BACKGROUND:To increase the number of postmortem organ and tissue donors, donor registries (DRs) have been introduced. The aim of this review was to understand why people in nations with an Opt-in system, who are for or against donation after death, do not register in the DR. Knowing these barriers will help in developing policies to increase the registration rate in the DR.METHODS:For this review, 2 authors independently assessed the eligibility of the identified studies from 2000 to 2015 in the Pubmed- Medline database. Included were observational and interventional studies concerned with reported barriers to residents joining the national DR in Denmark, The Netherlands, and the United Kingdom.RESULTS:We included 15 relevant articles for the review. The main barriers to signing the DR in nations using the Opt-in system were: religion; medical mistrust, anxiety, and affective emotions; lack of information; concern about insufficient time to mourn, and that the funeral may be delayed and the deceased not look presentable; physical integrity; ignorance about how to register in the DR; own benefit; and social status.CONCLUSIONS:The outcome suggests that the main barriers to enrolling in the DR are based on people's doubts about their own ability to perform the registration and cope with the consequences, knowledge, outcome expectations, and concerns about what others will think of them for agreeing to donation. However, not all barriers are easily modifiable, owing to their association with affect or emotions.

The pectoral nerves (Pecs) blocks are challenging the conventional approach of basing change in practice on scientific evidence. Indeed, several practitioners have already incorporated these blocks into their practice before conclusive evidence regarding their efficacy and safety has been published. This systematic literature review examines the analgesic efficacy of Pecs type I and II blocks for their current indications. We searched publications indexed by MEDLINE, EMBASE, Cochrane Library and Google Scholar from inception to October 2016 without publication type, status, language or publication period restrictions. In addition, we searched references and citations for other relevant studies. Results from our systematic literature search show encouraging and consistent evidence that the Pecs blocks produce effective analgesia, and reduce perioperative opioid consumption as compared to control groups without regional anesthesia, as well as other regional anesthesia techniques. Furthermore, the Pecs blocks provide favorable analgesic results in a wide range of indications including regional anesthesia and pain medicine technique. The absence of block-related complications reported in the literature may suggest that the Pecs blocks are easy to apply and safe for patients.

Two hours after swallowing of a two-euro coin, general anesthesia was administered in an 8-yearold girl for therapeutic esophagoscopy. Despite the absence of preoperative respiratory distress and a coronal position of the coin on a pre-operatively performed chest radiograph, a narrowing of the tracheal lumen unexpectedly complicated endotracheal intubation. Based on the age a much smaller endotracheal tube size was required, which could be placed with a rotating movement. The endoscopic removal of the foreign body from the upper esophagus was performed without further complications. Anatomical, pathophysiological and anesthesiological aspects of the relation between the trachea and the bulging esophagus arc being discussed. Airway management must include awareness of an increased risk of airway obstruction by the esophageal foreign body. The anesthesiologist must be prepared for unexpected and changing situations.

Background: This study assesses the effect of the implementation of a concise pretransfusion checklist as a means for restrictive blood transfusion strategy.Objectives: To achieve an optimal use of red blood cells and to prevent overdosing of transfusion by implementation of a decision support algorithm.Methods: To ensure adequate use of red blood cells, physicians were obliged to complete the checklist with pretransfusion patient information before transfusion was approved. Laboratory employees checked the information and provided approval or refused to process the request. The red blood cell transfusion events, length of stay and mortality were analysed during a pre-and post-implementation period of 1 year.Results: Transfusion requests decreased by 17.0%. The proportion of 1-unit and 2-unit transfusions decreased by 5.6% and 29.2%, respectively, corresponding with a total red blood cell units reduction of 22.6% and a yearly direct local cost reduction of 190.000(sic). The median length of stay of transfused patients on wards decreased by 1.07 days (P < 0.05). Average pre-and post-transfusion haemoglobin levels before and after implementation of the checklist decreased by 0.32-0.35 g L-1 (P < 0.05) for one unit red blood cell transfusions and 0.72-0.87 g L-1 (P < 0.05) for two units of red blood cell transfusions.Conclusion: Decision support for transfusion necessity, in the form of a concise checklist as part of the transfusion request, is an example of a successful restricted blood transfusion strategy. The checklist can be applied in other hospitals as well.

