A Department-of-Anesthesiology-based management protocol for perioperative corneal abrasions.

INTRODUCTION: Corneal abrasions (CAs) are the most prevalent ocular injuries in the perioperative period. Previously, patients at our community hospital would wait for an ophthalmologist to be available to manage these minor injuries. To decrease this waiting period - and thereby increase patient satisfaction - we developed an anesthesiology-based protocol to manage minor CAs arising in the recovery room. The current study sought to assess this protocol's efficacy as well as further establish the incidence and some risk factors of CA. METHODS: This was a hospital-based, observational study. As per protocol, anesthesiologists saw and diagnosed any patient exhibiting symptoms of CA, after which they initiated a preestablished treatment regimen. To examine the efficacy of this protocol between March 2007 and December 2011, the number of CAs anesthesiologists managed and time to treatment were recorded. Additionally, the frequency of CAs was established along with some of their risk factors. RESULTS: Throughout the study period, there were 91,064 surgical cases, with 118 CAs (0.13% incidence). Anesthesiology alone managed 110 (93.22%) of these cases. The median time between the end of anesthesia to the time of prescribed ophthalmic medication was 156 minutes (first-third interquartile range: 108-219). All patients experienced resolution of symptoms by the morning following their complaint. Compared to the general surgical population, CA patients were older (P<0.01) and underwent longer surgeries (P<0.01). CONCLUSION: Minor CAs can be safely and effectively managed using an anesthesiology-based approach. Advanced age and longer surgery are confirmed as risk factors for these injuries.

Combination of Superficial and Deep Blocks with Rivaroxaban.

OBJECTIVE: Rivaroxaban is a new Xa inhibitor indicated for thromboprophylaxis in patients undergoing joint arthroplasty. This study was designed to assess the risk of major bleeding from the combination of either a single or a continuous deep, superficial, and plexus block and the use of rivaroxaban for thromboprophylaxis following joint arthroplasty. METHOD: Patients undergoing either primary, redo, unilateral, or bilateral total hip or knee replacement while receiving a femoral, sciatic, lumbar plexus nerve block alone or in combination and receiving at least one dose of rivaroxaban 10 mg once a day for thromboprophylaxis postoperatively were included in this analysis. RESULTS: In this series, 766 patients (199 total hip replacements and 567 total knee replacements) were included. A total of 1,104 blocks were performed including 1,029 continuous blocks (509 femoral, 320 sciatic, and 200 lumbar plexus). No major bleeding related to the performance of peripheral nerve blocks was recorded. In contrast, three patients developed hematomas in the operated knee requiring a surgical evacuation. Minor bleeding was recorded at the surgical site in 12 patients vs 10 patients at the site of the block. Although all minor bleeding at the surgical site occurred after the initiation of the rivaroxaban therapy, 80% of minor bleeding at the site of the block was recorded before the initiation of thromboprophylaxis. CONCLUSION: Our data supports the concept that there is no increased risk of major bleeding when deep and superficial blocks are performed in combination in patients receiving thromboprophylaxis rivaroxaban following joint arthroplasty.

The use of intravenous infusion or single dose of low-dose ketamine for postoperative analgesia: a review of the current literature.

OBJECTIVE: As an analgesic and N-methyl-D-aspartate receptor antagonist, ketamine has been increasingly used as an adjunct in the management of acute perioperative pain. Although several meta-analyses have examined low-dose intravenous (i.v.) ketamine, they do not distinguish between different types of infusions. Additionally, the many clinical trials published on ketamine vary by regimen of administration and surgical site. This review seeks to exclusively examine the evidence supporting the use of low-dose i.v. infusion of ketamine for the management of perioperative pain. METHODS: We searched Medline for any clinical trials or meta-analyses that were conducted on low-dose i.v. infusion of ketamine between 1966 and November 2013. Using six equations, we were left with 695 references. Of those, five meta-analyses and 39 clinical trials met the criteria to be included our review. These clinical trials represent 2,482 patients, 1,403 of whom received ketamine. We then examined the efficacy of low-dose i.v. ketamine by regimen and site of surgery using pain scores and opioid consumption as endpoints. Finally, we assessed the safety and long-term impact of low-dose ketamine. RESULTS: Low-dose i.v. ketamine reduces opioid consumption by 40%. It also lowers pain scores, but these findings are less clear. No major complications have been reported with low-dose i.v. infusion of ketamine when given up to 48 hours after surgery. While our review lends support to using low-dose i.v. infusion of ketamine in the management of perioperative pain, its optimal dose and regimen remain to be determined. CONCLUSIONS: Thirty-nine clinical trials assessed a continuous infusion or a bolus of low-dose ketamine for postoperative analgesia using reduction of pain scores or reduction of the opioid consumption as the primary endpoint. The mean reduction of opioid consumption when using low-dose i.v. infusion ketamine (infusion rate less than 1.2 mg/kg/h) is 40%. Ketamine also reduces pain scores, but the amplitude of the effect is less clear. No major complications have been reported with low-dose i.v. infusion of ketamine up to 48 hours following surgery.

