High-throughput Operating Room System for Joint Arthroplasties Durably Outperforms Routine Processes

Background: Recent publications have focused on increased operating room (OR) throughput without increasing total OR time. The authors hypothesized that a system of parallel processing for lower extremity joint arthroplasties sustainably reduces nonoperative time and increases throughput.

Methods: The high-throughput parallel processing strategy included neuraxial anesthesia performed in an "induction room" adjacent to the OR, patient selection, an additional circulating nurse, and end-of-case transfer of care to a recovery room nurse who transported the patient from the OR to recovery. Instruments and supplies were prepared in a dedicated sterile setup area. Data were extracted from administrative databases. Group comparisons used standard statistical methods; statistical process control was used to evaluate performance over time.

Results: There were 688 historic control cases from 299 days over 16 months, and 905 high-throughput cases from 304 days spanning 24 consecutive months starting September 1, 2004. Throughput increased from 2.6 +/- 0.7 (mean +/- SD) to 3.4 +/- 0.8 arthroplasties per day per room. Nonoperative time decreased by 36 min (or 50%) per case. Operative time also decreased by 14 min (12%) per case. The end time for the high-throughput OR day was only 16 min later than control. Nonoperative time, operative time, and throughput remained significantly improved after 2 yr of operation. Contribution margin increased 19.6%.     

Renal retransplantation: a retrospective monocentric study

Approximately 10% to 20% of all annual renal transplantations are retransplantations and up to 20% of patients on waiting lists need a repeat kidney because of previous graft failure. The immunological risk is much greater among retransplanted patients than first-time kidney recipients. It is likely that retransplantation will become even more prevalent in the future. However, clinical studies or retrospective data are rare in this patient population. We retrospectively investigated 50 recipients after second or third renal transplantations in our center since 2001. Immunosuppression was performed with corticosteroids, mycophenolate mofetil (MMF), tacrolimus, and induction therapy with either thymoglobulin (2.5 mg/kg body weight; n = 27) or 20 mg basiliximab on days 0 and 4 (n = 22) after renal transplantation; 1 patient was treated with antithymoglobulin Fresenius after combined liver-kidney transplantation. Acute rejection occurred in 12 recipients (44.4%) after thymoglobulin and in 7 recipients (31.8%) after basiliximab induction therapy (P < .05). In 4 (14.8%) thymoglobulin- and 5 (22.7%) basiliximab-treated recipients, vascular rejections were observed (P = NS). Patients with basiliximab treatment showed improved renal function at 1 year after transplantation: serum creatinine 134.3 mumol/L versus 199.6 mumol/L in the thymoglobulin group (P < .05). Over the observation period the renal function remained stable or improved in both groups if rejection treatment was successful. However, allograft failure was higher in the basiliximab-treated group, namely, 18.1% versus 14.8% in thymoglobulin-treated patients, but the difference did not reach statistical significance. In 3 (11.1%) thymoglobulin- and 4 (18.2%) basiliximab-treated patients cytomegalovirus (CMV) infections complicated the follow-up (P = NS). In the follow-up period of 5 years, no malignant diseases were seen in either group. Three basiliximab-treated recipients died in the first year due to sepsis or cardiovascular complications. Two thymoglobulin-treated patients developed BK virus nephropathy in the follow-up period. In conclusion, we observed a high immunological risk and rejection risk among retransplanted kidney recipients in our center. Particularly, severe vascular rejections with a harmful long-term impact on allograft function were observed in this population. Induction treatment seems to be successful to reduce risk and achieve better results. Single-shot thymoglobulin may be preferable to reduce severe vascular rejection and prevent allograft failure than basiliximab with the same infection rate.     

Platelet storage lesion: a new understanding from a proteomic perspective

Platelet storage and availability for the purposes of transfusion are currently restricted by a markedly short shelf life of 5 to 7 days owing to an increased risk of bacterial growth and storage-related deterioration called the platelet storage lesion. Because most bacteria grow to confluence within 5 days during storage at room temperature, there is little increased risk of bacterial overgrowth with testing in place, and the only remaining issue is the quality of platelets during the extended storage. Although the manifestations of the storage lesion have been well studied using a variety of in vitro measures, the precise biochemical pathways involved in the initiation and progression of this process have yet to be identified. Proteomics has emerged as a powerful tool to identify and monitor changes during platelet storage and, in combination with biochemical and physiologic studies, facilitates the development of a sophisticated mechanistic view. In this review, we summarize recent experimental work that has led to a detailed overview of protein changes linked to platelet functions and signaling pathways, providing potential targets for inhibitors to ameliorate the storage lesion.     

Anesthetic considerations for intraoperative management of cerebrovascular disease in neurovascular surgical procedures

Despite new surgical methods and interventions a considerable number of patients who undergo neurovascular procedures emergently or electively have substantial mortality, morbidity, and disability. Sound knowledge of pathophysiology of cerebral hypoperfusion, reliable and timely information from monitoring devices, and appropriate choice of therapeutic intervention is essential for successful anesthetic management of these patients. The management of perioperative vasospasm and temporary ischemia during aneurysm clipping require an understanding of cerebral vascular pathophysiology and neuroprotective measures.