Background. In hospitals, physicians are rarely confronted with tissue donation. Besides correctly identifying an eligible tissue donor, the physician also must deal with the bereaved family. When the immediate family members were asked to consent for tissue donation, objection by the next of kin appears to be the main reason for the loss of potential tissue donors, if no registration is found in the donor register. Therefore, physicians' guidance of next of kin through the consent process for tissue donation is an essential part of the recruitment process and requires adequate communication about donation skills and techniques. We analyzed if physicians educated with a video-based E-learning program on "communication about donation skills" successfully contributes to a higher consent rate for tissue donation.Methods. This retrospective study was conducted in 2014 in a Dutch teaching hospital. Two groups of physicians were compared; physicians receiving a lecture on "tissue donation" and physicians receiving additional E-learning on "communication about donation." The results were analyzed on the outcome "obtained consent" for tissue donation from next of kin.Results. Analyses show that physicians receiving a lecture about organ and tissue donation extended with video-based E-learning on communication about donation obtain a significantly (P <= .011) higher consent rate (55.6%) for tissue donation compared with physicians who only receive a lecture (15.5%).Conclusions. A mandatory offer for physicians to follow E-learning on communication about donation must be considered. This could help the availability of tissue donors.

Background. Post-operative anaemia following total knee arthroplasty is reported to impede functional mobility in the early period following surgery, whereas allogeneic blood transfusions, used to correct low post-operative haemoglobin levels, have concomitant disadvantages. The use of a post-operative autologous blood re-transfusion drainage system as well as no drainage system following total knee arthroplasty have been shown to reduce pen-operative blood loss and allogeneic blood transfusions, compared to the regularly used closed-suction drains. No randomised studies have been performed, to the best of our knowledge, that indicate the superiority of either method.Materials and methods. An open, randomised controlled study was conducted in 115 patients undergoing total knee arthroplasty who were randomly allocated to an autotransfusion drain or no drainage system. The primary end-point was haemoglobin level on the first post-operative day.Results. In the autotransfusion group 515 mL (0-1,500 mL) of drained blood was re-transfused within the first 6 hours after surgery. Haemoglobin levels on the first (11.6 vs 11.0 g/dL), second (11.0 vs 10.3 g/dL) and third (10.5 vs 9.8 g/dL) days after surgery were significantly higher in the autotransfusion group. Total pen-operative net blood loss (1,576 mL vs 1,837 mL; P=0.03) and allogeneic transfusion rates (10.2% vs 19.6%; P=0.15) were lower in the autotransfusion group. There were no differences in pain scores, range of motion or adverse events during hospital stay and the first 3 months after surgery.Discussion. Compared with no drainage, the use of a post-operative autologous blood re-transfusion drainage system following total knee arthroplasty results in higher post-operative haemoglobin levels and less total blood loss.

In dit artikel laten wij zien dat de ziekenhuissterfte in de afgelopen 10 jaar duidelijk gedaald is. Als deze trend zich voortzet, zal de beschikbaarheid van potentiële orgaanen weefseldonoren fors afnemen. In Nederland komen organen en weefsels namelijk alleen beschikbaar voor donatie na overlijden in een ziekenhuis. Donatie van weefsel na een overlijden thuis komt vrijwel niet voor. Een overzicht uit 2004 van het Centraal Bureau voor de Statistiek (CBS) geeft aan dat ongeveer 1 op de 3 mensen overlijdt in het ziekenhuis. Anders gezegd: twee derde van de Nederlanders valt al bij voorbaat af als donor van organen of weefsel voor transplantatie na overlijden.

SUMMARYTotal hip arthroplasty (THA) and total knee arthroplasty (TKA) are associated with a considerable amount of total blood loss. This results in a significant postoperative decline in hemoglobin levels, and thereby the use of allogeneic blood transfusion (ABT), which is not a risk‐free therapy. Postoperative shed blood (PSB) salvage and retransfusion, after washing or filtering, was introduced as a unique blood saving concept to decrease perioperative blood loss, to maintain higher postoperative hemoglobin levels and to decrease the use of ABT. PSB reinfusion must be restricted to elective procedures with an anticipated postoperative blood loss between 750 mL and 1500 mL, allowing for the recovery of at least the equivalent of one unit of packed red cells, and used in conjunction with a defined ABT protocol. The results of a number of clinical and laboratory studies strongly suggest that reinfusion of unwashed PSB can reduce the requirements for ABT, and that most of the potential adverse effects of unwashed PSB are no more than theoretical. Therefore, reinfusion of unwashed PSB after THA and TKA is easy‐to‐use, safe, economic and clinically beneficial, as it may reduce ABT‐associated risks. The superiority of washed PSB over unwashed PSB in these procedures has not been demonstrated. All these make widespread use of unwashed PSB available for all patients and justified.

