Prevention of postoperative atrial fibrillation in cardiac surgery: a quality improvement project.

PURPOSE: Postoperative atrial fibrillation (POAF) has an incidence of 20-60% in cardiac surgery. The Society of Cardiovascular Anesthesiologists and the European Association of Cardiothoracic Anaesthesiology Practice Advisory have recommended postoperative beta blockers and amiodarone for the prevention of POAF. By employing quality improvement (QI) strategies, we sought to increase the use of these agents and to reduce the incidence of POAF among our patients undergoing cardiac surgery. METHODS: This single-centre QI initiative followed the traditional Plan, Do, Study, Act (PDSA) cycle scientific methodology. A POAF risk score was developed to categorize all patients undergoing cardiac surgery as either normal or elevated risk. Risk stratification was incorporated into a preprinted prescribing guide, which recommended postoperative beta blockade for all patients and a postoperative amiodarone protocol for patients with elevated risk starting on postoperative day one (POD1). A longitudinal audit of all patients undergoing cardiac surgery was conducted over 11 months to track the use of prophylactic medications and the incidence of POAF. RESULTS: Five hundred and sixty patients undergoing surgery were included in the QI initiative from 1 December 2020 to 1 November 2021. The baseline rate of POAF across all surgical subtypes was 39% (198/560). The use of prophylactic amiodarone in high-risk patients increased from 13% (1/8) at the start of the project to 41% (48/116) at the end of the audit period. The percentage of patients receiving a beta blocker on POD1 did fluctuate, but remained essentially unchanged throughout the audit (34.8% in December 2020 vs 46.7% in October 2021). After 11 months, the overall incidence of POAF was 29% (24.9% relative reduction). Notable reductions in the incidence of POAF were observed in more complex surgical subtypes by the end of the audit, including multiple valve replacement (89% vs 56%), aortic repair (50% vs 33%), and mitral valve surgery (45% vs 33%). CONCLUSIONS: This single-centre QI intervention increased the use of prophylactic amiodarone by 28% for patients at elevated risk of POAF, with no change in the early postoperative initiation of beta blockers (46.7% of patients by POD1). There was a notable reduction in the incidence of POAF in patients at elevated risk undergoing surgery.

RéSUMé: OBJECTIF: Il y a une incidence de 20 à 60 % de fibrillation auriculaire postopératoire (FAPO) en chirurgie cardiaque. Dans un avis de pratique, la Society of Cardiovascular Anesthesiologists et l'European Association of Cardiothoracic Anaesthesiology ont recommandé l'utilisation de bêtabloquants et d'amiodarone en postopératoire pour la prévention du FAPO. En employant des stratégies d'amélioration de la qualité (AQ), nous avons cherché à augmenter l'utilisation de ces agents et à réduire l'incidence de FAPO chez nos patient·es bénéficiant d'une chirurgie cardiaque. MéTHODE: Cette initiative d'AQ monocentrique a suivi la méthodologie scientifique traditionnelle du cycle Plan, Do, Study, Act (PDSA), soit Planifier, Réaliser, Étudier, Agir. Un score de risque de FAPO a été mis au point pour catégoriser toute la patientèle bénéficiant d'une chirurgie cardiaque comme présentant un risque normal ou élevé. La stratification du risque a été intégrée dans un guide de prescription préimprimé, qui recommandait des bêtabloquants en période postopératoire pour tou·tes les patient·es et un protocole postopératoire d'amiodarone pour celles et ceux présentant un risque élevé et débutant à partir du premier jour postopératoire (JPO1). Une vérification longitudinale de toute la patientèle bénéficiant d'une chirurgie cardiaque a été menée sur une période de 11 mois afin de suivre l'utilisation de médicaments prophylactiques et l'incidence de FAPO. RéSULTATS: Cinq cent soixante personnes opérées ont été incluses dans l'initiative d'AQ entre le 1er décembre 2020 et le 1er novembre 2021. Le taux initial de FAPO pour tous les sous-types chirurgicaux était de 39 % (198/560). L'utilisation d'amiodarone prophylactique chez les patient·es à risque élevé est passée de 13 % (1/8) au début du projet à 41 % (48/116) à la fin de la période de vérification. Le pourcentage de patient·es recevant un bêtabloquant au JPO1 a fluctué, mais est resté fondamentalement inchangé tout au long de la période de vérification (34,8 % en décembre 2020 vs 46,7 % en octobre 2021). Après 11 mois, l'incidence globale de FAPO était de 29 % (réduction relative de 24,9 %). Des réductions notables de l'incidence de FAPO ont été observées dans des sous-types chirurgicaux plus complexes à la fin de la vérification, y compris le remplacement de plusieurs valves (89 % vs 56 %), la réparation aortique (50 % vs 33 %) et la chirurgie valvulaire mitrale (45 % vs 33 %). CONCLUSION: Cette intervention monocentrique d'amélioration de la qualité a augmenté l'utilisation de l'amiodarone prophylactique de 28 % chez les patient·es présentant un risque élevé de FAPO, sans changement dans l'amorce postopératoire précoce des bêtabloquants (46,7 % des patient·es au JPO1). Il y a eu une réduction notable de l'incidence de FAPO chez les patient·es à risque élevé bénéficiant d'une intervention chirurgicale.

