October 31, 2023
Literature selections curated by Lewis Flint, MD, FACS, and reviewed by theĢżĀé¶¹“«Ć½BriefĢżeditorial board.Ģż
Riley MS, Etheridge J, Palter V, et al. . J Am Coll Surg. 2023, in press.
Compliance with the components of the World Health Organization Surgical Safety Checklist (SSC) has been associated with improvements in OR teamwork, communication, and surgical outcomes. The three main āpause pointsā of the SSC are the brief before anesthesia induction, the timeout before skin incision, and the debrief before the patient leaves the OR. A major impediment to documenting adequate compliance with the SSC has been the need for real-time, in-person verification of compliance, an approach that is expensive and difficult to apply efficiently.
This study reported the use of the OR Black Box, an electronic data-gathering device (audio, video, and patient physiologic measures) as a means of capturing the needed information to confirm SSC usage by surgical teams. Data from 7,243 procedures were analyzed; a timeout was performed in 98.4% of cases and a debrief in 62.3%. The proportion of OR team members participating in the timeout and debrief was 75.5% and 54.6%, respectively.
The data showed that debrief completion was less than timeout completion, a finding similar to data from other published studies. Of interest was the observation that when a team introduction was included in the brief prior to anesthesia induction or the timeout prior to the skin incision, compliance with SSC components was significantly improved.
The authors concluded that evaluation of SSC compliance using the OR Black Box was feasible and potentially cost-effective.
Davenport R, Curry N, Fox EE, et al. ." JAMA. 2023, in press.
Editorial: Tisherman SA, Brenner, ML. . JAMA. 2023, in press.
Hemorrhage is a major cause of trauma-related mortality, and massive hemorrhage is associated with coagulopathy that is due, in part, to fibrinogen deficiency. Correction of fibrinogen deficiency can be accomplished with replacement using cryoprecipitate, but the effectiveness of this approach is reduced by the fact that cryoprecipitate administration is often delayed.
This randomized, multicenter study compared early, empirical, high-dose cryoprecipitate (6 g fibrinogen equivalent) with standard care in 1,604 patients (799 received cryoprecipitate) who were treated for trauma-related hemorrhage using a massive transfusion protocol and received cryoprecipitate within 3 hours of injury.
Median ISS was 29, and 36% of patients sustained penetrating injury. All-cause, 28-day mortality was similar in both groups (26.1% in the standard care group and 25.3% in the cryoprecipitate group). Safety outcomes and risk of thrombotic events were similar in both groups.
The authors concluded that early administration of cryoprecipitate did not improve all-cause mortalityĢż and noted that the findings of the study were limited by lack of a placebo group, lack of blood fibrinogen testing, and variation in timing of cryoprecipitate administration.
In the accompanying editorial by Samuel A. Tisherman, MD, and Megan L. Brenner, MD, the editorialists emphasized that cryoprecipitate may not have improved outcomes because of reduced severity of hemorrhage-associated coagulopathy resulting from the use of early balanced blood product resuscitation in massive transfusion protocols. In addition, numbers of patients with actual uncontrolled hemorrhage may not have been sufficient to disclose a treatment effect. Additional prospective studies are needed to define the potential benefits of early cryoprecipitate administration more completely in injured patients with uncontrolled hemorrhage.