Preoperative anaemia is common in patients undergoing orthopaedic and other major surgery. Anaemia is associated with increased risks of postoperative mortality and morbidity, infectious complications, prolonged hospitalization, and a greater likelihood of allogeneic red blood cell (RBC) transfusion. Evidence of the clinical and economic disadvantages of RBC transfusion in treating perioperative anaemia has prompted recommendations for its restriction and a growing interest in approaches that rely on patients' own (rather than donor) blood. These approaches are collectively termed ‘patient blood management' (PBM). PBM involves the use of multidisciplinary, multimodal, individualized strategies to minimize RBC transfusion with the ultimate goal of improving patient outcomes. PBM relies on approaches (pillars) that detect and treat perioperative anaemia and reduce surgical blood loss and perioperative coagulopathy to harness and optimize physiological tolerance of anaemia. After the recent resolution 63.12 of the World Health Assembly, the implementation of PBM is encouraged in all WHO member states. This new standard of care is now established in some centres in the USA and Austria, in Western Australia, and nationally in the Netherlands. However, there is a pressing need for European healthcare providers to integrate PBM strategies into routine care for patients undergoing orthopaedic and other types of surgery in order to reduce the use of unnecessary transfusions and improve the quality of care. After reviewing current PBM practices in Europe, this article offers recommendations supporting its wider implementation, focusing on anaemia management, the first of the three pillars of PBM.

Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. A standardized approach for the detection, evaluation, and management of anaemia in this setting has been identified as an unmet medical need. A multidisciplinary panel of physicians was convened by the Network for Advancement of Transfusion Alternatives (NATA) with the aim of developing practice guidelines for the detection, evaluation, and management of preoperative anaemia in elective orthopaedic surgery. A systematic literature review and critical evaluation of the evidence was performed, and recommendations were formulated according to the method proposed by the Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. We recommend that elective orthopaedic surgical patients have a haemoglobin (Hb) level determination 28 days before the scheduled surgical procedure if possible (Grade 1C). We suggest that the patient’s target Hb before elective surgery be within the normal range, according to the World Health Organization criteria (Grade 2C). We recommend further laboratory testing to evaluate anaemia for nutritional deficiencies, chronic renal insufficiency, and/or chronic inflammatory disease (Grade 1C). We recommend that nutritional deficiencies be treated (Grade 1C). We suggest that erythropoiesis-stimulating agents be used for anaemic patients in whom nutritional deficiencies have been ruled out, corrected, or both (Grade 2A). Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value. Implementation of anaemia management in the elective orthopaedic surgery setting will improve patient outcomes.

The Dutch health care system introduced a simple and efficacious blood management. Among European countries, the Netherlands has the lowest frequency of allogeneic blood transfusions. Dutch blood management comprises from acceptance of a low transfusion trigger, the treatment of anaemia before elective surgery and use of autologous retransfusion. The simple concept is applied to a fairly high volume of orthopedic surgery. Meanwhile, it is certified as a quality management concept and gets an external audit every year. The success of the Dutch blood management is the reduced mortality and the decreased infection rate. Furthermore, it is cost-efficient by direct savings of 100 million (sic) a year. The critical elements - such as the consensus between medical societies about the resulting improved patient care, the cost-efficiency and the limitation to only a few blood sparing techniques responsable for the blood management's prosperousness might be worth to consider in Germany.

