Correlation of Ondansetron Timing in Postoperative Nausea and Vomiting: A Retrospective Evaluation Amongst Adult Patients Receiving General Anesthesia

Background Addressed as a national quality initiative by the Centers for Medicare and Medicaid Services (CMS), postoperative nausea and vomiting (PONV) is a vexing complication requiring further attention by anesthesia providers.3 Medication optimization is an area of focus to address this complication.4 Ondansetron, a selective 5- hydroxytryptophan subtype 3 (5-HT3 ) receptor antagonist, is effective and considered the “gold standard” in the prevention of PONV.4 GlaxoSmithKline™ suggests administering Zofran® (ondansetron) before the induction of anesthesia.5 These directions are in contrast to the synthesis of the research evidence, which supports increased effectiveness of ondansetron when administered 30 minutes before emergence from anesthesia.4 The purpose of this evidence-based practice (EBP) project was to evaluate ondansetron timing, report the incidence proportion of PONV among adult general surgical patients and evaluate the prevalence of rescue antiemetics utilized at 2, 6, and 24 hours postoperatively. Methods A retrospective, EBP project was conducted at Providence Sacred Heart Medical Center (PSHMC) and Providence Holy Family Hospital (PHFH) in Spokane, WA. • Permission was obtained by the facility and exemption determination was granted by the IRB. • Patient data was securely extracted and stored in a HIPPA complaint REDCap database. Patient data was fully deidentified. Data extraction included all surgeries receiving general anesthesia from October 1, 2018, to September 30, 2019. • Inclusion criteria: Adult patients 18-90 years old, general surgery (ETT, LMA) using volatile inhalational agents, admitted for 24hrs. • Exclusion Criteria: Pediatric, obstetric, direct admission to ICU, postoperative intubation requirements in PACU. • PONV outcome was determined by nursing documentation of PONV scale or administration of antiemetic medication. • Descriptive data analysis was completed and stratified by ondansetron timing. Independent risk factors was determined and controlled for using a binary logistic regression. Level of significance set at 0.05. Discussion The literature reports approximately 30% of patients who undergo general anesthesia will be affected by PONV. 1,2,4 In addition, research evidence supports ondansetron administration during emergence of anesthesia as an avenue to combat the incidence of PONV. 4 This project mirrored the literature by correlating a relationship between ondansetron timing administration on emergence and reducing the risk of PONV at 2, 6, and 24 hours. When controlling for Apfel risk factors and confounding bias, this project’s PONV incidence was consistent with literature, depicting a reduction in PONV incidence at 2, 6, and 24 hours. The prevalence of a rescue antiemetic medication at 2, 6, and 24 hours postoperatively was also statistically significant for the emergence group when compared to the induction group. Understanding the pharmacokinetics of ondansetron, especially its half-life of 3.8 (+/- 1) hours, provides insight regarding the length of time serotonin receptors may be blocked, and thus prevention of subsequent PONV occurrences. 6 Of the patients that received ondansetron at PSHMC and PHFH, 71% of patients received ondansetron on emergence. Anesthesia providers should continue to tailor prophylactic antiemetic administration based on patient selection and antiemetic pharmacokinetic profiles.https://digitalcommons.psjhealth.org/other_pubs/1107/thumbnail.jp

Postoperative Nausea and Vomiting with Low-Dose Propofol Infusions in Patients Undergoing Gynecological Surgeries with Volatile Anesthetics at Providence Sacred Heart Medical Center and Providence Holy Family Hospital

