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Background: The clinical use of epidural analgesia has changed over past decades. Minimally invasive surgery and emergence of alternative analgesic techniques have led to an overall decline in its use. In addition, there is increasing awareness of the patient‐specific risks for complications such as spinal haematoma and abscess. Local guidelines for management of severe neurological complications during or after epidural analgesia, ie, "epidural alert systems", have been introduced in hospitals to coordinate and potentially streamline early diagnosis and treatment. How widely such protocols have been implemented in daily practice is unknown. Methods: We conducted a survey to analyse trends in practice, key indications, safety measures, safety reporting, and management of complications of epidural analgesia in the Netherlands. Data were gathered using a web‐based questionnaire and analysed using descriptive statistics. Results: Questionnaires from 85 of all 94 Dutch hospitals performing epidural analgesia were collected and analysed, a 90% response rate. Fifty‐five percent reported a trend towards decreased use of perioperative epidural analgesia, while 68% reported increasing use of epidural analgesia for labour. Reported key indications for epidural analgesia were thoracotomy, upper abdominal laparotomy, and abdominal cancer debulking. An epidural alert system for neurological complications of epidural analgesia was available in 45% of hospitals. Conclusions: This national audit concerning use and safety of epidural analgesia demonstrates that a minority of Dutch hospitals have procedures to manage suspected neurological complications of epidural analgesia, whereas in the remaining hospitals responsibilities and timelines for management of epidural emergencies are determined on an ad hoc basis. [ABSTRACT FROM AUTHOR]

Background Recently, various near-infrared vascular imaging devices aimed at facilitating peripheral intravenous cannulation ( PIC) were introduced, all claiming to increase success rate of PIC. We evaluated the clinical utility of a near-infrared vascular imaging device (VascuLuminator®) in pediatric patients who were referred to the anesthesiologist because of difficult cannulation. Methods There were 226 consecutive children referred to pediatric anesthesiologists by the treating pediatrician of the in- and outpatient clinic, because of difficulties with intravenous cannulation, were included in this cluster randomized clinical trial. The presence and use of the near-infrared vascular imaging device for PIC was randomized in clusters of 1 week. Success at first attempt (Fisher exact test) and time to successful cannulation (Log-rank test) were assessed to evaluate differences between groups. Results Success at first attempt in the group with the VascuLuminator® (59%) was not significantly different from the control group (54%, P = 0.41), neither was the median time to successful cannulation: 246 s and 300 s, respectively ( P = 0.54). Conclusions Visualization of blood vessels with near-infrared light and with near-infrared vascular imaging device did not improve success of PIC in pediatric patients who are known difficult to cannulate. [ABSTRACT FROM AUTHOR]

Background Cardiac surgery is often complicated by excessive bleeding that is commonly treated with blood products. In the year 2009 a transfusion protocol was introduced specifically designed for cardiac surgery procedures. This study aims to evaluate the effect of this protocol on transfusion of blood products and the occurrence of clinical events. Study Design and Methods This was a nonrandomized intervention study. The index group was transfused according to a tailor-made transfusion protocol (operation in 2009/2010) and the control group was transfused according to the Dutch national transfusion guideline (operation in 2007/2008). The primary outcome was mean number of units transfused and proportion of patients transfused. Secondary outcomes were in-hospital mortality, myocardial infarction, cerebrovascular accident or transient ischemic attack, renal injury or failure, rethoracotomy, and prolonged mechanical ventilation. Results The control group comprised 2685 patients and the index group 2534 patients. The tailor-made transfusion protocol resulted in a decrease of patients transfused with red blood cells ( RBCs) and fresh-frozen plasma ( FFP) during surgery with odds ratio of 0.69 (95% confidence interval [ CI], 0.55-0.86) and 0.63 (95% CI, 0.46-0.86), respectively. Fewer myocardial infarctions were observed in the index group with OR of 0.67 (95% CI, 0.47-0.96). Conclusion The cardiac surgery-specific transfusion protocol resulted in fewer patients transfused with RBCs and FFP and a lower incidence of myocardial infarction. This tailor-made protocol has led to a more judicious use of blood products and is a basis for further refinement of coagulation management during cardiac surgery procedures. [ABSTRACT FROM AUTHOR]