Autologous retransfusion of filtered drained blood is widely used after total hip (THA) and knee arthroplasty (TKA) in many countries. Despite its wide use, prospective studies on clinical side effects with a substantial number of patients have not been published. In this prospective clinical trial, 1819 consecutive patients in 38 hospitals were retransfused using a low-suction drainage autologous blood transfusion system, after THA (n = 995) or TKA (n = 824). The occurrence of adverse events during retransfusion of the filtered shed blood was studied. An average of 460 mL of drained blood (THA, 374 mL; TKA, 563 mL) was retransfused within 6 hours postoperatively. The frequency of serious adverse events was 0.1%, which concerned two patients: one had a short asystole during reinfusion that responded quickly to medication; and the other with a history of deep vein thrombosis had pulmonary embolism. By way of non-serious adverse events, febrile reactions (fever, shivering) were observed in 3.1% of the patients during retransfusion. Clot formation was observed in the drained blood in six (0.3%) patients; therefore, retransfusion was not carried out. These minor adverse events were seen more often after TKA (5.8%) than after THA (1.5%). Nine (0.5%) patients were retransfused with volumes above 1500 mL (average 1657, range 1550–1900), without adverse events. Additional allogenic blood transfusions were required by 18% of the THA and 9% of the TKA patients. In this study, few adverse events were detected during retransfusion. The frequency of serious (0.1%) and minor (3.5%) adverse events was similar to other smaller clinical studies. Based on the low incidence of side effects in this large cohort of orthopedic patients, postoperative cell salvage with such a retransfusion system is considered to be safe.

Purpose Total knee arthroplasty (TKA) is often associated with major postoperative blood loss, postoperative pain, and impaired wound healing. The application of autologous platelet gel (APG), prepared from the buffy coat of a unit of autologous blood, has been advocated to improve haemostasis after surgery, to decrease perioperative blood loss, diminish postoperative pain and to enhance the wound healing process. This randomized controlled pilot study was developed to assess the effects of APG after total knee arthroplasty on blood loss, wound healing, pain, range of motion, and hospital stay.Method A prospective, randomized observer blind controlled trial was performed. Forty patients with only osteoarthritis of the knee were scheduled to have a TKA, and they were randomized into two groups. Patients in the treatment group were all treated with the application of autologous platelet gel after the prosthesis was implanted. Patients in the control group were treated with the same protocol but no APG was used.Results Preoperative and postoperative Hb levels showed no significant difference and allogenic blood transfusions were not given in either group. Haematomas were significantly larger in the control group than in the platelet gel group (P = 0.03). The pain score at rest was higher in the control group on the 3rd day (P = 0.04). Wound healing disturbances were seen in four patients in the control group and in no patients in the APG group (n.s.). Range of motion of the knee was similar postoperatively. Hospital stay was 6.2 days in the APG and 7.5 days in the control group (n.s.).Conclusion In this prospective randomized pilot study on APG in total knee arthroplasty, differences in favour of the use of platelet gel were found, but these were subjective evaluations, marginal in effect, or did not reach statistical significance. The use of drains might have decreased the concentration of delivered platelets and may have diminished the effect. However, in this study, a statistically significant clinically important effect in favour of platelet gel application was not found. Further studies with larger numbers of patients, and without the use of drains, are warranted to investigate the possible benefits of autologous platelet gel in total knee arthroplasty.

SUMMARYThe objectives of the study were to compare an autologous blood salvage low‐vacuum drainage system with a high‐vacuum drainage system with regard to blood loss, postoperative hemoglobin levels and need for allogeneic transfusion. The study was an open, randomized, prospective and single‐center trial. Two hundred patients scheduled for revision total hip surgery were randomized to either the Bellovac ABT (autologous blood salvage, low vacuum) or the Medinorm AG (high vacuum) drainage system. Blood loss, transfusion volumes and hemoglobin levels were measured during the whole postoperative period. No statistically significant differences were detected between the two drainage systems with regard to transfusion rate, blood loss and adverse events. The hemoglobin decrease during the first postoperative day was statistically significantly less in the Bellovac ABT group (P = 0.0111). Postoperative hemoglobin concentrations were found to be higher in the Bellovac ABT group compared with the Medinorm group at day 1. In addition, the Bellovac ABT system offers a possibility of transfusion of postoperatively salvaged blood that may decrease the need for allogeneic blood transfusion.

