruct separating surfaces among multiple regions from sparse cross-sectional contours. We define a topology graph for each region, that describes the topological skeleton of the region's boundary surface and that shows between which contours the surface patches should be generated. We provide a graph-directed triangulation algorithm to reconstruct surface patches between contours. We combine our graph-directed triangulation algorithm together with a piecewise parametric curve fitting technique to ensure that abutting or shared surface patches are precisely coincident. We show that our method overcomes limitations in 1) traditional contours-from-surfaces algorithms that assume binary, not multiple, regionalization of space, and in 2) few existing separating surfaces algorithms that assume conversion of input into a regular volumetric grid, which is not possible with sparse interplanar resolution.

An evaluation of the PA(Xpress) pharyngeal airway - a new single use airway device.

The PA(xpress) phayngeal airway (PA(x)) is a new single use airway device that might be used for airway maintenance during anaesthesia or cardiopulmonary resuscitation. We evaluated the performance of the PA(x) in 103 anaesthetised non-paralysed patients undergoing non-emergency anaesthesia. We recorded success of insertion, quality of airway achieved and complications of its use. We were successful in establishing a clear airway on the first attempt on 68 (67%) occasions. We were unable to establish a patent airway in nine (9%) patients. Partial or intermittent airway obstruction occurred during maintenance of anaesthesia in ten (11%) cases but none required removal of the device. Jaw thrust was used to assist insertion in all cases. A mean of 1.37 further manipulations per patient were required to establish an airway and 0.60 per patient were required during maintenance of anaesthesia. In the 94 patients in whom an airway was established, assisted ventilation was excellent in 77 (82%). Leak pressure was 20 cmH2O or above in 58% cases. Intracuff pressure was measured in 55 patients: mean pressure was 68 cmH2O and was above 100 cmH2O in ten (18%) cases. Complications occurred in 38 (37%) patients during insertion, in a further 12 (13%) during maintenance and in eight (9%) during emergence. The device was difficult to insert and associated with a high incidence of trauma: blood was visible on the device after removal in 56 (55%) cases. We conclude that the PA(x) is associated with too high a failure rate and too high an incidence of minor complications for routine airway maintenance.