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Lou SS, Dewey MM, Bollini ML, Harford DR, Ingold C, Wildes TS, Stevens TW, Martin JL, Grossman BJ, Kangrga I. Reducing perioperative red blood cell unit issue orders, returns, and waste using failure modes and effects analysis. Transfusion 2023; 63:755-762. [PMID: 36752098 PMCID: PMC10089960 DOI: 10.1111/trf.17275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/07/2022] [Accepted: 01/13/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Surgical transfusion has an outsized impact on hospital-based transfusion services, leading to blood product waste and unnecessary costs. The objective of this study was to design and implement a streamlined, reliable process for perioperative blood issue ordering and delivery to reduce waste. STUDY DESIGN AND METHODS To address the high rates of surgical blood issue requests and red blood cell (RBC) unit waste at a large academic medical center, a failure modes and effects analysis was used to systematically examine perioperative blood management practices. Based on identified failure modes (e.g., miscommunication, knowledge gaps), a multi-component action plan was devised involving process changes, education, electronic clinical decision support, audit, and feedback. Changes in RBC unit issue requests, returns, waste, labor, and cost were measured pre- and post-intervention. RESULTS The number of perioperative RBC unit issue requests decreased from 358 per month (SD 24) pre-intervention to 282 per month (SD 16) post-intervention (p < .001), resulting in an estimated savings of 8.9 h per month in blood bank staff labor. The issue-to-transfusion ratio decreased from 2.7 to 2.1 (p < .001). Perioperative RBC unit waste decreased from 4.5% of units issued pre-intervention to 0.8% of units issued post-intervention (p < .001), saving an estimated $148,543 in RBC unit acquisition costs and $546,093 in overhead costs per year. DISCUSSION Our intervention, designed based on a structured failure modes analysis, achieved sustained reductions in perioperative RBC unit issue orders, returns, and waste, with associated benefits for blood conservation and transfusion program costs.
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Affiliation(s)
- Sunny S. Lou
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Megan M. Dewey
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Mara L. Bollini
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Derek R. Harford
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Cindy Ingold
- Transfusion Services, Barnes-Jewish Hospital, St Louis, MO
| | - Troy S. Wildes
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
- Currently at University of Nebraska Medical Center, Omaha, NE
| | - Tracey W. Stevens
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | | | - Brenda J. Grossman
- Transfusion Services, Barnes-Jewish Hospital, St Louis, MO
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, MO
| | - Ivan Kangrga
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
- Perioperative Services, Barnes-Jewish Hospital, St Louis, MO
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Fritz BA, King CR, Mickle AM, Wildes TS, Budelier TP, Oberhaus J, Park D, Maybrier HR, Ben Abdallah A, Kronzer A, McKinnon SL, Torres BA, Graetz TJ, Emmert DA, Palanca BJ, Stevens TW, Stark SL, Lenze EJ, Avidan MS. Effect of electroencephalogram-guided anaesthesia administration on 1 yr mortality: 1 yr follow-up of a randomised clinical trial. Br J Anaesth 2021; 127:386-395. [PMID: 34243940 DOI: 10.1016/j.bja.2021.04.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/25/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intraoperative EEG suppression duration has been associated with postoperative delirium and mortality. In a clinical trial testing anaesthesia titration to avoid EEG suppression, the intervention did not decrease the incidence of postoperative delirium, but was associated with reduced 30 day mortality. The present study evaluated whether the EEG-guided anaesthesia intervention continued to be associated with reduced 1 yr mortality. METHODS This manuscript reports 1 yr follow-up of patients from a single-centre RCT, including a post-hoc secondary outcome (1 yr mortality) in addition to pre-specified secondary outcomes. The trial included patients aged 60 yr or older undergoing surgery with general anaesthesia between January 2015 and May 2018. Patients were randomised to receive EEG-guided anaesthesia or usual care. The previously reported primary outcome was postoperative delirium. The outcome of the current study was all-cause 1 yr mortality. RESULTS Of the 1232 patients enrolled, 614 patients were randomised to EEG-guided anaesthesia and 618 patients to usual care. One year mortality was 57/591 (9.6%) in the guided group and 62/601 (10.3%) in the usual-care group. No significant difference in mortality was observed (adjusted absolute risk difference, -0.7%; 99.5% confidence interval, -5.8% to 4.3%; P=0.68). CONCLUSIONS An EEG-guided anaesthesia intervention aiming to decrease duration of EEG suppression during surgery did not significantly decrease 1 yr mortality. These findings, in the context of other studies, do not provide supportive evidence for EEG-guided anaesthesia to prevent intermediate term postoperative death. CLINICAL TRIAL REGISTRATION NCT02241655.
