Safe surgery: how accurate are we at predicting intra‐operative blood loss?

Introduction Preoperative estimation of intra‐operative blood loss by both anaesthetist and operating surgeon is a criterion of the World Health Organization's surgical safety checklist. The checklist requires specific preoperative planning when anticipated blood loss is greater than 500 mL. The aim of this study was to assess the accuracy of surgeons and anaesthetists at predicting intra‐operative blood loss. Methods A 6‐week prospective study of intermediate and major operations in an academic medical centre was performed. An independent observer interviewed surgical and anaesthetic consultants and registrars, preoperatively asking each to predict expected blood loss in millilitre. Intra‐operative blood loss was measured and compared with these predictions. Parameters including the use of anticoagulation and anti‐platelet therapy as well as intra‐operative hypothermia and hypotension were recorded. Results One hundred sixty‐eight operations were included in the study, including 142 elective and 26 emergency operations. Blood loss was predicted to within 500 mL of measured blood loss in 89% of cases. Consultant surgeons tended to underestimate blood loss, doing so in 43% of all cases, while consultant anaesthetists were more likely to overestimate (60% of all operations). Twelve patients (7%) had underestimation of blood loss of more than 500 mL by both surgeon and anaesthetist. Thirty per cent (n = 6/20) of patients requiring transfusion of a blood product within 24 hours of surgery had blood loss underestimated by more than 500 mL by both surgeon and anaesthetist. There was no significant difference in prediction between patients on anti‐platelet or anticoagulation therapy preoperatively and those not on the said therapies. Conclusion Predicted intra‐operative blood loss was within 500 mL of measured blood loss in 89% of operations. In 30% of patients who ultimately receive a blood transfusion, both the surgeon and anaesthetist significantly underestimate the risk of blood loss by greater than 500 mL. Theatre staff must be aware that 1 in 14 patients undergoing intermediate or major surgery will have an unexpected blood loss exceeding 500 mL and so robust policies to identify and manage such circumstances should be in place to improve patient safety.     

Case Report: A Technique to Remove a Jammed Locking Screw from a Locking Plate

Background  

Locking titanium plates revolutionized the treatment of osteoporotic and metaphyseal fractures of long bones. However as with any innovation, with time new complications are identified. One of the problems with titanium locking plates is removal of screws, often attributable to cold welding of screw heads into the locking screw holes. Several techniques have been described to overcome this problem. We describe a new easy technique to remove a jammed locking screw in a locking plate that is easily reproducible and suggest an algorithm to determine the method to remove screws from locking plates.     

Stent implantation to relieve native obstructed left partial anomalous pulmonary venous connections

Obstructed partial anomalous pulmonary venous connections (APVC) are rare but may be associated with severe pulmonary hypertension (PHTN) and warrant urgent relief. There are a number of case reports of successful catheter intervention for obstructed total APVC. We present the first reported case of catheter intervention to relieve obstructed, left sided PAPVC in a neonate with Turner syndrome. © 2016 Wiley Periodicals, Inc.     

Inhibition of pentagastrin-stimulated gastric secretion by duodenal acidification or administration of fat in normal subjects and in patients with duodenal ulcer

The inhibitory effect of duodenal acidification and intraduodenal fat infusion on pentagastrin-stimulated gastric secretion in normal subjects and in patients with duodenal ulcer was studied. Intraduodenal infusion of acid resulted in inhibition of HCl secretion found to be significant only in ulcer patients. Pepsin output, although lower during the first 15 minutes of duodenal acidification, later increased. Intraduodenal infusion of olive oil resulted in significant inhibition of HCl and pepsin output in both groups of patients, which was maximal 45–60 minutes after the beginning of fat infusion. Gastric secretion was more readily inhibited in ulcer patients than in normal subjects; this difference was particularly evident in inhibition of pepsin secretion. In addition, decrease in concentration of HCl and pepsin was observed to be significant only in ulcer patients. Mechanisms by which duodenal acidification and fat inhibit gastric secretion are discussed. The results obtained suggest that secretin, which is probably responsible for inhibition after duodenal acidification, is not the inhibitor during inhibition by fat. The ulcer patients were found to have unimpaired mechanisms of inhibition by acid and fat.