Background Postoperative nausea and vomiting (PONV) is a common complication following surgery. It remains the most important determinant of length of stay and leading cause of dissatisfaction in anesthesia.4 Females undergoing gynecological laparoscopic surgery have the highest rates.8 Apfel’s baseline risk factors for PONV include female gender, history of motion sickness and/or PONV, non-smoking status and administration of postoperative opioids.1 Propofol has antiemetic properties and Gan’s evidence supports the use of an intraoperative low-dose infusion to reduce baseline risk factors for PONV.6 This project aims to describe the rates of intraoperative low-dose propofol infusions in female patients undergoing gynecological surgery and baseline characteristics associated with its use. Methods • A retrospective, observational evidence-based practice project was conducted at Providence Sacred Heart Medical Center (PSHMC) and Providence Holy Family Hospital (PHFH) in Spokane, WA. • CIRC approval was obtained by the facility and IRB exemption granted. All patient data was securely extracted by a Providence sponsor and stored in a HIPAA compliant REDCap database. Patient data was fully de-identified. • Inclusion criteria consisted of adult patients ≥18 to 90 years of age undergoing general anesthesia with volatile anesthetics in gynecological surgeries that were hospitalized for at least 24 hours and no more than 14 days at PSHMC and PHFH from January 2014 to December 2019. Patients receiving intraoperative low-dose propofol infusions of ≤25 mcg/kg/min were identified. • Exclusion criteria consisted of patients \u3c18 and \u3e90 years of age, infusions \u3e25 mcg/kg/min, and any patient hospitalized for \u3c24 hours and \u3e14 days. • 24-hour PONV outcome was determined by PACU nurse assessment of PONV in EPIC or administration of antiemetic medication in the EMR. • Statistical data analysis was conducted and stratified by the number of Apfel risk factors. • Univariate and bivariate analysis were conducted on categorical and continuous data. • Multivariable analysis was conducted through binary logistic regression controlling for variables that contributed to the use of a propofol infusion. Discussion This multi-year evidence-based practice project examined 499 cases and found that intraoperative low-dose propofol infusions were used 45 times accounting for 9% of the total sample. Current research literature supports the utilization of low-dose propofol infusions for patients at high-risk of developing PONV. 3,6,7 Age, BMI, case duration, ASA status, smoking status and post-op opioids did not influence whether a patient received an intraoperative low-dose propofol infusion. Bivariate analysis only showed a statistical significance with history of PONV (P=0.04). Similar findings were demonstrated in a multivariable model. This project focused on a clinically vulnerable population with low-dose propofol infusions and PONV. Overall rates for 24-hour PONV in this patient sample were 76% (N=499). 24-hour rates for patients that received an infusion were 84% (n=45) which may be explained by treatment by indication in this high-risk sample. Overall, results from this project identify areas for care improvement and CRNA education.https://digitalcommons.psjhealth.org/other_pubs/1112/thumbnail.jp

Prophylactic Phenylephrine Infusion to Mitigate Intraoperative Hypotension after Spinal Anesthesia among Orthopedic Patients

Background Intraoperative Hypotension (IOH) is common after spinal anesthesia (SA) and is associated with an increased risk of end organ damage.1 2 3 The treatment regimen for IOH after SA varies in the orthopedic population. However, the current research literature suggests that a prophylactic infusion of phenylephrine significantly reduces the number of episodes and duration of hypotension.1 This EBP project aims to report the proportion of patients receiving prophylactic phenylephrine infusions and the incidence of hypotension following SA among orthopedic surgery patients at Providence Sacred Heart Medical Center (PSHMC) in Spokane, WA. Methods • A retrospective, observational EBP project was conducted at PSHMC. • Permission was obtained by PSHMC Clinical Innovation and Research Council and deemed exempt from human subjects research by the Providence Health Care Institutional Review Board. • Patient data was securely extracted, deidentified, and stored in a HIPPA compliant REDCap database. • Inclusion criteria: Adult patients ≥ 18 years old who received SA for non-emergent orthopedic surgery. • Exclusions: Pediatric, obstetric, emergency surgery, and surgery lines other than orthopedic. • IOH outcome determined by absolute mean arterial pressure (MAP) thresholds, as described in Wesselink et al. (2018) systematic review.4 • Descriptive analyses were conducted to examine baseline demographics and IOH treatment regimens utilized at PSHMC. • Independent risk factors determined using binary logistic regression and time-to-event (MAP \u3c60 mmHg) analyses determined using the Kaplan-Meier estimator (α = 0.05). Discussion The primary objective of this observational EBP project of 3,745 patients was to measure the use of prophylactic phenylephrine infusions among orthopedic surgery patients at PSHMC. Overall, we found that 16% of patients received a prophylactic phenylephrine infusion. The median infusion start time for a prophylactic infusion was 19 minutes following SA [IQR 10-29]. Patients who did not receive a prophylactic phenylephrine infusion following SA had significantly increased risk of MAP \u3c60mmHg for ≥ 10 minutes (RR 3.42, 2.55-4.62, p\u3c0.001). The observed median time to the first MAP \u3c60 mmHg was longer in patients who received prophylactic phenylephrine infusions (80 [41-99] vs 29 [16-57] minutes, p \u3c 0.0001). Patients who were male, advanced age, higher physical status scores and history of CVD were more likely to receive a prophylactic infusion. This project is the first to establish the utilization rate of prophylactic phenylephrine infusions and the incidence of IOH after SA among orthopedic patients at a large academic health center. However, due to the lack of prospective studies, further investigation is warranted.https://digitalcommons.psjhealth.org/other_pubs/1105/thumbnail.jp

