Concepts of blood transfusion in adults. Lancet 2013; 381:1845–54
Alternatives to blood transfusion. Lancet 2013; 381:1855–65 Challenges in the management of the blood supply. Lancet 2013; 381:1866–75
Although blood transfusions may be unavoidable to save a patient’s life, blood transfusions convey risks, are expensive, and blood supply is scarce. In this issue of the Lancet, a series of three top-level reviews discuss the strengths and weaknesses of transfusion practices, alternatives to blood transfusion, and challenges in the management of blood supply. In the first article, the presumed cost to benefit ratio of blood supply on outcome is shown to become more and more controversial according to recent trials, which support equivalence or superiority of restrictive versus liberal transfusion practices. Specific patient subpopulations (cardiothoracic surgery, trauma) as well as the role of preoperative hemoglobin levels are examined in details. Noteworthy, there is a growing body of evidence for a decrease in transfusion practices together with an increased use of nontransfusion-based strategies (such as antifibrinolytics). Similarly, the need for alternatives to transfusion will be continuously pushed by both costs and impact on outcome. These alternatives are nicely discussed in the second article. The third article focuses on the management of blood supply in the future, with particular emphasis on the challenge to combine the necessity to increase blood stocks together with prevention from waste and taking too much blood from donors. Personalized medicine (blood matching, genetics) could be helpful with this regard, as well as upcoming techniques such as growing erythrocytes and platelets from stem cells. By reading this excellent series of articles, anesthesiologists and intensivists will refresh their knowledge and learn a lot about a cornerstone domain of their clinical practice.
Predisposing and precipitating factors of delirium after cardiac surgery. A prospective observational cohort study. Ann Surg 2013; 257:1160–7
Delirium is a devastating complication increasing postoperative mortality after cardiac and noncardiac surgery. The primary goal of this study was to identify predisposing and predictive factors for developing delirium after cardiac operations. A prospective cohort of 221 consecutive patients greater than 50 yr of age was assessed for preoperative cognitive performance, and functional and physical status, and clinical and biological parameters were recorded. Independent predictors of delirium were older age, Charlson comorbidity index, lower preoperative Mini–Mental state, length of cardiopulmonary bypass, and systemic inflammatory response (fig. 1). These results may help to identify patient subpopulations at high risk of developing delirium after cardiac surgery.
Critical Care Medicine
A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med 2013; 368:2201–9
Most of the studies suggest that intensive physicians improve patient outcome in intensive care units (ICUs). Thus, increasing numbers of ICUs are adopting the practice of nighttime intensivist staffing despite the lack of experimental evidence of its effectiveness. A recent multicenter, retrospective cohort study showed that among 22 U.S. ICUs with “low-intensity” daytime physician staffing (i.e., patients were not routinely cared for by intensivists during the day), ICUs that used in-hospital intensivists at night had lower risk-adjusted mortality than did ICUs without nighttime intensivists. Among 27 ICUs that used recommended “high-intensity” daytime physician staffing (i.e., mandatory involvement of intensivists as primary physicians or consultants), no such benefits were shown. Given the limitations of observational studies, concerns about the costs and the high burnout of nighttime intensivist staffing as well as the uncertain effect of nighttime intensivist staffing on the education and training of residents, investigators at the University of Pennsylvania conducted a randomized clinical trial of nighttime intensivist staffing at their medical ICU that had high-intensity daytime staffing and continuous coverage by medical residents. The results showed that nighttime in-hospital intensivist staffing did not improve patient outcomes despite the fact that 61% of the patient admission occurred at night (rate ratio = 0.81 [95% CI, 0.86–1.12]; P = 0.81). In summary, these results suggest that each hospital should evaluate the level of daytime in-hospital intensivist staffing and the quality of care delivered to ICU patients before implementing a costly nighttime in-hospital intensivist staffing.
(This article was suggested by Jean-François Pittet.)
Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013; 368:2159–68
Previous trials involving patients with the acute respiratory distress syndrome (ARDS) have failed to show a beneficial effect of prone positioning during mechanical ventilatory support on outcomes. This randomized clinical trial evaluated the effect of early application of prone positioning on outcomes in patients with severe ARDS. Severe ARDS was defined as a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (Fio2) of less than 150 mmHg, with a Fio2 of at least 0.6, a positive end-expiratory pressure of at least 5 cm H2O, and a tidal volume close to 6 ml/kg of predicted body weight. The primary outcome was the proportion of patients who died from any cause within 28 days after inclusion. The results showed that in patients with severe ARDS, early application of prolonged prone-positioning sessions significantly decreased 28-day and 90-day mortality (fig. 2). The important aspects of this trial were that the prone positioning was used early in the treatment of severe ARDS for a large portion of the time ascribed to the intervention and was concentrated over a period of a few days. Thus, if confirmed by another randomized controlled trial, this therapeutic approach may become an important tool in the treatment of severe ARDS, a syndrome for which there is only limited proven treatment except for supportive low-tidal volume ventilation and fluid restriction.
(This article was suggested by Jean-François Pittet.)
Persistent pain in postmastectomy patients: Comparison of psychophysical, medical, surgical, and psychosocial characteristics between patients with and without pain. Pain 2013; 154:660–8
Persistent postsurgical pain, seldom discussed in years past, is increasingly recognized as a problem for many patients. Yet, not all persistent postsurgical pain is created equally. A range of etiologies, manifestations, and predisposing factors have been associated with an array of persistent postsurgical pain conditions. Mastectomy is a type of surgery associated with a relatively high rate of persistent pain, although controversy exists in terms of the psychological, surgical, anesthetic, and cancer therapy-related variables making persistent pain more or less likely. In their recently published study, Schreiber et al. studied 200 women with histories of mastectomy. They collected data on the surgery type, follow-up therapy, and psychological factors and performed quantitative sensory testing. Collecting information within the same study population on multiple possible contributors enhanced the power of the findings. The results suggested that the psychological factors, for example, anxiety, depression, catastrophizing, and somatization, were strongly associated with persistent postsurgical pain as were some of the quantitative sensory tests such as pressure pain thresholds performed on nonsurgically affected areas of the body. Previously associated factors such as factors related to the extent of surgery and adjuvant cancer therapies were not linked to persistent pain in this cohort. These findings are important as they suggest that patient, rather than surgery or treatment specific factors, may be more important in understanding persistent postmastectomy pain. Identifying predisposing or protective factors for chronic pain after specific types of surgery may lead to better strategies for risk stratification or pain prevention.
(This article was suggested by David Clark.)
Medical education in the Electronic Medical Record (EMR) era: Benefits, challenges, and future directions. Acad Med 2013; 88:748–52
Twenty-first century medical care has embraced technological advances that have changed the way physicians practice their craft. Among the technological advances, the electronic medical record (EMR) has had a far-reaching impact on how doctors understand disease and manage their patients and their illnesses. Tierney et al. recognizing that although much has been studied that documents clinical benefit that accrues from use of the EMR, little is known about its benefits to and detractors from medical education. Using the Accreditation Council for Graduate Medical Education medical education competency template (Medical Knowledge, Practice-Based Learning and Improvement, Patient Care, Interpersonal and Communication Skills, Professionalism and Systems-Based Practice), these authors raise the reader’s level of awareness on the positive and not so positive consequences that the EMR has on medical education as well as areas for future research into the “right” place for the EMR in medical education. As an example, the EMR may extend a student’s knowledge about a medical problem through a clinical decision support system embedded into the record that enables just in time/point of care education at the patient’s bedside. This greatly expanded content, however, may overwhelm the novice clinical practitioner and therefore be underused or ignored. A second example of the benefit of the EMR is its reliable ability to track student experiences and document attainment of milestone markers. A third issue springs from today’s patient’s comments on how the EMR diverts the physician’s focus as they offer more attention to the computer screen than their personal charges. Tierney et al. cite this as a threat to the education of our students and their ability to learn professionalism competency. The reference to the articles by Verghese et al. (Verghese A. N Engl J Med 2008; 359:2748–51 and Verghese A, Brady E, et al. Ann Intern Med 2011; 155:550–3) on the iPatient, highlighting this problem, is worthy for our serious consideration.
(This article was suggested by Alan Jay Schwartz.)