S136-operationalizing an enhanced recovery protocol after bariatric surgery: single institutional pilot experience forging data-driven standard work.

BACKGROUND: Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations. METHODS AND PROCEDURES: An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student's t-tests. RESULTS: Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (P < 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4-80.8% post-implementation (P < 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes. CONCLUSION: Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.

PPE training and the effectiveness of universal masking in preventing exposures: The importance of the relationship between anesthesia and infection prevention.

Early in the pandemic, infection prevention (IP), in collaboration with our local anesthesia leadership, took the approach of ensuring all members of the Anesthesia Department understood the importance of universal masking, were individually trained on the use of the Controlled Air Purifier Respirator, as well the appropriate method for donning/doffing N95 respirators. Multiple providers in the department tested positive for COVID, resulting in the IP Department to conduct the routine contact tracing investigation. During the investigation, it was determined that all persons who met the CDC (Centers for Disease Control & Prevention) contact exposure guidelines would undergo COVID testing, which consequently was 109 team members due to the exposure risk identified in the break room space. IP worked with the Anesthesia Preoperative Clinic to test all team members identified over a 3-day period (approximately 5-7 days postexposure). Out of the 109 team members who were tested postexposure, there were 0 conversions. The department attributes this to the consistency in personal protective equipment training, support and collaboration between anesthesia and IP which led to successful care for COVID patients with a limited provider infection rate.

Liposomal bupivacaine and novel local anesthetic formulations.

Novel preparations allowing for the extended duration of action of local anesthetics have many clinically relevant benefits. With regard to this, the development of liposomal bupivacaine has the potential to significantly impact patient care by improving perioperative pain control. The unique liposomal bilayer that encapsulates bupivacaine allows for a sustained release of local anesthetic for up to 72 h after a single use and can significantly decrease postoperative opioid consumption. SABER-bupivacaine is another depot formulation that helps in sustained release of bupivacaine from an encapsulated bupivacaine in a biodegradable sucrose acetate isobutyrate biolayer. HTX-011 is an investigational extended-release local anesthetic formulation currently undergoing Phase 3 clinical trials. HTX-011 is composed of a bioerodible polymer with bupivacaine and low-dose meloxicam in which the polymer undergoes hydrolysis and allows for sustained release of bupivacaine and meloxicam for 3 days. The present investigation reviews pharmacologic considerations related to the formulation of liposomal bupivacaine, current FDA-approved indications for its use, and future extended-release local anesthetic formulations currently under investigation.

Guia para o tratamento da AIDS-HIV / Guide for the treatment of the AIDS-HIV

Avalia os riscos de infecção pelo HIV e traz recomendações para os exames. Mostra a incidência da AIDS nos Estados Unidos, os exames laboratoriais utilizados no diagnóstico e manejo da infecção pelo HIV, a classificação do HIV segundo o CDC, a evolução da infecção e da doença pelo HIV em adultos, a avaliação inicial do paciente adulto infectado pelo HIV, o tratamento com fármacos anti-retrovirais, os produtos biológicos para o tratamento das hematopenias, os agentes utilizados na perda de peso, os agentes antimicrobianos primários contra pátogenos oportunistas, a evolução da infecção pelo HIV e doença neurológica em adultos, o tratamento empírico das infecções oportunistas potencialmente fatais, o diagnóstico das infecções oportunistas, a evolução da infecção pelo HIV e doença pulmonar em adultos, o HIV/AIDS em mulheres e em crianças, a imunização de adultos infectados, o manejo a exposição ocupacional, o controle da infecção e as terapias alternativas para o HIV

Guia para o tratamento da AIDS-HIV / Guide for the treatment of the AIDS-HIV

Avalia os riscos de infecção pelo HIV e traz recomendações para os exames. Mostra a incidência da AIDS nos Estados Unidos, os exames laboratoriais utilizados no diagnóstico e manejo da infecção pelo HIV, a classificação do HIV segundo o CDC, a evolução da infecção e da doença pelo HIV em adultos, a avaliação inicial do paciente adulto infectado pelo HIV, o tratamento com fármacos anti-retrovirais, os produtos biológicos para o tratamento das hematopenias, os agentes utilizados na perda de peso, os agentes antimicrobianos primários contra pátogenos oportunistas, a evolução da infecção pelo HIV e doença neurológica em adultos, o tratamento empírico das infecções oportunistas potencialmente fatais, o diagnóstico das infecções oportunistas, a evolução da infecção pelo HIV e doença pulmonar em adultos, o HIV/AIDS em mulheres e em crianças, a imunização de adultos infectados, o manejo a exposição ocupacional, o controle da infecção e as terapias alternativas para o HIV