Quality-improvement analytics for intravenous infusion pumps.

PURPOSE: The implementation of a smart-pump continuous quality-improvement (CQI) program across a large health system is described, with an emphasis on key metrics for outcomes analyses and program refinement. SUMMARY: Three years ago, the University of Pittsburgh Medical Center health system launched a CQI initiative to help ensure the safe use of 6000 smart pumps in its 14 inpatient facilities. A centralized team led by pharmacists is responsible for the retrieval and interpretation of smart-pump data, which is continuously transmitted to a main server. CQI findings are regularly posted on the health system's interdisciplinary intranet. Monitored metrics include rates of compliance with preprogrammed infusion limits, the top 20 drugs involved in alerts, drugs associated with alert-override rates of ≥90%, numbers of alerts by infusion type, nurse responses to alerts, and alert rate per drug library update. Based on the collected CQI data and site-specific requests, four systemwide updates of the smart-pump drug library were performed during the first 18 months of the program, reducing "nuisance alerts" by about 10% per update cycle and enabling targeted interventions to reduce rapid-infusion errors, other adverse drug events (ADEs), and pump-programming workarounds. Over one 12-month period, bedside alerts prompted nurses to reprogram or cancel continuous infusions an average of 400 times per month, potentially averting i.v. medication ADEs. CONCLUSION: A smart-pump CQI program is an effective tool for enhancing the safety of i.v. medication administration. The ongoing refinement of the drug library through the development and implementation of key interventions promotes the growth and sustainability of the smart-pump initiative systemwide.

Thromboprophylaxis and peripheral nerve blocks in patients undergoing joint arthroplasty.

This study was designed to assess the risk of hematoma related to the combination of peripheral nerve blocks and thromboprophylaxis. A total of 3588 patients undergoing joint arthroplasty were included. Blocks performed included continuous lumbar plexus, continuous femoral, and continuous or single sciatic. The perineural catheters were removed on postoperative days 2 or 3. A total of 6935 blocks were performed in patients receiving warfarin (50.0%), fondaparinux (12.8%), deltaparin (11.6%), enoxaparin (1.8%), and aspirin (23.8%). In this patient population, no perineural hematoma was recorded. Our data provide evidence that continuous/single peripheral nerve blocks can be safely performed before thromboprophylaxis initiation, and perineural catheters can be safely removed while the patient is receiving thromboprophylaxis and/or aspirin.

Prevention of postoperative mediastinitis: a clinical process improvement model.

In a prospective study of more than 4,000 consecutive patients who underwent any cardiovascular procedure requiring sternotomy incision in a 650-bed tertiary care hospital, a gradual increase in deep sternal infections from 0.8% in 1995 to 2.1% in 1999 was noted. By using a Plan-Do-Check-Act process improvement model, several interventions to decrease the infection rate were planned and implemented based on hypotheses generated from the characteristics of infected patients. These interventions included chlorhexidine preoperative shower, discontinuation of shaving, administration of antibiotics in the holding area, segregation of instruments, and implementation of an insulin protocol. Findings included a decrease in deep sternal and leg infections after implementation of these interventions. Deep sternal infection rates decreased from 2.1% to 1.5% and leg infection rates, from 1.93% to 0.47%. Results were not statistically significant but were clinically relevant. Furthermore, a total of $200,000 was achieved in cost savings in 1 year.