An Operational evaluation of head up displays for civil transport operations. NASA/FAA phase 3 report

The advantages and disadvantages of head-up displays (HUDs) in commercial jet transport approach and landing operations was evaluated. Ten airline captains currently qualified in the B-727 aircraft flew a series of instrument landing system (ILS) and nonprecision approaches in a motion base simulator using both a flight director HUD concept and a flightpath HUD concept as well as conventional head-down instruments under a variety of environmental and operational conditions to assess: (1) the potential benefits of these HUDs in airline operations; (2) problems which might be associated with their use; and (3) flight crew training requirements and flight crew operating procedures suitable for use with the HUDs. Results are presented in terms of objective simulator based performance measures, subject pilot opinion and rating data, and observer data

Multiple insecticide resistance mechanisms involving metabolic changes and insensitive target sites selected in anopheline vectors of malaria in Sri Lanka

<p>Abstract</p> <p>Background</p> <p>The current status of insecticide resistance and the underlying resistance mechanisms were studied in the major vector of malaria, <it>Anopheles culicifacies</it>, and the secondary vector, <it>Anopheles subpictus </it>in five districts (Anuradhapura, Kurunegala, Moneragala, Puttalam and Trincomalee) of Sri Lanka. Eight other anophelines, <it>Anopheles annularis, Anopheles barbirostris, Anopheles jamesii, Anopheles nigerrimus, Anopheles peditaeniatus, Anopheles tessellatus, Anopheles vagus </it>and <it>Anopheles varuna </it>from Anuradhapura district were also tested.</p> <p>Methods</p> <p>Adult females were exposed to the WHO discriminating dosages of DDT, malathion, fenitrothion, propoxur, λ-cyhalothrin, cyfluthrin, cypermethrin, deltamethrin, permethrin and etofenprox. The presence of metabolic resistance by esterase, glutathione S-transferase (GST) and monooxygenase-based mechanisms, and the sensitivity of the acetylcholinesterase target site were assessed using synergists, and biochemical, and metabolic techniques.</p> <p>Results</p> <p>All the anopheline species had high DDT resistance. All <it>An. culicifacies </it>and <it>An. subpictus </it>populations were resistant to malathion, except <it>An. culicifacies </it>from Kurunegala, where there was no malathion carboxylesterase activity. Kurunegala and Puttalam populations of <it>An. culicifacies </it>were susceptible to fenitrothion. All the <it>An. culicifacies </it>populations were susceptible to carbamates. Both species were susceptible to the discriminating dosages of cypermethrin and cyfluthrin, but had different levels of resistance to other pyrethroids. Of the 8 other anophelines, only <it>An. nigerrimus </it>and <it>An. peditaeniatus </it>were resistant to all the insecticides tested, probably due to their high exposure to the insecticides used in agriculture. <it>An. vagus </it>showed some resistance to permethrin.</p> <p>Esterases, GSTs and monooxygenases were elevated in both <it>An. culicifacies </it>and <it>An. subpictus</it>. AChE was most sensitive to insecticides in Kurunegala and Trincomalee <it>An. culicifacies </it>populations and highly insensitive in the Trincomalee <it>An. subpictus </it>population.</p> <p>Conclusion</p> <p>The complexity of the resistance segregating in these field populations underlines the need for new molecular tools to identify the genomic diversity, differential upregulation and different binding specificities of resistance conferring genes, and the presence of different subspecies with different vectorial capacities.</p

