Towards evidence-based medicine in surgical practice: best BETs

Surgeons are faced with the dilemma that many clinical questions in their daily practice to do not have universally agreed answers, but patients increasingly demand the 'best practice' from their doctors. In addition time pressures mean that clinicians are unable to keep up with the full spectrum of published research. We have adopted an approach first pioneered in emergency medicine, namely the Best Evidence Topic or Best BET. Clinicians select a clinical scenario from their daily practice that highlights an area of controversy. From this, a three-part question is generated and this is used to search Medline and other appropriate databases for relevant papers. Once the relevant papers are found, these papers are critically appraised, the relevant data to answer the question is extracted, tabulated and summarised. A clinical bottom line is reached after this process. The resulting BETs, written by practising surgeons can then provide robust evidence-based answers to important clinical questions asked during our daily practice.     

Transfusion practice in trauma patient

Anemia is common in critically ill patients and carries risk of reduced oxygen carriage and worse outcomes. Transfusion, however, carry their own risk, and the physician must balance the risks of anemia with the risk of transfusion in each patient. Some recent studies compared a liberal with a restrictive approach to transfusion, and a clinical practice guidelines were made. This protocols consider that acute hemorrhage has been controlled, the initial resuscitation has been completed, and the patient is stabile in the intensive care unit without ongoing bleeding. The trigger for PRBC transfusion in patients without severe cardiovascular disease is hemoglobin g/dL (or a hematocrit %).     

Evidence-based medicine—from best research evidence to a better surgical practice and health care

Background The use of the terms evidence-based medicine (EBM) and healthcare (EBHC) has become commonplace in the medical as well as in the surgical literature. Using the best available evidence, however, is not yet a working routine among surgeons because of the large amount and complexity of published research and the lack of user-friendly tools and necessary skills for the use of research results. Discussion This article encourages to formulate surgically relevant questions and to answer them on the basis of high-quality research, preferably by using systematic reviews which are based on the quality criteria of the Cochrane Collaboration. Conclusions As currently only 77 Cochrane reviews address surgical procedures; much work remains to be done to enlarge the number of high-quality and relevant reviews. Similarly, the number and quality of randomized controlled trials need to be increased in all surgical specialties.     

Simultaneous surgical interventions in surgical practice

The results of 308 emergency (61%) and elective (39%) simultaneous operative interventions, comprising 2.2% of the total number of operations for 10 years, are presented. In performing the simultaneous operations for strict indications, the risk of intervention increases insignificantly. The incidence of postoperative complications and lethality after such interventions do not exceed the corresponding indices after similar operations, but performed separately.     

Urologists and their surgical practice

The work characteristics of urologists were studied as part of a national study of surgeon manpower. Urologists were found to work short hours relative to other surgical specialties, and their operative work load ranked sixth among the ten surgical specialties. The major conclusion was that the supply of urologists was greater than necessary to meet the need for urologic consultants.     

Transfusion insurgency: practice change through education and evidence-based recommendations

Background

In 2000, we implemented an evidence-based guideline in the surgical intensive care unit (SICU) using a transfusion threshold of hemoglobin <8 g/dL. We hypothesized that continual education on the transfusion protocol would decrease transfusions.

Methods

We analyzed 2-month samples of admissions in even-numbered years from 1998 to 2006. Any infusion of packed red blood cells (PRBCs) was included.

Results

We analyzed data from 2,138 patients resulting in 5,130 transfusions. Thirty-six patients received >20 U of blood. The only difference between groups occurred in 2006 when renal failure increased. Transfusions decreased from 3.2 ± 0.34 (SE) to 1.7 ± 0.2. The number of patients who received blood also decreased. Mortality and length of stay (LOS) were not different among the groups. Every unit of blood transfused increased the mortality risk by 14%.

Conclusions

Implementation of an evidence-based transfusion guideline reduced the number of infused units and patients transfused without an increase in mortality.     

Transfusion medicine management for reconstructive spinal repair in a patient with von Willebrand's disease and a history of heavy surgical bleeding.

STUDY DESIGN: A case report of a multidisciplinary approach to a second reconstructive back surgery in a patient with von Willebrand's disease, flatback syndrome, and a history of heavy surgical bleeding is presented. OBJECTIVE: To review the perioperative planning and assessment of hemostasis and transfusion medicine management, including administration of Humate P, a Factor VIII preparation with high von Willebrand factor content. SUMMARY OF BACKGROUND DATA: Reconstructive spinal procedures may require significant transfusion support even in patients with normal preoperative hemostasis. In addition to the hemostatic problem caused by von Willebrand's disease, the reported patient requested minimal exposure to allogeneic blood products because of hepatitis C infection acquired from previous transfusions. METHODS: The multidisciplinary team included the patient, hematologist, blood bank medical director, anesthesiologist, and operating surgeon. Preoperative assessment showed a Type 2A von Willebrand's disease variant. A careful planning process included a test infusion of desmopressin and extensive autologous donations of red cells, plasma, and platelets, which were collected before the procedure. RESULTS: Anterior and posterior spine fusions were performed during a 14-hour procedure. Hemostasis and clinical response were excellent. Humate P was administered perioperatively as assessed by the baseline Factor VIII and von Willebrand's disease levels, the plasma volume, the half-life of infused Humate P, and the anticipated risk and tolerance for bleeding. The estimated blood loss was 5 L. Replacement included 9 units of autologous red cells, 6 units of autologous plasma, 2 autologous plateletpheresis collections, a single allogeneic plateletpheresis product, and 17,000 units of Humate P administered over the perioperative period. CONCLUSIONS: Using a careful multidisciplinary approach, excellent hemostasis can be achieved with minimal exposure to untreated allogeneic blood products during aggressive spinal surgery in a patient with a clinically significant congenital coagulopathy.