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Study Objective: Whether having an emergency manual (EM) available for use during perioperative crises enhances or detracts from team performance, especially for multi-factorial diagnostic situations that do not explicitly match a chapter of the EM., Design: A simulation-based, prospective randomized trial based upon two perioperative crises, one involving a patient with a transfusion reaction for which the EM contains a specific chapter, and the other involving a patient with refractory hypotension progressing into septic shock for which the EM does not have a specific chapter., Setting: 52 regularly scheduled 6-h courses at the Center for Medical Simulation in Boston, Massachusetts, USA., Study Group: 304 US-trained practicing anesthesiologists., Interventions: The absence or presence of the EM during the simulation case., Measurements: Teams were rated in the following categories: primary underlying diagnosis, fluid resuscitation, treatment of primary diagnosis, cardiac arrest management, overall crisis management, and (if applicable) EM usage. Also, raters recorded free-text 'field notes' about the usage-patterns and perceived utility of the EM. Using these 'field notes' and a two-stage, inductively revised procedure, two independent reviewers examined a subset of case videos for action analysis., Main Results: Performance ratings for a total of 51 teams and 95 simulations were included in the final analysis. No effect on performance was demonstrated with providing the EM in either the refractory hypotension/septic shock case or the transfusion reaction case, with the exception of the PEA arrest category. In the subset of simulations in which resuscitation from PEA arrest performance could be evaluated, EM availability was associated with an adjusted mean 1.3 point (99% confidence interval [CI]: 0.2, 2.4) improvement in performance in the transfusion reaction case (p = 0.004), but only an adjusted mean 0.2 point (99% CI, -0.7, 1.1) improvement in the refractory hypotension/septic shock case (p = 0.530) (p for interaction = 0.069). Analysis of actions found that when available, the EM was usually used, but often not until after cardiac arrest had occurred. In some cases, teams persisted with incorrect diagnoses and treatments irrespective of the presence or absence of an EM., Conclusions: Providing an EM did not affect team performance in areas like diagnosis, treatment, fluid resuscitation, communication, and teamwork in management of perioperative crises such as transfusion reaction where an explicit chapter in the EM exists and refractory hypotension / septic shock where an explicit chapter does not exist. A suggestion of improved cardiac arrest resuscitation with the availability of an EM was found, but should be interpreted with caution given a limited sample size. Observed actions using the EM demonstrated that only about half of the teams used the EM to any substantive degree and most used it relatively late in the crisis. By observation, the EM appeared to be helpful in about half of the cases and did not, by itself, deter from appropriate management., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Understanding the risk factors and clinical outcomes associated with acute kidney injury (AKI) after craniotomy may help clinicians identify perioperative patients at risk for AKI and lead clinicians to institute preventive measures. The objective of this study was to identify risk factors associated with AKI after craniotomy and understand whether patients who develop AKI after craniotomy have worse clinical outcomes., Patients and Methods: We performed a retrospective, propensity score matched cohort study consisting of 344 patients who developed an AKI or required renal dialysis post-operatively versus those who did not. An AKI was defined using a composite of two NSQIP variables: progressive renal insufficiency and acute renal failure. All data were derived from the American College of Surgeons National Safety Quality Improvement Program (ACS-NSQIP) between 2009-2017., Results: Of the 50,691 patients who underwent a craniotomy, 202 developed post-operative AKI or required post-operative renal dialysis. Male gender, black race, age 65 and older, and a body mass index 30 or greater were associated with AKI. Patients with hypertension (OR [95 % CI] 4.41 [3.21-6.06]; p < 0.001), diabetes (OR [95 % CI] 3.5 [2.62-4.69]; p < 0.001), chronic obstructive pulmonary disease (OR [95 % CI] 2.27 [1.4-3.69]; p = 0.001), congestive heart failure (OR [95 % CI] 8.17 [4.29-15.58]; p < 0.001), chronic kidney disease (OR [95 % CI] 10.59 [6.09-18.41]; p < 0.001), bleeding disorder (OR [95 % CI] 3.83 [2.59-5.65]; p < 0.001), those who developed sepsis (OR [95 % CI] 4.63 [3.33-6.45]; p < 0.001), and emergent craniotomy (OR [95 % CI] 5.35 [4.05-7.06); p < 0.00) were more likely to develop AKI. The largest association between AKI after surgery was found in patients whose preoperative functional status was totally dependent in activities of daily living (OR [95 % CI] 5.93 [3.53-9.95]; p < 0.001). AKI was associated with a higher number of complications experienced by each patient (OR [95 % CI] 1.79 [1.4-2.3; p < 0.001]. Patients with higher ASA physical status were more likely to develop AKI, and mortality was significantly higher in the AKI cohort. There was a significant increase in the rates of returning to the operating room, failure to wean from the ventilator, unplanned intubations, number of complications, and length of stay between the two groups. AKI was also associated with a higher rate of perioperative pneumonia, venous thromboembolism, urinary tract infection, and sepsis., Conclusion: AKI is associated with significantly worse clinical outcomes after craniotomy. Perioperative strategies for prevention, management and supportive care of AKI for patients undergoing craniotomy may improve clinical outcomes., (Copyright © 2019 Elsevier B.V. All rights reserved.)