Preoperative anxiolytic and antidepressant medications as risk factors for increased opioid use after total knee arthroplasty: a matched retrospective cohort analysis.

INTRODUCTION: Previous literature has suggested that the presence of anxiety or depression may be linked to increased postoperative pain. The objective of this retrospective analysis was to assess whether patients who use anxiolytics or antidepressants preoperatively were associated with worse acute pain outcomes after elective total knee arthroplasty (TKA). MATERIAL AND METHODS: A chart review of patients who underwent TKA at our institution was conducted. The primary outcome was mean opioid use in oral morphine equivalents (OME) on the day of surgery (POD 0) through postoperative day 1 (POD1). Secondary outcomes included median pain scores during hospitalization, the need for an acute pain service (APS) consultation, and mean length of stay. Patients were matched (1 : 1) according to multiple factors including age, surgical anaesthesia type, preoperative pain scores, and placement of a single-injection adductor canal block. RESULTS: 83 patients were successfully matched in each group. During POD0-1, patients with anxiolytic or antidepressant prescriptions required a mean of 101.36 mg OME (SD = 66.89), compared to 86.78 mg (SD = 62.66) among patients without use of these medications ( P = 0.011) (estimate of average treatment effect of +22.86). Similarly, these patients were more likely to report a slightly higher median pain score than patients not taking anxiolytics or antidepressants (4.00 [SD 1.95] vs. 3.77 [SD 2.01], P = 0.031) (estimate of average treatment effect of +0.55). However, there were no differences in hospital length of stay, acute pain service consultation, visit to an Emergency Department within one week of discharge, and readmission within one week of discharge. There were also no differences in outcomes when comparing patients with a history of anxiety or depression to those without this history. CONCLUSIONS: The use of chronic anxiolytics or antidepressants was associated with increased opioid use and slightly higher pain scores in patients undergoing TKA. These associations were independent of a medical diagnosis of anxiety or depression. The mode-rate increase in perioperative opioid consumption and pain scores was not associated with an increase in APS consultations or length of stay.

Impact of a Hemoglobin Trigger Communication Tool on Perioperative Transfusion in Cardiac Surgery.

OBJECTIVES: Blood transfusion represents an important and potentially modifiable risk in the daily practice of cardiac surgery. The risk profile and increasing cost of transfusion led us to study the effect of different maneuvers, interventions, or surgical techniques to minimize transfusion while maintaining patient safety. This study compares postoperative outcomes before and after incorporating a verbal hemoglobin (Hb) trigger during the surgical timeout in which the surgeon and anesthesiologist preemptively agree on a threshold for packed red blood cell (PRBC) administration in the perioperative period. METHODS: The authors performed a chart review of patients who underwent cardiac surgery from July 2013 through June 2014 at our institution. Patients who underwent surgery from July 2013 through December 2013 served as the pre-Hb trigger group, and patients who underwent surgery from January 2014 through June 2014 served as the post-Hb trigger group. Information collected included patient demographics, type of cardiac surgery, preoperative Hb, Hb trigger, and intraoperative and postoperative variables. The primary outcome was the incidence of PRBC transfusions. Secondary outcomes included the incidence of frozen plasma (FP) transfusion, mechanical ventilation beyond postoperative day 1, and 30-day mortality. RESULTS: The study included 191 patients, with 84 in the pre-Hb trigger group and 107 in the post-Hb trigger group. Intraoperative PRBC transfusions did not decrease in the posttrigger group compared with the pretrigger group (pretrigger 51.4% vs posttrigger 52.4%, P = 1.0); however, intraoperative FP administration was lower in the posttrigger group (65.4% vs 50.0%, P = 0.038). Postoperative mechanical ventilation beyond postoperative day 1 also was significantly lower in the posttrigger group compared with the pretrigger group (27.1% vs 14.3%, P = 0.035). CONCLUSIONS: Implementation of a verbal Hb trigger during the surgical timeout was associated with a reduction in FP administration and duration of mechanical ventilation, but not a decrease in PRBC transfusion and mortality.

Intravenous Access in Gastrointestinal Hemorrhage: A Multidisciplinary Quality Improvement Initiative Led by Emergency Department Nurses and Internal Medicine Physicians.

BACKGROUND: The management of acute gastrointestinal hemorrhage (GIH) is focused on early resuscitation through 2 large-bore intravenous (2LBIV) catheters, although adherence to this recommendation is low. LOCAL PROBLEM: Of 100 patients hospitalized with GIH in 2017, only 14 received 2LBIV access. The goal of this study was to improve this measure. METHODS: A multidisciplinary team used the DMAIC (define, measure, analyze, improve, and control) framework to perform a quality improvement initiative. INTERVENTIONS: The team used quality tools including a stakeholder survey, swimlane diagram, and fishbone diagram. The first intervention involved education of the hospitalists directing admissions, and the second intervention involved education of emergency department (ED) physicians and nurses regarding the importance of 2LBIV placement. RESULTS: Following the second intervention, there was a substantial increase in 2LBIV placement to 37 of 86 (43%). CONCLUSIONS: Carefully directed education of ED physicians and nurses with monthly feedback was effective in improving appropriate intravenous placement in patients with GIH.

