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Background: Device-related bloodstream infections are associated with a significant increase in patient morbidity and mortality in multiple health care settings. Recently, intraoperative bacterial contamination of conventional open-lumen 3-way stopcock sets has been shown to be associated with increased patient mortality. Intraoperative use of disinfectable, needleless closed catheter devices (DNCCs) may reduce the risk of bacterial injection as compared to conventional open-lumen devices due to an intrinsic barrier to bacterial entry associated with valve design and/or the capacity for surface disinfection. However, the relative benefit of DNCC valve design (intrinsic barrier capacity) as compared to surface disinfection in attenuation of bacterial injection in the clinical environment is untested and entirely unknown. The primary aim of the current study was to investigate the relative efficacy of a novel disinfectable stopcock, the Ultraport zero, with and without disinfection in attenuating intraoperative injection of potential bacterial pathogens as compared to a conventional open-lumen stopcock intravascular device. The secondary aims were to identify risk factors for bacterial injection and to estimate the quantity of bacterial organisms injected during catheter handling., Methods: Four hundred sixty-eight operating room environments were randomized by a computer generated list to 1 of 3 device-injection schemes: (1) injection of the Ultraport zero stopcock with hub disinfection before injection, (2) injection of the Ultraport zero stopcock without prior hub disinfection, and (3) injection of the conventional open-lumen stopcock closed with sterile caps according to usual practice. After induction of general anesthesia, the primary anesthesia provider caring for patients in each operating room environment was asked to perform a series of 5 injections of sterile saline through the assigned device into an ex vivo catheter system. The primary outcome was the incidence of bacterial contamination of the injected fluid column (effluent). Risk factors for effluent contamination were identified in univariate analysis, and a controlled laboratory experiment was used to generate an estimate of the bacterial load injected for contaminated effluent samples., Results: The incidence of effluent bacterial contamination was 0% (0/152) for the Ultraport zero stopcock with hub disinfection before injection, 4% (7/162) for the Ultraport zero stopcock without hub disinfection before injection, and 3.2% (5/154) for the conventional open-lumen stopcock. The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of bacterial injection as compared to the conventional open-lumen stopcock (RR = 8.15 × 10(-8), 95% CI, 3.39 × 10(-8) to 1.96 × 10(-7), P = <0.001), with an absolute risk reduction of 3.2% (95% CI, 0.5% to 7.4%). Provider glove use was a risk factor for effluent contamination (RR = 10.48, 95% CI, 3.16 to 34.80, P < 0.001). The estimated quantity of bacteria injected reached a clinically significant threshold of 50,000 colony-forming units per each injection series., Conclusions: The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of inadvertent bacterial injection as compared to the conventional open-lumen stopcock. Future studies should examine strategies designed to facilitate health care provider DNCC hub disinfection and proper device handling.

Background: We have recently shown that intraoperative bacterial transmission to patient IV stopcock sets is associated with increased patient mortality. In this study, we hypothesized that bacterial contamination of anesthesia provider hands before patient contact is a risk factor for direct intraoperative bacterial transmission., Methods: Dartmouth-Hitchcock Medical Center is a tertiary care and level 1 trauma center with 400 inpatient beds and 28 operating suites. The first and second operative cases in each of 92 operating rooms were randomly selected for analysis. Eighty-two paired samples were analyzed. Ten pairs of cases were excluded because of broken or missing sampling protocol and lost samples. We identified cases of intraoperative bacterial transmission to the patient IV stopcock set and the anesthesia environment (adjustable pressure-limiting valve and agent dial) in each operating room pair by using a previously validated protocol. We then used biotype analysis to compare these transmitted organisms to those organisms isolated from the hands of anesthesia providers obtained before the start of each case. Provider-origin transmission was defined as potential pathogens isolated in the patient stopcock set or environment that had an identical biotype to the same organism isolated from hands of providers. We also assessed the efficacy of the current intraoperative cleaning protocol by evaluating isolated potential pathogens identified at the start of case 2. Poor intraoperative cleaning was defined as 1 or more potential pathogens found in the anesthesia environment at the start of case 2 that were not there at the beginning of case 1. We collected clinical and epidemiological data on all the cases to identify risk factors for contamination., Results: One hundred sixty-four cases (82 case pairs) were studied. We identified intraoperative bacterial transmission to the IV stopcock set in 11.5 % (19/164) of cases, 47% (9/19) of which were of provider origin. We identified intraoperative bacterial transmission to the anesthesia environment in 89% (146/164) of cases, 12% (17/146) of which were of provider origin. The number of rooms that an attending anesthesiologist supervised simultaneously, the age of the patient, and patient discharge from the operating room to an intensive care unit were independent predictors of bacterial transmission events not directly linked to providers., Conclusion: The contaminated hands of anesthesia providers serve as a significant source of patient environmental and stopcock set contamination in the operating room. Additional sources of intraoperative bacterial transmission, including postoperative environmental cleaning practices, should be further studied.

