Anesthesia Management in a Pregnant Woman with Severe Sub-glottic Stenosis

ABSTRAC

Modeling of formation damage during smart water flooding in sandstone reservoirs

Abstract Impairment of permeability has been observed as an effective factor in production decline during secondary and tertiary recovery processes such as water flooding. Among different permeability damage mechanisms, fines migration and deposition is known as the main mechanism which occurs due to pore throat clogging and blocking. Because injected water and formation water are usually incompatible, permeability damage evaluation and scale formation prediction must be done before the water flooding process in the oil field is implemented. For this purpose, compatibility tests and core flood experiments are common, but experimental approaches with time and facility limitations are expensive. Thus, by decreasing the time required for conducting experiments, modeling approaches can replace the routine laboratory experiments. Based on thermodynamic balance and the solubility of ions in water, scale development due to seawater injection in an Iranian oil field was predicted in this work using the OLI ScaleChem software. After that, it was suggested that special water be introduced to help reduce the amount of scales that had accumulated in the rock pore space. The extent of permeability damage in various seawater injection scenarios was then assessed via dynamic core flood experiments. Finally, scales-seawater injection into the core was simulated using digital core analysis (DCA) results and the pore scale modeling approach. The core flood experiment data are consistent with the scale formation prediction made by the OLI ScaleChem software, which indicates that smart water can be determined by optimizing the salinity and ion content of injected water. Also, results of permeability damage prediction by our modeling approach have good agreement with the core flood experiment data. Therefore, our modeling approach can replace the conventional core flood experiments as a low-cost method with high computational efficiency and high enough accuracy to evaluate formation damage in the water flooding process

Quality Improvement: Arterial Grafting Redux, 2010:2019

BACKGROUND: The evidence base favoring utilization of multiple arterial conduits in coronary artery bypass grafting has strengthened in recent years. Nevertheless, utilization of arterial conduits in the US lags behind that of many European peers. We describe a statewide collaborative based approach to improving utilization. METHODS: Four metrics of arterial revascularization were devised. These were displayed and discussed at quarterly statewide quality collaborative meetings from January 2016 onwards, integrated with an educational program regarding attendant benefits. We undertook retrospective review of isolated coronary artery bypass grafting statewide from 2012-2019 to assess impact. RESULTS: A total of 38,523 cases met inclusion/exclusion criteria. Statewide incidence of multiple arterial grafting increased from 7.4% at baseline to 21.7% in 2019 (P < .001), implementation across hospitals varied widely, ranging from 67.6% to 0.0%. Utilization of total arterial revascularization increased 1.9% to 4.4% (P < .001) between time frames. Utilization of both radial artery and bilateral internal thoracic artery conduit increased significantly from 5.3% to 13.2% (P < .001) and 2.1% to 8.5% (P < .001), respectively; radial artery utilization was significantly higher than bilateral internal thoracic artery for each year (P < .001 for all comparisons). CONCLUSIONS: Our statewide quality improvement initiative improved rates of utilization of multiple arterial grafting by all metrics. Barriers to current utilization were identified to guide future quality improvement efforts. This reproducible approach is readily transferable to improve quality of care in other domains and geographical areas

Establishment and Implementation of Evidence-Based Opioid Prescribing Guidelines in Cardiac Surgery

BACKGROUND: Despite the risk of new persistent opioid use after cardiac surgery, post-discharge opioid use has not been quantified and evidence-based prescribing guidelines have not been established. METHODS: Opioid-naïve patients undergoing primary cardiac surgery via median sternotomy between January-December 2019 at 10 hospitals participating in a statewide collaborative were selected. Clinical data were linked to patient-reported outcomes collected at 30-day follow-up. An opioid prescribing recommendation stratified by inpatient opioid use on the day before discharge (0, 1-3, or ≥4 pills) was implemented in July 2019. Interrupted time-series analyses were performed for prescription size and post-discharge opioid use before (January-June) and after (July-December) guideline implementation. RESULTS: Among 1495 patients (729 prerecommendation and 766 postrecommendation), median prescription size decreased from 20 pills to 12 pills after recommendation release (P \u3c .001), while opioid use decreased from 3 pills to 0 pills (P \u3c .001). Change in prescription size over time was +0.6 pill/month before and -0.8 pill/month after the recommendation (difference = -1.4 pills/month; P = .036). Change in patient use was +0.6 pill/month before and -0.4 pill/month after the recommendation (difference = -1.0 pills/month; P = .017). Pain levels during the first week after surgery and refills were unchanged. Patients using 0 pills before discharge (n = 710) were prescribed a median of 0 pills and used 0 pills, while those using 1 to 3 pills (n = 536) were prescribed 20 pills and used 7 pills, and those using greater than or equal to 4 pills (n = 249) were prescribed 32 pills and used 24 pills. CONCLUSIONS: An opioid prescribing recommendation was effective, and prescribing after cardiac surgery should be guided by inpatient use

Predictors of Discharge Home Without Opioids After Cardiac Surgery: A Multicenter Analysis

BACKGROUND: Whether all patients will require an opioid prescription after cardiac surgery is unknown. We performed a multicenter analysis to identify patient predictors of not receiving an opioid prescription at the time of discharge home after cardiac surgery. METHODS: Opioid-naïve patients undergoing coronary artery bypass grafting and/or valve surgery through a sternotomy at 10 centers from January to December 2019 were identified retrospectively from a prospectively maintained data set. Opioid-naïve was defined as not taking opioids at the time of admission. The primary outcome was discharge without an opioid prescription. Mixed-effects logistic regression was performed to identify predictors of discharge without an opioid prescription, and postdischarge opioid prescribing was monitored to assess patient tolerance of discharge without an opioid prescription. RESULTS: Among 1924 eligible opioid-naïve patients, mean age was 64 ± 11 years, and 25% were women. In total, 28% of all patients were discharged without an opioid prescription. On multivariable analysis, older age, longer length of hospital stay, and undergoing surgery during the last 3 months of the study were independent predictors of discharge without an opioid prescription, whereas depression, non-Black and non-White race, and using more opioid pills on the day before discharge were independent predictors of receiving an opioid prescription. Among patients discharged without an opioid prescription, 1.8% (10 of 547) were subsequently prescribed an opioid. CONCLUSIONS: Discharging select patients without an opioid prescription after cardiac surgery appears well tolerated, with a low incidence of postdischarge opioid prescriptions. Increasing the number of patients discharged without an opioid prescription may be an area for quality improvement