Dual color fluorescence in situ hybridization (FISH) assays for detecting Mycobacterium tuberculosis and Mycobacterium avium complexes and related pathogens in cultures.

Two rapid dual color fluorescence in situ hybridization (FISH) assays were evaluated for detecting M. tuberculosis and related pathogens in cultures. The MN Genus-MTBC FISH assay uses an orange fluorescent probe specific for the Mycobacterium tuberculosis complex (MTBC) and a green fluorescent probe specific for the Mycobacterium and Nocardia genera (MN Genus) to detect and distinguish MTBC from other Mycobacteria and Nocardia. A complementary MTBC-MAC FISH assay uses green and orange fluorescent probes specific for the MTBC and M. avium complex (MAC) respectively to identify and differentiate the two species complexes. The assays are performed on acid-fast staining bacteria from liquid or solid cultures in less than two hours. Forty-three of 44 reference mycobacterial isolates were correctly identified by the MN Genus-specific probe as Mycobacterium species, with six of these correctly identified as MTBC with the MTBC-specific probe and 14 correctly as MAC by the MAC-specific probe. Of the 25 reference isolates of clinically relevant pathogens of other genera tested, only four isolates representing two species of Corynebacterium gave a positive signal with the MN Genus probe. None of these 25 isolates were detected by the MTBC and MAC specific probes. A total of 248 cultures of clinical mycobacterial isolates originating in India, Peru and the USA were also tested by FISH assays. DNA sequence of a part of the 23S ribosomal RNA gene amplified by PCR was obtained from 243 of the 248 clinical isolates. All 243 were confirmed by DNA sequencing as Mycobacterium species, with 157 and 50 of these identified as belonging to the MTBC and the MAC, respectively. The accuracy of the MN Genus-, MTBC-and MAC -specific probes in identifying these 243 cultures in relation to their DNA sequence-based identification was 100%. All ten isolates of Nocardia, (three reference strains and seven clinical isolates) tested were detected by the MN Genus-specific probe but not the MTBC- or MAC-specific probes. The limit of detection for M. tuberculosis was determined to be 5.1x104 cfu per ml and for M. avium 1.5x104 cfu per ml in liquid cultures with the respective MTBC- and MAC-specific probes in both the MN Genus-MTBC and MTBC-MAC FISH assays. The only specialized equipment needed for the FISH assays is a standard light microscope fitted with a LED light source and appropriate filters. The two FISH assays meet an important diagnostic need in peripheral laboratories of resource-limited tuberculosis-endemic countries.

Sistematização da assistência de enfermagem na Estratégia Saúde da Família

O Programa de Saúde da Família surge com uma proposta do Ministério da Saúde onde o trabalho de equipe está proposto como uma das prerrogativas estratégicas para a mudança do atual modelo de assistência em saúde no sentido de imprimir uma nova dinâmica nos serviços de saúde e estabelecer uma relação de vínculo com a comunidade, humanizando esta prática direcionada à vigilância à saúde, na perspectiva da intersetorialidade. Este trabalho teve o propósito de analisar a produção do conhecimento nacional sobre a Sistematização da Assistência de Enfermagem na Atenção Primária / Programa Saúde da Família. É um estudo descritivo-qualitativo que se optou pela realização de uma revisão narrativa científica retrospectiva, do período de 2004-2010. Os artigos foram consultados nas bases de dados disponíveis no portal Biblioteca Virtual de Saúde utilizando os unitermos: "atenção primária em saúde", "processos de enfermagem", "planejamento de assistência ao paciente" e "enfermagem em saúde pública". Os artigos foram analisados conforme os seguintes critérios: ano de produção, propriedade dos autores que mais tem escrito sobre SAE, qual o método mais utilizado e o assunto abordado por cada autor. Foram avaliados 24 artigos após a leitura e o fichamento de cada produção. O contexto da práxis da assistência da enfermagem na atenção primária abordadas nas publicações discutidas foram consistentes em relação às descrições apresentadas nesta revisão bibliográfica. Diante disso, evidenciou-se a sistematização da prática assistencialista como um potente instrumento para as estratégias de saúde pública. Através da sistematização da coleta de dados é possível traçar um diagnóstico, a intervenção e orientação, o acompanhamento e a avaliação dos resultados finais dentro dos programas de saúde coletiva. Ressalta-se, sobretudo, que as fontes para pesquisa e aprimoramento do profissional durante a formação acadêmica ou no exercício da profissão são inúmeras e contribuem de forma contundente para a construção do conhecimento sobre esta temática. Portanto, salienta-se que grande parte das publicações consultadas são pesquisas descritivas qualitativas que buscam por meio de indagações e definições de termos e conceitos obter dados concretos para a constituição da literatura inerente a sistematização da assistência da enfermagem e da coleta de dados em saúde coletiva.