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1.
J Vasc Surg ; 74(5): 1668-1672, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34019988

RESUMO

OBJECTIVE: Within the vascular patient population, there is an increased risk of developing wound complications especially in infrainguinal incisions. There has been increasing interest in using closed incisional negative pressure dressings to decrease the risk of wound complications. To assess the efficacy of these incisional wound dressings, we studied surgical site infections (SSI) and seroma rates of infrainguinal incisions in our vascular patient population. METHODS: This was a multi-institutional, retrospective study from July 2015 to June 2019. In 2017, our institution began using the Prevena incisional wound system. Wound complication rates were compared with the non-Prevena group before 2017. There were a total of 100 infrainguinal incisions (left and right combined) that received the Prevena wound system and 138 infrainguinal incisions that had not. The primary end point was to assess for wound complication rates, including SSIs and seroma formation. SSIs were graded based on the American College of Surgeons National Surgical Quality Improvement Plan SSI criteria. Seroma formation was diagnosed based on clinical diagnosis, imaging studies (ultrasound examination, computed tomography scan) or needle aspiration of fluid collection. RESULTS: This analysis showed a statistically significant decrease in the rate of SSIs in the Prevena group when compared with the non-Prevena group (P = .012). There was no statistical difference between the two groups in the rate of seroma formation (P = .155). Of the 100 incisions that received the Prevena wound system, 1.2% (1/82) had a femoral SSI and 22.0% (4/18) had a popliteal SSI. For seroma formation, 24.4% (20/82) had a femoral seroma and 11.1% (2/18) had a popliteal seroma. Of the 138 incisions that did not have the Prevena wound system, 9.6% (10/104) had a femoral SSI and 8.8% (3/34) had a popliteal SSI. For seroma formation, 24.0% (25/104) had a femoral seroma and 8.8% (3/34) had a popliteal seroma. Comorbid conditions were assessed in the two study groups and there was no statistical significance regarding rates of SSIs between the groups. CONCLUSIONS: The use of an incisional negative pressure dressing decreases the rate of SSIs in infrainguinal incisions. Regarding the use of these wound systems for seromas, our study did not show a statistically significant decrease in seroma rates.


Assuntos
Tratamento de Ferimentos com Pressão Negativa , Infecção da Ferida Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos Vasculares , Cicatrização , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tratamento de Ferimentos com Pressão Negativa/efeitos adversos , Estudos Retrospectivos , Seroma , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/microbiologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Vasculares/efeitos adversos
2.
J Trauma Acute Care Surg ; 91(1): 212-218, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33797489

RESUMO

BACKGROUND: Opioids are often used to treat pain after traumatic injury, but patient education on safe use of opioids is not standard. To address this gap, we created a video-based opioid education program for patients. We hypothesized that video viewing would lead to a decrease in overall opioid use and morphine equivalent doses (MEDs) on their penultimate hospital day. Our secondary aim was to study barriers to video implementation. METHODS: We performed a prospective pragmatic cluster-randomized pilot study of video education for trauma floor patients. One of two equivalent trauma floors was selected as the intervention group; patients were equally likely to be admitted to either floor. Nursing staff were to show videos to English-speaking or Spanish-literate patients within 1 day of floor arrival, excluding patients with Glasgow Coma Scale score less than 15. Opioid use and MEDs taken on the day before discharge were compared. Intention to treat (ITT) (intervention vs. control) and per-protocol groups (video viewers vs. nonviewers) were compared (α = 0.05). Protocol compliance was also assessed. RESULTS: In intention to treat analysis, there was no difference in percent of patients using opioids or MEDs on the day before discharge. In per-protocol analysis, there was no different in percent of patients using opioids on the day before discharge. However, video viewers still on opioids took significantly fewer MEDs than patients who did not see the video (26 vs. 38, p < 0.05). Protocol compliance was poor; only 46% of the intervention group saw the videos. CONCLUSION: Video-based education did not reduce inpatient opioid consumption, although there may be benefits in specific subgroups. Implementation was hindered by staffing and workflow limitations, and staff bias may have limited the effect of randomization. We must continue to establish effective methods to educate patients about safe pain management and translate these into standard practices. LEVEL OF EVIDENCE: Therapeutic, Level IV.


Assuntos
Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Dor/tratamento farmacológico , Educação de Pacientes como Assunto/métodos , Conhecimento do Paciente sobre a Medicação/métodos , Adulto , Idoso , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Análise de Intenção de Tratamento , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Projetos Piloto , Estudos Prospectivos , Gravação de Videoteipe , Ferimentos e Lesões/complicações
3.
J Trauma Acute Care Surg ; 85(4): 697-703, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30036259