Dexmedetomidine Use in Intensive Care Unit Sedation and Postoperative Recovery in Elderly Patients Post-Cardiac Surgery (DIRECT).

OBJECTIVE: This study examined recovery, delirium, and neurocognitive outcome in elderly patients receiving dexmedetomidine or propofol sedation after undergoing cardiac surgery. DESIGN: Open-label randomized trial. SETTING: Single center. PARTICIPANTS: A total of 70 patients older than 75 years without English language limitations and Mini Mental State Examination scores >20. INTERVENTIONS: Patients received either propofol (group P) or dexmedetomidine (group D) postoperatively until normothermic and hemodynamically stable. MEASUREMENTS AND MAIN RESULTS: Quality of recovery (QoR) was measured by the QoR-40 questionnaire on postoperative day (POD) three. Secondary outcomes were incidence and duration of delirium, time to extubation, length of hospital stay, hospital mortality rate, postoperative quality of life (QoL; measured by SF-36 performed at baseline and six months postoperatively), and neurocognitive disorder (measured by Minnesota Cognitive Acuity Screen [MCAS] performed at baseline, POD5, and six months postoperatively). A total of sixty-seven patients completed the trial. There was no significant difference in QoR-40 scores (95% confidence interval [CI], -7.6081-to-10.9781; p = 1.000), incidence of delirium (group P, 42%; group D, 24%; p = 0.191), mean hospital stay (95% CI, -5.4838-to-1.5444; p = 0.297), mean time to extubation (95% CI, -19.2513-to-7.5561; p = 0.866), or mean duration of delirium (95% CI, -4.3065-to-1.067; p = 0.206) between groups. No patients died in the hospital. There were no significant differences in changes in SF-36 or MCAS scores over time between groups. There was a decline in MCAS score from preoperatively to POD5 in group P (95% CI, -8.95725-to- -2.61775; p = 0.0005), which was greater than that observed in group D. CONCLUSIONS: The authors' findings demonstrated that the use of dexmedetomidine compared with propofol in elderly patients undergoing cardiac surgery was unlikely to improve QoR/postoperative QoL. Although the study was underpowered to detect secondary outcomes, the results suggested no reductions in delirium, time to extubation, and hospital stay, but a potential decrease in delayed neurocognitive recovery.

A comparison of droplet and contact contamination using 3 simulated barrier techniques for COVID-19 intubation: a quality assurance study.

BACKGROUND: The intubation of patients with coronavirus disease 2019 (COVID-19) puts health care workers at risk of infection through aerosol, droplet and contact contamination. We evaluated the risk of droplet and contact contamination for health care workers using 3 intubation barrier techniques as part of a quality assurance study at our institution. METHODS: This randomized quality assurance study was completed at a tertiary academic hospital in Vancouver, British Columbia, Canada, on Apr. 4, 2020. Participants in personal protective equipment performed simulated intubations on a manikin with (a) no barrier, (b) a clear plastic sheet covering the manikin and (c) a plexiglass intubation box over the manikin, in random order. Fluorescein was ejected from inside the manikin's mouth to simulate droplet and contact spread during a standard intubation sequence. Two blinded independent assessors evaluated the location and degree of contamination on the intubator and assistant using an ultraviolet light. Contamination severity was rated in a standard fashion (0 = none; 1 = minor; 2 = major). The primary outcome was total contamination score and secondary outcomes were scores between intubator and assistant, anatomic areas contaminated and qualitative feedback on ease of intubation. RESULTS: Five participants completed this study. Total contamination score was different between the 3 groups for the intubator (p = 0.02) but not the assistant (p = 0.2). For the intubator, the total contamination score was higher when the sheet was used (median 29 [interquartile range (IQR) 25-34]) than when the box was used (median 17 [IQR 15-22]) or when no barrier was used (median 18 [IQR 13-21]). All 5 participants reported challenges during intubation using the sheet. INTERPRETATION: Use of a plastic sheet while intubating patients with COVID-19 may increase the risk of droplet and contact contamination during intubation and impede intubation. Further study should be undertaken before implementing barrier techniques in practice.

