COMPARING NERVE BLOCK PAIN PUMPS TO STANDARD OF CARE IN PATIENTS FOLLOWING CARDIOTHORACIC SURGERY

INTRODUCTION: Post-operative pain management following cardiothoracic surgery (CTS) can be challenging. Although opioids are commonly prescribed, multimodal strategies are used to decrease opioid consumption. One strategy includes the use of local anesthetics via peripheral nerve block pain pumps (PNBPP). However, literature in CTS patients is limited and conflicting. This study evaluated the efficacy and safety of PNBPP in patients following CTS. METHODS: This was a quasi-experimental study that included adult patients admitted to the cardiac intensive care unit following CTS. The intervention group included those who received PNBPP and they were compared to a group that received standard of care (SOC). The primary endpoint was the total oral morphine milligram equivalents (MMEs) used in the four days following surgery. Secondary endpoints included adverse events, incidence of post-operative ileus, time to first bowel movement, pain scores, length of stay and cost of intervention. Statistical analysis was performed with Chi-square, Fisher\u27s exact, Mann-Whitney U and t-tests where appropriate (IBM SPSS Statistics Software version 28.0.1.1). A sample size of 126 was calculated to detect a 50% reduction in opioid consumption with an alpha of 0.05 and power of 80%. RESULTS: Baseline characteristics were similar between groups with a median age of 60 and 63 in the PNBPP and SOC groups, respectively. The majority of patients were male and had a coronary artery bypass graft performed. Median oral MMEs was 375 (IQR: 268.5, 457.5) in the SOC group compared to 304.5 (IQR: 240, 416) in the PNBPP group (p-value 0.189). When comparing the SOC and PNBPP groups, incidence of post-operative ileus was 2 (3.2%) and 12 (19%) (p-value 0.005) with median time in hours to first bowel movement of 68.38 (IQR: 50.31, 85.50) and 66.11 (IQR: 50.28, 76.13) (p-value 0.336). There was no significant difference between groups in pain scores or length of stay. Median cost (USD) of PNBPP therapy was $125 in those that received an electronic pump and$3,138 in those that received an elastomeric pump. CONCLUSIONS: Addition of PNBPP post-CTS did not significantly reduce opioid consumption compared to SOC. Larger studies are needed to better define the role of PNBPP in post-operative pain management following CTS

Project #37: Management Guidelines for Patients with COVID-19: Rapid Cycle Improvement

Project’s purpose is to rapidly devise, continually improve, educate, and implement a live and changing COVID-19 management guideline based upon emerging best available evidence. This project also aims to optimize the care of patients with COVID-19 and improve patient outcomes.https://scholarlycommons.henryford.com/qualityexpo2022/1004/thumbnail.jp

Serotonin Syndrome Following Methylene Blue Administration for Vasoplegic Syndrome

Methylene blue (MB) has been used for additional blood pressure support in patients who develop severe, refractory vasoplegia; however, MB can induce serotonin syndrome, especially when used in conjunction with other serotonergic agents. We describe a case of serotonin syndrome in a patient who received MB for vasoplegic syndrome after left ventricular assist device implantation and discuss its presentation and management

Serotonin Syndrome Following Methylene Blue Administration for Vasoplegic Syndrome

Methylene blue (MB) has been used for additional blood pressure support in patients who develop severe, refractory vasoplegia; however, MB can induce serotonin syndrome, especially when used in conjunction with other serotonergic agents. We describe a case of serotonin syndrome in a patient who received MB for vasoplegic syndrome after left ventricular assist device implantation and discuss its presentation and management

Serotonin Syndrome Following Methylene Blue Administration for Vasoplegic Syndrome

Methylene blue (MB) has been used for additional blood pressure support in patients who develop severe, refractory vasoplegia; however, MB can induce serotonin syndrome, especially when used in conjunction with other serotonergic agents. We describe a case of serotonin syndrome in a patient who received MB for vasoplegic syndrome after left ventricular assist device implantation and discuss its presentation and management

Utilization of a Standardized Discharge Checklist to Improve the Transition of Care for Patients Receiving Parenteral Nutrition

BACKGROUND: Guidelines recommend using discharge checklists to discharge patients receiving parenteral nutrition (PN). Transition-of-care (TOC) tools have not been extensively studied in the PN population. The purpose of this study is to evaluate the impact of a standardized PN discharge checklist on TOC for PN patients. METHODS: This is an Institutional Review Board-approved, retrospective quasi-experimental study of patients discharged receiving PN between January 1, 2014, and May 31, 2018. The primary end point was the completion of a PN discharge bundle (identification of a responsible provider to monitor PN after discharge, meeting daily caloric requirement of 20-35 kcal/kg/d, cycling PN prior to discharge). Secondary end points included documentation of PN discharge checklist components, hospital length of stay, frequency of 30-day hospital encounters, cause of hospital encounters, and time to readmission. RESULTS: Fifty encounters were included in the pregroup and postgroup each (n = 100). There was a significant increase in completion of the TOC bundle in the postgroup (54% vs 76%, P = .035), driven by identification of a responsible provider for outpatient PN management (54% vs 82%, P = .005). Other PN discharge checklist components impacted included the following: case manager had the PN prescription for home infusion (50% vs 80%, P = .003), assessment for home glucometer (40% vs 90%, P \u3c .001), and PN plan-of-care note documentation at discharge (18% vs 82%, P \u3c .001). CONCLUSIONS: A standardized PN discharge checklist improved completion of discharge bundle

