Journal of the American College of Surgeons
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Despite the risks associated with transfusion, the medical community continues to view blood as a safe and abundant product. In this article, we provide an effective strategy to accomplish orthotopic liver transplantation without transfusion. ⋯ Preoperative blood augmentation and acute normovolemic hemodilution provide a safe cushion against operative blood loss. Elective living donor liver transplantation allows full implementation of a transfusion-free strategy in the setting of early hepatic failure, portal hypertension, and anemia. This feat is an important step toward global standardization of transfusion-free surgical practice and an important response to widespread blood shortages and transfusion risks.
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Many large academic practices have accepted the notion that subspecialization provides certain benefits-more consistent care, a higher degree of state-of-the-art knowledge, improved teaching, and better working relationships and communication among the subspecialty anesthesia faculty and their surgical and nursing colleagues. But a rigid subspecialty grouping is rarely done in the main body of an academic faculty. ⋯ The faculty did not perceive an overall benefit from a move to greater subspecialization in the organization of the anesthesia department, despite the leadership's opinion that the workplace had become much more functional and productive.
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Trimodal distribution of trauma deaths, described more than 20 years ago, is still widely taught in the design of trauma systems. The purpose of this study was to examine the applicability of this trimodal distribution in a modern trauma system. ⋯ The classic "trimodal" distribution of deaths does not apply in our trauma system. Temporal distribution of deaths is influenced by the mechanism of injury, age of the patient, and body area with severe trauma. Knowledge of the time of distribution of deaths might help in allocating trauma resources and focusing research effort.
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Corporate performance-improvement methodologies can outperform traditional ones in addressing ICU-based adverse events. My colleagues and I used Six Sigma methodology to address our catheter-related bloodstream infection (CR-BSI) rate, which considerably exceeded the nationally established median over a 9-year period. We hypothesized that use of Six Sigma methodology would result in a substantial and sustainable decrease in our CR-BSI rate. ⋯ This represents the first successful application of Six Sigma corporate performance-improvement method impacting purely clinical outcomes. CR-BSI reduction was highly substantial and sustained after other traditional strategies had failed.
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Improvement in day-to-day functioning is a valued outcome of surgical intervention. A new functional status assessment instrument, the Activities Assessment Scale (AAS), was designed for a randomized clinical trial evaluating laparoscopic versus open hernia repair procedures. ⋯ The AAS has been demonstrated to be a reliable, valid, and clinically responsive instrument that can be used to evaluate patient functioning after hernia surgery. It is easy to administer and requires less than 5 minutes of patient time to complete. This measurement system may prove useful in assessing surgical outcomes in both research and office practice settings.