The role of regional analgesia in personalized postoperative pain management.

Pain management plays a fundamental role in enhanced recovery after surgery pathways. The concept of multimodal analgesia in providing a balanced and effective approach to perioperative pain management is widely accepted and practiced, with regional anesthesia playing a pivotal role. Nerve block techniques can be utilized to achieve the goals of enhanced recovery, whether it be the resolution of ileus or time to mobilization. However, the recent expansion in the number and types of nerve block approaches can be daunting for general anesthesiologists. Which is the most appropriate regional technique to choose, and what skills and infrastructure are required for its implementation? A multidisciplinary team-based approach for defining the goals is essential, based on each patient's needs, and incorporating patient, surgical, and social factors. This review provides a framework for a personalized approach to postoperative pain management with an emphasis on regional anesthesia techniques.

NHS connecting for health: healthcare professionals, mobile technology, and infection control.

BACKGROUND: Mobile phones improve the efficiency of clinical communication and are increasingly involved in all areas of healthcare delivery. Despite this, healthcare workers' mobile phones provide a known reservoir of pathogenic bacteria, with the potential to undermine infection control efforts aimed at the reducing bacterial cross-contamination in hospitals. This potential could be amplified further when employers require doctors to carry additional electronic devices for communication, without concurrently providing appropriate guidance on decontamination or use. METHODS: Eighty-seven on-call doctors' mobile phones were sampled for bacterial growth prior to, and 12 h after, a cleaning intervention involving 70% isopropyl alcohol. RESULTS: Seventy-eight percent of doctors were aware that mobile phones could carry pathogenic bacteria, but only 8% cleaned their phones regularly. The cleaning intervention reduced the number of phones that grew bacteria by 79% (55% [48 of 87] before versus 16% [14 of 87] after cleaning). Eight percent of the phones grew Staphyloccus aureus, and 44.8% of phones grew Gram-positive cocci. All S. aureus isolates were methicillin-sensitive. Bacterial contamination was not associated with gender, specialty, or seniority of the phone user (p>0.05). CONCLUSIONS: Simple cleaning interventions can reduce the surface bioburden of hospital-provided doctors' mobile phones and therefore the potential for cross-contamination. This cleaning intervention is inexpensive, easily instituted, and effective. Healthcare workers should carry the minimum number of electronic devices on their person, maintain good hand hygiene, and clean their device appropriately in order to minimize the potential for cross-contamination in the work place.

11beta-hydroxysteroid dehydrogenase type 1 expression is increased in the aged mouse hippocampus and parietal cortex and causes memory impairments.

Increased neuronal glucocorticoid exposure may underlie interindividual variation in cognitive function with aging in rodents and humans. 11beta-Hydroxysteroid dehydrogenase type 1 (11beta-HSD1) catalyzes the regeneration of active glucocorticoids within cells (in brain and other tissues), thus amplifying steroid action. We examined whether 11beta-HSD1 plays a role in the pathogenesis of cognitive deficits associated with aging in male C57BL/6J mice. We show that 11beta-HSD1 levels increase with age in CA3 hippocampus and parietal cortex, correlating with impaired cognitive performance in the water maze. In contrast, neither circulating corticosterone levels nor tissue corticosteroid receptor expression correlates with cognition. 11beta-HSD1 elevation appears causal, since aging (18 months) male transgenic mice with forebrain-specific 11beta-HSD1 overexpression ( approximately 50% in hippocampus) exhibit premature age-associated cognitive decline in the absence of altered circulating glucocorticoid levels or other behavioral (affective) deficits. Thus, excess 11beta-HSD1 in forebrain is a cause of as well as a therapeutic target in memory impairments with aging.