Background: Exposure to red blood cell (RBC) transfusions has been associated with increased mortality after cardiac surgery. We examined long-term survival for cardiac surgical patients who received one or two RBC units during index hospitalization., Methods: Nine thousand seventy-nine consecutive patients undergoing coronary artery bypass graft, valve, or coronary artery bypass graft/valve surgery at eight centers in northern New England during 2001-2004 were examined after exclusions. A probabilistic match between the regional registry and the Social Security Administration's Death Master File determined mortality through June 30, 2006. Cox Proportional Hazard and propensity methods were used to calculate adjusted hazard ratios., Results: Thirty-six percent of patients (n = 3254) were exposed to one or two RBC units. Forty-three percent of RBCs were given intraoperatively, 56% in the postoperative period and 1% were preoperative. Patients transfused were more likely to be anemic, older, smaller, female and with more comorbid illness. Survival was significantly decreased for all patients exposed to 1 or 2 U of RBCs during hospitalization for cardiac surgery compared with those who received none (P < 0.001). After adjustment for patient and disease characteristics, patients exposed to 1 or 2 U of RBCs had a 16% higher long-term mortality risk (adjusted hazard ratios = 1.16, 95% CI: 1.01-1.34, P = 0.035)., Conclusions: Exposure to 1 or 2 U of RBCs was associated with a 16% increased hazard of decreased survival after cardiac surgery.

Studies of pediatric sedation practice have suffered from the lack of an objective scale that would allow for a comparison of the effectiveness and safety of sedation provided by various providers and techniques. We present the Dartmouth Operative Conditions Scale (DOCS), which is designed as a research tool to codify the appropriateness of the procedural conditions provided by various sedation interventions. To begin, human factors methodology was used to develop a model of the pediatric sedation process and to define the criteria for measuring a patient's condition during a procedure (DOCS). To accomplish validation, 70 video clips (30-s duration) were then selected from more than 300 h of procedural video tape for testing/grading purposes. Inter-rater reliability was tested by comparing the score for each video clip among 10 different raters. Intra-rater reliability was evaluated by retesting all of the raters 1 yr after their initial rating. Construct validity was confirmed by analyzing the change in DOCS score relative to the time that sedation intervention was undertaken. Criterion validity was tested by comparing the DOCS to a modified COMFORT score. The DOCS was completed with excellent inter-rater (kappa = 0.84) and intra-rater (kappa = 0.91) agreement by 10 health care providers with various backgrounds during the 1-yr study period. Criterion validity was supported by the close correlation between the DOCS and the modified COMFORT scores for 20 distinct video clips (Spearman correlation coefficient = 0.98; P <0.001). The distribution of DOCS scores 20 min after the anesthetic induction was significantly lower than the scores before initiation of sedation, and scores after emergence were consistently higher than those 20 min after sedation (P <0.001), thus confirming construct validity of the scale. The DOCS is a validated research tool when used with video data for comparing the effectiveness and safety of pediatric sedation service, regardless of technique used for decreasing anxiety or pain during a procedure.

Unlabelled: Avoidance of tachycardia is a commonly described goal for anesthetic management during coronary artery bypass graft (CABG) surgery. However, an association between increased intraoperative heart rate and mortality has not been described. We conducted an observational study to evaluate the association between preinduction heart rate (heart rate upon arrival to the operating room) and in-hospital mortality during CABG surgery. Data were collected on 5934 CABG patients. Fifteen percent of patients had an increased preinduction heart rate > or =80 bpm. Crude mortality was significantly more frequent among patients with increased preinduction heart rate (P(trend) = 0.002). After adjustment for baseline differences among patients, preinduction heart rate > or =80 bpm remained associated with increased mortality (P(trend) < 0.001). The increased heart rate may be a cause of the observed mortality. Alternatively, faster heart rate may be either a marker of patients with irreversible myocardial damage, or a marker of patients with limited cardiac reserve at risk for further injury. Lastly, faster heart rate may be a marker for under-use of beta-adrenergic blockade. Because the use of preoperative beta-adrenergic blockade in CABG patients is associated with improved in-hospital survival, further investigation concerning the effect of intraoperative treatment of increased heart rate with beta-adrenergic blockers on mortality after CABG surgery is warranted., Implications: We conducted an observational study to evaluate the association between heart rate upon arrival to the operating room (preinduction heart rate) and in-hospital mortality during coronary artery bypass graft surgery. After adjustment for baseline differences among patients, preinduction heart rate > or =80 bpm was associated with an increased in-hospital mortality after coronary artery bypass graft surgery.

Unlabelled: Heart failure is the most common cause of death among coronary artery bypass graft (CABG) patients. In addition, most variation in observed mortality rates for CABG surgery is explained by fatal heart failure. The purpose of this study was to develop a clinical risk assessment tool so that clinicians can rapidly and easily assess the risk of fatal heart failure while caring for individual patients. Using prospective data for 8,641 CABG patients, we used logistic regression analysis to predict the risk of fatal heart failure. In multivariate analysis, female sex, prior CABG surgery, ejection fraction <40%, urgent or emergency surgery, advanced age (70-79 yr and >80 yr), peripheral vascular disease, diabetes, dialysis-dependent renal failure and three-vessel coronary disease were significant predictors of fatal postoperative heart failure. A clinical risk assessment tool was developed from this logistic regression model, which had good discriminating characteristics (receiver operating characteristic clinical source = 0.75, 95% confidence interval: 0.71, 0.78)., Implications: In contrast to previous cardiac surgical scoring systems that predicted total mortality, we developed a clinical risk assessment tool that evaluates risk of fatal heart failure. This distinction is relevant for quality improvement initiatives, because most of the variation in CABG mortality rates is explained by postoperative heart failure.