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Affiliation(s)
- Bradley A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Christopher R King
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Angela M Mickle
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Thaddeus P Budelier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Park
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Hannah R Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sherry L McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Brian A Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Thomas J Graetz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A Emmert
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ben J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Tracey W Stevens
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Susan L Stark
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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Fritz BA, King CR, Ben Abdallah A, Lin N, Mickle AM, Budelier TP, Oberhaus J, Park D, Maybrier HR, Wildes TS, Avidan MS, Apakama G, Aranake-Chrisinger A, Bolzenius J, Burton J, Cui V, Emmert DA, Goswami S, Graetz TJ, Gupta S, Jordan K, Kronzer A, McKinnon SL, Muench MR, Murphy MR, Palanca BJ, Patel A, Spencer JW, Stevens TW, Strutz P, Tedeschi CM, Torres BA, Trammel ER, Upadhyayula RT, Winter AC, Jacobsohn E, Fong T, Gallagher J, Inouye SK, Schmitt EM, Somerville E, Stark S, Lenze EJ, Melby SJ, Tappenden J. Preoperative Cognitive Abnormality, Intraoperative Electroencephalogram Suppression, and Postoperative Delirium: A Mediation Analysis. Anesthesiology 2020; 132:1458-1468. [PMID: 32032096 DOI: 10.1097/aln.0000000000003181] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Postoperative delirium is a common complication that hinders recovery after surgery. Intraoperative electroencephalogram suppression has been linked to postoperative delirium, but it is unknown if this relationship is causal or if electroencephalogram suppression is merely a marker of underlying cognitive abnormalities. The hypothesis of this study was that intraoperative electroencephalogram suppression mediates a nonzero portion of the effect between preoperative abnormal cognition and postoperative delirium. METHODS This is a prespecified secondary analysis of the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized trial, which enrolled patients age 60 yr or older undergoing surgery with general anesthesia at a single academic medical center between January 2015 and May 2018. Patients were randomized to electroencephalogram-guided anesthesia or usual care. Preoperative abnormal cognition was defined as a composite of previous delirium, Short Blessed Test cognitive score greater than 4 points, or Eight Item Interview to Differentiate Aging and Dementia score greater than 1 point. Duration of intraoperative electroencephalogram suppression was defined as number of minutes with suppression ratio greater than 1%. Postoperative delirium was detected via Confusion Assessment Method or chart review on postoperative days 1 to 5. RESULTS Among 1,113 patients, 430 patients showed evidence of preoperative abnormal cognition. These patients had an increased incidence of postoperative delirium (151 of 430 [35%] vs.123 of 683 [18%], P < 0.001). Of this 17.2% total effect size (99.5% CI, 9.3 to 25.1%), an absolute 2.4% (99.5% CI, 0.6 to 4.8%) was an indirect effect mediated by electroencephalogram suppression, while an absolute 14.8% (99.5% CI, 7.2 to 22.5%) was a direct effect of preoperative abnormal cognition. Randomization to electroencephalogram-guided anesthesia did not change the mediated effect size (P = 0.078 for moderation). CONCLUSIONS A small portion of the total effect of preoperative abnormal cognition on postoperative delirium was mediated by electroencephalogram suppression. Study precision was too low to determine if the intervention changed the mediated effect.
