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J Med Syst ; 46(5): 26, 2022 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-35396607


We investigated the impact of preoperative gabapentin on perioperative intravenous opioid requirements and post anesthesia care unit length of stay (PACU LOS) for patients undergoing laparoscopic and vaginal hysterectomies within an Enhanced Recovery After Surgery (ERAS) pathway. A multidisciplinary team retrospectively examined 2,015 patients who underwent laparoscopic or vaginal hysterectomies between October 2016 and January 2020 at a single academic institution. The average PACU LOS was 168 min among patients who did not receive gabapentin vs. 180 min both among patients who received ≤ 300 mg of gabapentin and patients who received > 300 mg of gabapentin. After adjusting for demographics and medical comorbidities, PACU LOS for patients given ≤ 300 mg gabapentin was 6% longer (rate ratio (RR) = 1.06, 95% CI = 1.01-1.11) than for patients who were not given gabapentin, and for patients who received > 300 mg of gabapentin was 7% longer (RR = 1.07, 95%CI = 1.01-1.13) than for those who did not receive gabapentin. Patients who received ≤ 300 mg gabapentin received 9% less perioperative intravenous hydromorphone than patients who did not receive gabapentin (RR = 0.91, 95% CI = 0.86 - 0.97); patients who received > 300 mg of gabapentin received 12% less perioperative intravenous hydromorphone than patients who did not receive gabapentin (RR = 0.88, 95% CI = 0.82 - 0.95). These findings represent an absolute difference of 0.09 mg intravenous hydromorphone. There were no statistically significant differences in total intravenous fentanyl received. Preoperative gabapentin given as part of an ERAS pathway is associated with statistically but not clinically significant increases in PACU LOS and decreases in total perioperative intravenous opioid use.

Analgésicos Opioides , Recuperação Pós-Cirúrgica Melhorada , Analgésicos Opioides/uso terapêutico , Feminino , Gabapentina , Humanos , Hidromorfona , Histerectomia , Tempo de Internação , Dor Pós-Operatória/tratamento farmacológico , Estudos Retrospectivos
Ann Surg ; 2021 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-34225295


OBJECTIVE: We aimed to compare discharge opioid prescriptions pre- and post-Enhanced Recovery After Surgery (ERAS) implementation. SUMMARY BACKGROUND DATA: ERAS programs decrease inpatient opioid use, but their relationship with post-discharge opioids remains unclear. METHODS: All patients undergoing hysterectomy between October 2016-November 2020 and pancreatectomy or hepatectomy between April 2017-November 2020 at one tertiary care center were included. For each procedure, ERAS was implemented during the study period. Propensity-score matching (PSM) was performed to compare pre- vs. post-ERAS patients on discharge opioids (number of pills and oral morphine equivalents [OME]). Patients were matched on age, gender, race, payor, American Society of Anesthesiologists score, prior opioid use, and procedure. Sensitivity analyses in open versus minimally invasive surgery (MIS) cohorts were performed. RESULTS: 3,983 patients were included (1929 pre-ERAS; 2054 post-ERAS). Post-ERAS patients were younger (56.0 vs. 58.4 years; p<0.001), more often female (95.8% vs. 78.1%; p<0.001), less often white (77.2% vs. 82.0%; p<0.001), less often had prior opioid use (20.1% vs. 28.1%; p<0.001), and more often underwent hysterectomy (91.1% vs. 55.7%; p<0.001). After PSM, there were no significant differences between cohorts in baseline characteristics. Matched post-ERAS patients were prescribed fewer opioid pills (17.4 pills vs. 22.0 pills; p<0.001) and lower OMEs (129.4 mg vs. 167.6 mg; p<0.001) than pre-ERAS patients. Sensitivity analyses confirmed these findings [Open (18.8 pills vs. 25.4 pills; p<0.001 | 138.9 mg vs. 198.7 mg; p<0.001); MIS (17.2 pills vs. 21.1 pills; p<0.001 | 127.1 mg vs. 160.1 mg; p<0.001). CONCLUSIONS: Post-ERAS patients were prescribed significantly fewer opioids at discharge compared to matched pre-ERAS patients.