Objective To produce comparable risk-adjusted outcome rates for an international sample of hospitals in a collaborative project to share outcomes and learning. Data Sources Administrative data varying in scope, format, and coding systems were pooled from each participating hospital for the years 2005-2010. Study Design Following reconciliation of the different coding systems in the various countries, in-hospital mortality, unplanned readmission within 30 days, and 'prolonged' hospital stay (>75th percentile) were risk-adjusted via logistic regression. A web-based interface was created to facilitate outcomes analysis for individual medical centers and enable peer comparisons. Small groups of clinicians are now exploring the potential reasons for variations in outcomes in their specialty. Principal Findings There were 6,737,211 inpatient records, including 214,622 in-hospital deaths. Although diagnostic coding depth varied appreciably by country, comorbidity weights were broadly comparable. U.S. hospitals generally had the lowest mortality rates, shortest stays, and highest readmission rates. Conclusions Intercountry differences in outcomes may result from differences in the quality of care or in practice patterns driven by socio-economic factors. Carefully managed administrative data can be an effective resource for initiating dialog between hospitals within and across countries. Inclusion of important outcomes beyond hospital discharge would increase the value of these analyses. [ABSTRACT FROM AUTHOR]

Summary Background: It is generally believed that certain patient characteristics (e.g., Body Mass Index and age) predict difficulty of intravenous cannulation in children, but there is not much literature evaluating these risk factors. In this study, we investigated predictive factors for success rate at first attempt and time needed for intravenous cannulation. Methods/Materials: In a prospective cohort study, we observed characteristics of intravenous cannulations in pediatric patients at the operating room ( n = 1083) and the outpatient care unit ( n = 178) of a tertiary referral pediatric hospital. Time to successful intravenous cannulation, success at first attempt, and potential predictors for difficult cannulation (age, gender, skin color, BMI or weight-to-age z-score, the child being awake or anesthetized, operator profession and surgical specialty) were recorded. Regression models were constructed to find significant predictors. Results: Success at first attempt was 73% and 81%, respectively. In the operating room age, operator and surgical specialty were predictive for a successful first attempt and time to successful cannulation. No significant predictive factors were found for the outpatient care unit. BMI or weight-to-age was not related to difficult intravenous cannulation. Conclusions: This study shows that in one-fifth to one-third of the patients, intravenous cannulation required more than one attempt. It is difficult to predict with accuracy the difficulty of intravenous cannulation solely with easily obtainable patient characteristics. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Although many barriers to practising evidence-based medicine (EBM) are described, it remains poorly understood why clinicians do, and do not, incorporate high-quality evidence into their routine practice. To date, a comprehensive framework for the classification for barriers to practising EBM is lacking. This qualitative study explored the relationship between differences in career stage and work setting among doctors and their perceived barriers for practising EBM. We also explored an alternative classification of barriers. Methods Purposive participant sampling reflected three career stages in two different work settings: four registrars, four consultant anaesthetists and four senior anaesthetists from two departments of anaesthesiology, in an academic and a general hospital, in The Netherlands. Perceptions on practising EBM and its barriers were explored in semi-structured interviews. Using grounded theory approach, we build a framework for the classification of these barriers. Results In both departments, registrars and consultants demonstrated little sense of urgency to work on their EBM performance; registrars struggled with information overload and hierarchical dependence, and consultants practised confidence-based medicine. Senior doctors in both departments reported that combining clinical work with leadership tasks made them more reflective, and therefore more susceptible to the reasoning approach inherent within the current approach to EBM. They considered themselves willing and able to apply EBM, and were reported to act accordingly. Differences in setting that complicated practising EBM related to the general hospital. The absence of formal hierarchy among doctors resulted in a lack of medical consensus and an absence of integrated management teams hindered collaboration between doctors and non-medical managers. We identified 10 conditions that were conducive to the practice of EBM. Conclusions Both career stage and work setting were associated with perceived barriers to practising EBM. We have included these in our theoretical framework for classification of these barriers. [ABSTRACT FROM AUTHOR]