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Affiliation(s)
- Bradley A Fritz
- From the Department of Anesthesiology (B.A.F., C.R.K., A.B., A.M.M., T.P.B., J.O., D.P., H.R.M., T.S.W., M.S.A) the Division of Biostatistics (N.L.), Washington University School of Medicine, St. Louis, Missouri the Department of Mathematics and Statistics, Washington University in St. Louis, St. Louis, Missouri (N.L.). Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, University of Manitoba, Winnipeg, Canada Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri Department of Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri Department of Surgery, Washington University School of Medicine, St. Louis, Missouri Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Zoller JK, Gregory SH, Stevens TW, Sanchez LA, Hueneke R. Anesthetic Considerations for Aortic Arch Stenting. J Cardiothorac Vasc Anesth 2019; 33:3163-3175. [DOI: 10.1053/j.jvca.2019.01.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/19/2019] [Accepted: 01/24/2019] [Indexed: 01/16/2023]
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Wildes TS, Mickle AM, Ben Abdallah A, Maybrier HR, Oberhaus J, Budelier TP, Kronzer A, McKinnon SL, Park D, Torres BA, Graetz TJ, Emmert DA, Palanca BJ, Goswami S, Jordan K, Lin N, Fritz BA, Stevens TW, Jacobsohn E, Schmitt EM, Inouye SK, Stark S, Lenze EJ, Avidan MS. Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial. JAMA 2019; 321:473-483. [PMID: 30721296 PMCID: PMC6439616 DOI: 10.1001/jama.2018.22005] [Citation(s) in RCA: 252] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Intraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium. OBJECTIVE To assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 1232 adults aged 60 years and older undergoing major surgery and receiving general anesthesia at Barnes-Jewish Hospital in St Louis. Recruitment was from January 2015 to May 2018, with follow-up until July 2018. INTERVENTIONS Patients were randomized 1:1 (stratified by cardiac vs noncardiac surgery and positive vs negative recent fall history) to receive EEG-guided anesthetic administration (n = 614) or usual anesthetic care (n = 618). MAIN OUTCOMES AND MEASURES The primary outcome was incident delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration, EEG suppression, and hypotension. Adverse events included undesirable intraoperative movement, intraoperative awareness with recall, postoperative nausea and vomiting, medical complications, and death. RESULTS Of the 1232 randomized patients (median age, 69 years [range, 60 to 95]; 563 women [45.7%]), 1213 (98.5%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 157 of 604 patients (26.0%) in the guided group and 140 of 609 patients (23.0%) in the usual care group (difference, 3.0% [95% CI, -2.0% to 8.0%]; P = .22). Median end-tidal volatile anesthetic concentration was significantly lower in the guided group than the usual care group (0.69 vs 0.80 minimum alveolar concentration; difference, -0.11 [95% CI, -0.13 to -0.10), and median cumulative time with EEG suppression was significantly less (7 vs 13 minutes; difference, -6.0 [95% CI, -9.9 to -2.1]). There was no significant difference between groups in the median cumulative time with mean arterial pressure below 60 mm Hg (7 vs 7 minutes; difference, 0.0 [95% CI, -1.7 to 1.7]). Undesirable movement occurred in 137 patients (22.3%) in the guided and 95 (15.4%) in the usual care group. No patients reported intraoperative awareness. Postoperative nausea and vomiting was reported in 48 patients (7.8%) in the guided and 55 patients (8.9%) in the usual care group. Serious adverse events were reported in 124 patients (20.2%) in the guided and 130 (21.0%) in the usual care group. Within 30 days of surgery, 4 patients (0.65%) in the guided group and 19 (3.07%) in the usual care group died. CONCLUSIONS AND RELEVANCE Among older adults undergoing major surgery, EEG-guided anesthetic administration, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support the use of EEG-guided anesthetic administration for this indication. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02241655.