BMC Anesthesiol ; 21(1): 36, 2021 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-33546602


BACKGROUND: The Massachusetts General Hospital is a large, quaternary care institution with 58 operating rooms, 164 anesthesiologists, 76 certified nurse anesthetists (CRNAs), an anesthesiology residency program that admits 25 residents annually, and 35 surgeons who perform laparoscopic, vaginal, and open hysterectomies. In March of 2018, our institution launched an Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing hysterectomy. To implement the anesthesia bundle of this pathway, an intensive 14-month educational endeavor was created and put into effect. There were no subsequent additional educational interventions. METHODS: We retrospectively reviewed records of 2570 patients who underwent hysterectomy between October 2016 and March 2020 to determine adherence to the anesthesia bundle of the ERAS Hysterectomy pathway. RESULTS: Increased adherence to the four elements of the anesthesia bundle (p < 0.001) was achieved during the intervention period. Compliance with the pathway was sustained in the post-intervention period despite no additional actions. CONCLUSIONS: Implementing the anesthesia bundle of an ERAS pathway in a large anesthesia group with diverse providers successfully occurred using implementation science-based approach of intense interventions, and these results were maintained after the intervention ceased.

Serviço Hospitalar de Anestesia , Anestesiologia/métodos , Recuperação Pós-Cirúrgica Melhorada , Histerectomia , Feminino , Humanos , Massachusetts , Pessoa de Meia-Idade , Estudos Retrospectivos
Jt Comm J Qual Patient Saf ; 46(2): 81-86, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31699600


BACKGROUND: As health care expenditures continue to increase, thoughtful use of perioperative resources is important. Efforts to improve operating room (OR) efficiency often focus on increasing on-time first case starts to improve OR utilization, reduce subsequent delays, and reduce adverse events. One institution, with severely limited inpatient hospital capacity and an extensive daily add-on list of surgical cases, focused efforts to improve OR efficiency by improving on-time first case starts for unscheduled, nonemergent surgeries. METHODS: A multidisciplinary team was assembled to work together for this quality improvement (QI) initiative. The primary outcome measure was the percentage of cases starting on time. The team identified six key steps thought to contribute to on-time start performance. Data were collected for each of these process measures, and feedback was shared with stakeholders. RESULTS: By measuring adherence to and giving feedback about critical steps in the preoperative process, on-time starts improved from a baseline of 65% to 85% (p = 0.041). Sustained improvement was seen even after daily measurement ceased and the QI project was completed. CONCLUSION: Establishing a multidisciplinary team to improve timely care of unscheduled, nonelective surgical patients; identifying key elements necessary for on-time surgical case starts; and providing feedback to clinicians were associated with a sustained improvement in OR efficiency for a traditionally difficult-to-schedule patient population.

Centros Médicos Acadêmicos , Eficiência Organizacional , Humanos , Salas Cirúrgicas , Avaliação de Processos em Cuidados de Saúde , Melhoria de Qualidade
A A Pract ; 12(9): 317-320, 2019 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-30371522


Infection with either mobilized colistin resistance-1 gene-positive gram-negative bacteria or invasive Candida lusitaniae occurs rarely throughout the United States. Here we report the existence of both invasive infections occurring in a single, complex patient who initially presented with necrotizing pancreatitis and gastrointestinal bleeding. We detail the patient's history and perioperative course for enterocutaneous fistulae takedown and ureteral stenting, describe a template of preventative steps taken in the perioperative environment to prevent nosocomial pathogen transmission, and provide a brief overview of both the mobilized colistin resistance-1 gene and C lusitaniae.

Candidíase Invasiva/diagnóstico , Fístula Intestinal/cirurgia , Infecções por Klebsiella/diagnóstico , Pancreatite Necrosante Aguda/cirurgia , Candidíase Invasiva/tratamento farmacológico , Combinação Imipenem e Cilastatina/uso terapêutico , Coinfecção , Farmacorresistência Bacteriana Múltipla , Hemorragia Gastrointestinal/etiologia , Humanos , Fístula Intestinal/etiologia , Infecções por Klebsiella/tratamento farmacológico , Klebsiella pneumoniae/genética , Klebsiella pneumoniae/isolamento & purificação , Masculino , Micafungina/uso terapêutico , Pessoa de Meia-Idade , Resultado do Tratamento , Vancomicina/uso terapêutico