Applying health psychology theory to practice: cognitive behaviour therapy, motivational interviewing and mindfulness-based interventions for improving mental and physical health

Introduction Sleep is a key issue in maintaining good mental and physical health, but increasingly people are suffering with insomnia and experiencing poor health-related quality of life and daytime functioning as a result. Cognitive Behaviour Therapy for Insomnia (CBT-I) has been shown to be effective. However, there has been little research conducted which compares the efficacy of different treatment modalities on health-related quality of life alongside other measures related to patients’ experience of insomnia, such as daytime functioning, depression and anxiety; and treatments are not widely available or well understood. This original study therefore explored the effectiveness of three UK CBT-I treatment interventions, namely a manual-guided five-week group, a one-day workshop and an online programme on outcomes and participatory experience. Method The study used a mixed methods approach. This included a randomised controlled pilot study assessing insomnia severity, beliefs and attitudes about sleep, depression, anxiety, daytime functioning and health-related quality of life, sleep diary measures, use of psychotropic medication, non-prescription drugs, and alcohol use across and between interventions. The secondary aim of the study was to explore participatory experiences of patients in each intervention through the completion of a patient experience questionnaire (analysed with content analysis), and semi-structured interviews from each intervention to form a case study (analysed with interpretative phenomenological analysis). Results The findings revealed that CBT-I treatment resulted in significant improvements in insomnia severity, dysfunctional beliefs and attitudes about sleep, depression, anxiety, daytime functioning and health-related quality of life, mental health or insomnia related medication use, time in bed, sleep onset latency, wakefulness after sleep onset, and sleep efficiency across interventions. No significant differences between the effectiveness of the three CBT-I interventions were found, apart from more time in bed, for the online programme. Therefore, the one-day workshop and the online programme were assessed to be as effective overall on key outcomes as the five-week group. Secondary findings provided useful information on participant experience, which could provide future options and choice for individuals in determining what would be the most beneficial intervention for them based on their specific needs. Discussion The success of interventions in this pilot study therefore contributes to the ongoing development of accessible and effective stepped-care treatment. Findings from this research could also contribute to matching individual patient needs to treatment interventions. Through improving service delivery and funding training, savings could also be made by enabling sleep specialists to see only the most severe cases of insomnia, in addition to potential reductions of long-term use of medication in the general population. A challenge for the future is therefore to disseminate evidence-based therapies to both patients and health care professionals in order to make treatments more widely available and deployable, as well as enable better understanding of current approaches and options. Results will contribute to evidence for choice and accessibility to a greater range of interventions in future, led by feedback from participant experience. Conclusion The results have positive implications for improving the management of insomnia for a large number of patients, and thereby improving the well-being, mental and physical health of many people with sleep problems. As the interdependence between mental and physical health is more widely recognised, health psychology can make a valued contribution to research, training and delivery of CBT-I interventions

Implementation of the global plan for insecticide resistance management in malaria vectors: progress, challenges and the way forward