Peri-Operative Warfarin Protocol to Decrease Length of Stay After Left Ventricular Assist Device Implantation

Purpose: A limitation to left ventricular assist device (LVAD) implantation is cost with fixed reimbursement rates for the LVAD implantation hospitalization regardless of hospital length of stay and costs. Patients must have a therapeutic INR on warfarin prior to discharge which can take days and delay discharge. The purpose of this study is to evaluate the impact of a peri-operative warfarin protocol on decreasing length of stay during index LVAD implantation. Methods: This is a retrospective single center study of adult patients undergoing LVAD implantation between January 1, 2019 and December 31, 2020. Patients who died during the admission were excluded. Patients in the intervention group (INT) underwent LVAD between January 1-December 31, 2020. The peri-operative warfarin protocol included pre-operative vitamin K dosing according to INR, initiation of warfarin by post-operative day (POD) 3, and warfarin titration scheme. The historical control group (CON) included patients receiving LVADs between January 1-December 31, 2019. Warfarin start date was at the discretion of providers. All patients had a goal INR of 2-3. Endpoints included length of stay, post-operative warfarin start date, time to therapeutic INR, warfarin dosing requirements, pre-operative vitamin K dosing and bleeding complications. Results: Seventy-seven patients were included; n=41 (53.2%) CON and n=36 (46.8%) INT. Total hospital length of stay was 35 [26,43] days in the CON group compared to 27.5 [24,35] days in the INT group (p=0.095). Warfarin was started earlier in the INT group (POD 5.5 [2.8,7.0]) compared to the CON group (POD 8 [6,14]) (p=0.004). Time to therapeutic INR remained the same between the two groups with a median of 6 days. Pre-operative vitamin K decreased from 15 [10,15] mg in the CON group to 5 [0.0,11.3] mg in the INT group (p=\u3c0.001). There was no increase in bleeding with the peri-operative warfarin interventions: 8 bleeds in the CON group and 4 bleeds in the INT group. Conclusion: Initiating warfarin earlier post-operatively may help decrease hospital length of stay after LVAD implantation without increasing bleeding events

T2 Candida versus beta-D-glucan to facilitate antifungal discontinuation in the intensive care unit

T2 Magnetic Resonance Candida Panel (T2MR) detects Candida directly in blood. Rapid turnaround time and high negative predictive value make it a useful diagnostic test to support antifungal discontinuation. This retrospective quasi-experiment compared empiric anidulafungin days of therapy (DOTs) in intensive care unit (ICU) patients with suspected candidemia that had negative blood cultures and negative 1,3-β-D-glucan (BDG) versus negative blood cultures and negative T2MR. In 206 ICU patients, median anidulafungin DOTs were 2 (1, 5) compared to 1 (1, 2), respectively (P \u3c 0.001); T2MR was associated with early discontinuation, AdjOR 3.0 95% CI (1.7-5.6), P \u3c 0.001. Proven candidemia after discontinuation of anidulafungin occurred in 3% of BDG and 2% of T2MR patients at a median of 8 and 21 days, respectively. T2MR testing supports safe, early discontinuation of empiric antifungal therapy in ICU patients with suspected candidemia. Prospective studies to better define the role of T2MR in antifungal stewardship are warranted

T2 Candida versus beta-D-glucan to facilitate antifungal discontinuation in the intensive care unit

T2 Magnetic Resonance Candida Panel (T2MR) detects Candida directly in blood. Rapid turnaround time and high negative predictive value make it a useful diagnostic test to support antifungal discontinuation. This retrospective quasi-experiment compared empiric anidulafungin days of therapy (DOTs) in intensive care unit (ICU) patients with suspected candidemia that had negative blood cultures and negative 1,3-β-D-glucan (BDG) versus negative blood cultures and negative T2MR. In 206 ICU patients, median anidulafungin DOTs were 2 (1, 5) compared to 1 (1, 2), respectively (P \u3c 0.001); T2MR was associated with early discontinuation, AdjOR 3.0 95% CI (1.7-5.6), P \u3c 0.001. Proven candidemia after discontinuation of anidulafungin occurred in 3% of BDG and 2% of T2MR patients at a median of 8 and 21 days, respectively. T2MR testing supports safe, early discontinuation of empiric antifungal therapy in ICU patients with suspected candidemia. Prospective studies to better define the role of T2MR in antifungal stewardship are warranted