RESUMO

BACKGROUND: We initiated a prospective interventional study using a nurse-driven bedside dysphagia screen (BDS) in patients with cervical spine injury (CI) to address three objectives: (1) determine the incidence of dysphagia, (2) determine the utility of the new BDS as a screening tool, and (3) compare patient outcomes, specifically dysphagia-related complications, in the study period with a retrospective cohort. METHODS: All patients with CI admitted to a Level I trauma center were enrolled in a prospective 12-month study (June 2016-June 2017) and then were compared with a previous 18-month cohort of similar patients. Our new protocol mandated that every patient underwent a BDS before oral intake. If the patient failed the BDS, a modified barium swallow (MBS) was obtained. Exclusion criteria were emergency department discharge, inability to participate in a BDS, leaving against medical advice, BDS protocol violations, or death before BDS. A failed MBS was defined as a change in diet and a need for a repeat MBS. Dysphagia was defined as a failed MBS or the presence of a dysphagia-related complication. RESULTS: Of 221 consecutive prospective patients identified, 114 met inclusion criteria. The incidence of dysphagia was 16.7% in all prospective study patients, 14.9% in patients with isolated CI, and 30.8% in patients with spinal cord injury. The BDS demonstrated 84.2% sensitivity, 95.8% specificity, 80.0% positive predictive value, and 96.8% negative predictive value. There were no dysphagia-related complications. The prospective study patients demonstrated significantly less dysphagia-related complications (p = 0.048) when compared with the retrospective cohort of 276 patients. CONCLUSIONS: The introduction of the BDS resulted in increased dysphagia diagnoses, with a significant reduction in dysphagia-related complications. We recommend incorporating BDS into care pathways for patients with CI. LEVEL OF EVIDENCE: Study type diagnostic test, level III.


Assuntos
Síndrome Medular Central/complicações , Transtornos de Deglutição/diagnóstico , Testes Imediatos , Fraturas da Coluna Vertebral/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Vértebras Cervicais/lesões , Transtornos de Deglutição/etiologia , Ingestão de Líquidos , Reações Falso-Negativas , Reações Falso-Positivas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Inquéritos e Questionários , Água , Adulto Jovem
4.
Surg Infect (Larchmt) ; 18(5): 558-562, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28561600

RESUMO

BACKGROUND: In 2013, the Centers for Disease Control and Prevention (CDC) developed new surveillance definitions for ventilator-associated events (VAE), leading to concerns that hospitals may be underreporting the true incidence of ventilator-associated pneumonias (VAPs). We sought to compare rates of clinically diagnosed VAP with CDC defined possible VAPs (PVAPs) in patients with a VAE in the surgical/trauma intensive care unit (STICU). HYPOTHESIS: Significant difference exists between rates of clinical VAP and PVAP in patients with at least one VAE. PATIENTS AND METHODS: All STICU patients with ≥1 VAE, between 1/1/2013 and 10/31/2015 were identified. Age, length of stay (LOS), ICU and ventilator days were collected. RESULTS: There were 134 patients who had ≥1 VAE. Mean age was 54.3 (±17.1) years. Mean LOS, median ICU, and median ventilator days were 26.3 (±14.1), 21.0 (17.0-33.0), and 17.0 (12.8-24.0) days, respectively. There were 68 cases of clinically diagnosed VAP, but only 37% met PVAP criteria. We compared 43 cases of clinical VAP, not meeting PVAP criteria, with the 25 PVAPs. Both groups had similar outcomes. The PVAPs were more likely to have an abnormal temperature (48.0% vs. 14.0%, p = 0.004), abnormal white blood cell count (84.0% vs. 18.6%, p < 0.001), or new antibiotic agent initiated (100% vs. 18.6%, p < 0.001) as VAE triggers. Comparison of the 93 trauma and 41 surgical patients demonstrated trauma patients were younger (51.2 vs. 61.5 y, p = 0.001), but had similar outcomes and rates of clinical VAP (48.4% and 43.9%, p = NS). Only 20.4% of trauma and 14.6% of surgical patients, however, had a PVAP reported. For patients with at least one VAE, the sensitivity and specificity for PVAP detecting VAP was 36.8% and 96.0%, respectively. CONCLUSION: The new CDC definition for PVAP grossly underestimates the clinical diagnosis of VAP and reports less than a third of the patients treated for VAP. Reporting differences were similar for trauma and surgical patients.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Pneumonia Associada à Ventilação Mecânica/diagnóstico , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Respiração Artificial/efeitos adversos , Respiração Artificial/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios
5.
Am J Surg ; 211(3): 619-25, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26916960

RESUMO

BACKGROUND: Traumatic vascular injuries are infrequent but can be devastating. This study characterized their incidence and the need for vascular surgeons in their repair. Outcomes for patients repaired by vascular and trauma surgeons were compared. METHODS: Patients age ≥14, needing operations for acute traumatic vascular injuries from January 1, 2008 to December 31, 2013 were included. RESULTS: Of the 27,224 adult trauma patients, 1.4% had vascular injuries needing operations. Trauma surgeons treated 40% of them. The need for repair by vascular surgeons varied based on mechanism, transfer status, injury location, time of injury, trauma staff practice, and experience (P < .05). Patients repaired by vascular surgeons had more transfusions, longer arrival-to-operation time, surgery duration, hospital stay but lower mortality (P < .05). This mortality difference dissipated after excluding early deaths. CONCLUSIONS: Approximately 3% of trauma patients had vascular injuries. Trauma surgeons treated a significant portion of them; using less resources and achieving similar outcomes in select patients when compared with vascular surgeons.


Assuntos
Competência Clínica , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/cirurgia , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Masculino , Duração da Cirurgia , Fatores de Risco , Centros de Traumatologia , Resultado do Tratamento , Lesões do Sistema Vascular/epidemiologia , Recursos Humanos
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