In recent years, there has been an increase in resistance of malaria vectors to insecticides, particularly to pyrethroids which are widely used in insecticide-treated nets. The Global Plan for Insecticide Resistance Management in malaria vectors (GPIRM), released in May 2012, is a collective strategy for the malaria community to tackle this challenge. This review outlines progress made to date and the challenges experienced in the implementation of GPIRM, and outlines focus areas requiring urgent attention. Whilst there has been some advancement, uptake of GPIRM at the national level has generally been poor for various reasons, including limited availability of vector control tools with new mechanisms of action as well as critical financial, human and infrastructural resource deficiencies. There is an urgent need for a global response plan to address these deficits and ensure the correct and efficient use of available tools in order to maintain the effectiveness of current vector control efforts whilst novel vector control tools are under development. Emphasis must be placed on enhancing national capacities (such as human and infrastructural resources) to enable efficient monitoring and management of insecticide resistance, and to support availability and accessibility of appropriate new vector control products. Lack of action by the global community to address the threat of insecticide resistance is unacceptable and deprives affected communities of their basic right of universal access to effective malaria prevention. Aligning efforts and assigning the needed resources will ensure the optimal implementation of GPIRM with the ultimate goal of maintaining effective malaria vector control

Being well? A meta-ethnography of older patients and their relatives’ descriptions of suffering and well-being in the transition from hospital to home

Background: As the average length of hospital stay decreases, more and more older patients will need support during and after the hospital transition, which will mainly be provided by their relatives. Studies highlight the enormous effect such a transition has on the lives of older patients and their relatives. However, research is lacking regarding in-depth understanding of the complexities and the notions of suffering and well-being the older patients and their relatives describe in the transition from hospital to home. Therefore, this study aims to examine the description of suffering and well-being on a deeper, existential level by drawing on existing phenomenological research. Methods: In order to synthesize and reinterpret primary findings, we used the seven-step method for meta-ethnography. Following specific inclusion criteria and focusing on empirical phenomenological studies about older patients and their relatives experiences of hospital to home transitions, a systematic literature search was conducted. Data from ten studies have been analyzed. Results: Our analysis identified three intertwined themes: i) ‘Being excluded vs. being included in the transition process’, ii) ‘Being a team: a call for support and a call to support’ and iii) ‘Riding an emotional rollercoaster’. The last theme was unfolded by the two subthemes ‘Taking on the new role as a caregiver: oscillating between struggling and accepting’ and ‘Getting back to normal: oscillating between uncertainty and hope’. Within those themes, older patients and their relatives described rather similar than contradictory aspects. Conclusions: This study offers insights into the tension between existential suffering and well-being described by the older patients and their relatives during the transition from hospital to home. Especially, the description of well-being in all its nuances which, if achieved, enables older patients and their relatives to identify with the situation and to move forward, this process can then be supported by the health care professionals. However, there is still lack of knowledge with regards to a deeper understanding of existential well-being in this process. Given the increasing tendency towards early hospital discharges, the findings underpin the need to further investigate the experiences of well-being in this process

Landmarks and ant search strategies after interrupted tandem runs

© 2014. Published by The Company of Biologists Ltd. During a tandem run, a single leading ant recruits a single follower to an important resource such as a new nest. To examine this process, we used a motorized gantry, which has not previously been used in ant studies, to track tandem running ants accurately in a large arena and we compared their performance in the presence of different types of landmark. We interrupted tandem runs by taking away the leader and moved a large distant landmark behind the new nest just at the time of this separation. Our aim was to determine what information followers might have obtained from the incomplete tandem run they had followed, and how they behaved after the tandem run had been interrupted. Our results show that former followers search by using composite random strategies with elements of sub-diffusive and diffusive movements. Furthermore, when we provided more landmarks former followers searched for longer. However, when all landmarks were removed completely from the arena, the ants' search duration lasted up to four times longer. Hence, their search strategy changes in the presence or absence of landmarks. Even after extensive search of this kind, former followers headed back to their old nest but did not return along the path of the tandem run they had followed. The combination of the position to which the large distant landmark behind the new nest was moved and the presence or absence of additional landmarks influenced the orientation of the former followers' paths back to the old nest. We also found that these ants exhibit behavioural lateralization in which they possibly use their right eye more than their left eye to recognize landmarks for navigation. Our results suggest that former follower ants learn landmarks during tandem running and use this information to make strategic decisions