Background: Some patients with long-standing low back pain will benefit from treatment with strong opioids. However, it would be helpful to predict which patients will have a good response. A fixed-term opioid trial has been recommended, but there is little evidence to suggest how long this trial should be. We assessed data from a large-scale randomized comparison of transdermal fentanyl (TDF) and sustained-release oral morphine (slow-release morphine; SRM) to determine characteristics of treatment responders.Methods: This was a secondary analysis of a previously published 13-month randomized trial involving 680 patients with long-standing low back pain (median age 52 years, 61% women, median duration of back pain 87 months). Pain relief was recorded using visual analogue scales (VAS). Treatment response was defined as pain relief of at least 30% from baseline to any point during the trial. We used a step-wise logistic regression to identify variables that might predict response to treatment. Covariates included treatment group, sex, age, duration of pain, presence of neuropathic pain, baseline pain scores, educational/employment status, use of high doses of opioids, and social functioning (SF)-36 scores.Results: Over half the patients in both groups (n = 370; 54% TDF, 55% SRM) were treatment responders. There were no differences between the TDF and SRM responders in terms of age, sex, type or duration of pain between responders and non-responders. The difference in response to treatment between responders and non-responders could be detected at 3 weeks. Lack of response after 1 month had a stronger negative predictive value (i.e., ability to detect non-responders) than the presence of response after 1 month. The most influential factors for predicting a response were employment status (chi(2) = 11.06, p = 0.0259) and use of high doses of opioids (chi(2) = 3.04, p = 0.0811).Conclusion: No clear pattern of baseline pain (type or severity) or patient characteristics emerged that could be used to predict responders before the start of opioid treatment. However, a 1-month trial period appears sufficient to determine response and tolerability in most cases.

Results: Blocks with 60 ml worked statistically significantly quicker than blocks with 45 ml (P 0.036). Adrenaline did not significantly affect onset time. Blocks with 60ml and adrenaline scored best on all measures of block quality. Some of these values reached statistical significance, some not. Adrenaline had the more important effect, and significantly reduced alfentanil consumption (P 0.03) during the operation. All cases of toxicity were after 20–30 minutes. The incidence was 14% without adrenaline and 1% with adrenaline (P 0.0002) (average mepivacaine dose for toxicity was 9.8 mg/kg [7.2 – 15.8]). Signs of toxicity were generally mild, and often elicited on questioning; there were no convulsions.

Background Preoperative epoetin-alpha administration is said to have a limited effect in patients with chronic inflammatory diseases such as rheumatoid arthritis (RA), due to lower iron availability. We studied the effects of preoperative epoetin-alpha treatment in orthopedic surgery patients in a daily life setting in which iron supplementation was assured, and compared the effects in RA and non-RA patients.Methods In an open, naturalistic, randomized controlled trial, 695 orthopedic surgery patients with preoperative hemoglobin (Hb) values of 10-13 g/dL, either with RA (113) or without RA (582), received either preoperative epoetin-alpha treatment added to standard care, or standard care alone. Hb values and transfusions were evaluated from entry into the study until 4-6 weeks after surgery.Results Both in RA and non-RA patients, perioperative Hb values were significantly higher and transfusion requirements were significantly lower in epoetin-alpha treated patients than in control patients (p < 0.001). In RA patients, the outcomes regarding Hb values were not significantly or relevantly different from non-RA patients.Interpretation Just as with orthopedic patients in general, RA patients benefit from preoperative epoetin-alpha treatment in combination with iron supplementation. We postulate that iron supplementation during epoetin-alpha therapy in RA patients is important for optimal efficacy.

Purpose: To report successful resuscitation of ventricular fibrillation induced by accidental intravascular injection of ropivacaine.Clinical features: A 15-yr-old healthy girl weighing 59 kg was scheduled for transposition of the tibial tuberosity under combined sciatic/three-in-one block, No premedication was given. In the induction room, an iv infusion was started, along with electrocardiogram monitoring, non-invasive blood-pressure measurement and pulse-oximetry. The sciatic nerve was found with the use of a nerve stimulator at the first attempt by the classical approach of Labat. Aspiration for blood was negative and the injection of ropivacaine 0.75% without epinephrine started. Convulsions, followed within seconds by ventricular fibrillation occurred at the end of the injection of 18 mL ropivacaine 0.75%. Oxygen was administered by face mask ventilation and immediate defibrillation was successful on the second attempt (2 X 200 joules). Within two minutes convulsions stopped and normal cardiac rhythm returned. Propofol and sufentanil were injected and a laryngeal mask inserted to start general anesthesia for surgery, Postoperatively no evidence of sciatic block could be demonstrated. The patient did not remember the event and was discharged the following day with no residual effects.Conclusion: This case report shows that ventricular fibrillation after unintentional intravascular injection of ropivacaine can be treated successfully when one is prepared and cardiac life support measures are taken immediately.