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Affiliation(s)
- Troy S. Wildes
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Angela M. Mickle
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Hannah R. Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Sherry L. McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Park
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Brian A. Torres
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Thomas J. Graetz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel A. Emmert
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Ben J. Palanca
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Shreya Goswami
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Katherine Jordan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Nan Lin
- Department of Mathematics, Washington University School of Medicine, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Tracey W. Stevens
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Eric Jacobsohn
- Department of Anesthesiology, University of Manitoba, Winnipeg, Canada
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel-Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel-Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Susan Stark
- Department of Occupational Therapy, Washington University School of Medicine, St Louis, Missouri
| | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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Wildes TS, Winter AC, Maybrier HR, Mickle AM, Lenze EJ, Stark S, Lin N, Inouye SK, Schmitt EM, McKinnon SL, Muench MR, Murphy MR, Upadhyayula RT, Fritz BA, Escallier KE, Apakama GP, Emmert DA, Graetz TJ, Stevens TW, Palanca BJ, Hueneke RL, Melby S, Torres B, Leung J, Jacobsohn E, Avidan MS. Protocol for the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) study: a pragmatic, randomised clinical trial. BMJ Open 2016; 6:e011505. [PMID: 27311914 PMCID: PMC4916634 DOI: 10.1136/bmjopen-2016-011505] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Postoperative delirium, arbitrarily defined as occurring within 5 days of surgery, affects up to 50% of patients older than 60 after a major operation. This geriatric syndrome is associated with longer intensive care unit and hospital stay, readmission, persistent cognitive deterioration and mortality. No effective preventive methods have been identified, but preliminary evidence suggests that EEG monitoring during general anaesthesia, by facilitating reduced anaesthetic exposure and EEG suppression, might decrease incident postoperative delirium. This study hypothesises that EEG-guidance of anaesthetic administration prevents postoperative delirium and downstream sequelae, including falls and decreased quality of life. METHODS AND ANALYSIS This is a 1232 patient, block-randomised, double-blinded, comparative effectiveness trial. Patients older than 60, undergoing volatile agent-based general anaesthesia for major surgery, are eligible. Patients are randomised to 1 of 2 anaesthetic approaches. One group receives general anaesthesia with clinicians blinded to EEG monitoring. The other group receives EEG-guidance of anaesthetic agent administration. The outcomes of postoperative delirium (≤5 days), falls at 1 and 12 months and health-related quality of life at 1 and 12 months will be compared between groups. Postoperative delirium is assessed with the confusion assessment method, falls with ProFaNE consensus questions and quality of life with the Veteran's RAND 12-item Health Survey. The intention-to-treat principle will be followed for all analyses. Differences between groups will be presented with 95% CIs and will be considered statistically significant at a two-sided p<0.05. ETHICS AND DISSEMINATION Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) is approved by the ethics board at Washington University. Recruitment began in January 2015. Dissemination plans include presentations at scientific conferences, scientific publications, internet-based educational materials and mass media. TRIAL REGISTRATION NUMBER NCT02241655; Pre-results.
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Affiliation(s)
- T S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - A C Winter
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - H R Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - A M Mickle
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - E J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - S Stark
- Department of Occupational Therapy, Washington University Institute for Public Health, School of Medicine, St. Louis, Missouri, USA
- Department of Neurology, Washington University Institute for Public Health, School of Medicine, St. Louis, Missouri, USA
| | - N Lin
- Department of Mathematics, Biostatistics Division, Washington University in St. Louis, St. Louis, Missouri, USA
| | - S K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - E M Schmitt
- Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - S L McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - M R Muench
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - M R Murphy
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - R T Upadhyayula
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - K E Escallier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - G P Apakama
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - D A Emmert
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - T J Graetz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - T W Stevens
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - R L Hueneke
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - S Melby
- Department of Surgery, Cardiothoracic Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - J Leung
- Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - E Jacobsohn
- Department of Anesthesia, University of Manitoba/Winnipeg Regional Health Authority Anesthesia Program, Winnipeg, Manitoba, Canada
| | - M S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Affiliation(s)
- M S Avidan
- Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 South Euclid Avenue, Saint Louis, MO 63110, USA
| | - T W Stevens
- Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 South Euclid Avenue, Saint Louis, MO 63110, USA
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Haanappel VA, Stevens TW, Hovestad A, Skolnik V, Visser R. Gas chromatographic-mass spectrometric analysis of tar compounds formed during pyrolysis of rice husks. J Chromatogr 1991; 562:531-45. [PMID: 2026716 DOI: 10.1016/0378-4347(91)80605-c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Pyrolysis of agricultural waste to produce fuel gas involves formation of tars as noxious by-products. In this paper the qualitative analysis of tars formed during pyrolysis of rice husks is presented, based on identification by gas chromatography-mass spectrometry and interpolation of retention times on a polyaromatic hydrocarbon index scale. The influence of some reaction parameters on product formation is briefly discussed.
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Affiliation(s)
- V A Haanappel
- Biomass Technology Group, University of Twente, Enschede, The Netherlands
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Reid JA, Stevens TW, Sigwart U, Fulweber RC, Alexander JK. Hemodynamic evaluation of the Beall mitral valve prosthesis. Circulation 1972; 45:I1-7. [PMID: 5025052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Ginn HE, Anderson KE, Mercier RK, Stevens TW, Matter BJ. Camphor intoxication treated by lipid dialysis. JAMA 1968; 203:230-1. [PMID: 4965311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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