Preoperative multimodal protocol reduced postoperative nausea and vomiting in patients undergoing mastectomy with reconstruction.

Background: Mastectomy with immediate reconstruction is a high-risk cohort for postoperative nausea and vomiting (PONV). Known risk factors for PONV include female gender, prior PONV history, nonsmoker, age < 50, and postoperative opioid exposure. The objective of this observational, cohort analysis was to determine whether a standardized preoperative protocol with nonopioid and anti-nausea multimodal medications would reduce the odds of PONV.

Short-Term Clinical and Quality Outcomes Have Inconsistent Changes From a Quality Improvement Initiative to Increase Access to Physical Therapy in the Cardiovascular and Surgical ICU.

Unlabelled: Studies of mobility during critical illness have mostly examined transitions from immobility (passive activities) or limited mobility to active "early mobility."

Design: Observational analysis of a quality improvement initiative.

Setting: Two ICUs (surgical ICU, cardiovascular ICU) at a tertiary academic medical center.

Standard preoperative use of nonopioid multi-modal medications for patients undergoing mastectomy with immediate reconstruction and the effect on postoperative opioid needs.

Standardized nonopioid preoperative protocol effects perioperative opioids. Combined use of acetaminophen, pregabalin, celecoxib, and transdermal scopolamine (APCS), in mastectomy with immediate subpectoral reconstruction procedures. Retrospective (2014-2017) cohort study (n = 305) examined treatment groups; APCS, no treatment (NONE), and partial combination APCS (OTHER), employing multivariable gamma regression models controlling preoperative and perioperative variables, examining postoperative opioid use (oral morphine equivalents, OME) and hospital stay (hours, LOS).

Acid Suppression to Prevent Gastrointestinal Bleeding in Patients With Ventricular Assist Devices.

Background: The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) is well known, but there is limited evidence to support the use of proton pump inhibitors (PPIs) or histamine receptor antagonists (H2RA) for preventing GIB in patients with VAD.

Materials And Methods: The surgical ICU and VAD databases within a large regional academic cardiac mechanical support and transplant center were queried for patients who underwent VAD implantation between 2010 and 2014. An observational cohort study was conducted to identify which acid suppressing drug regimen was associated with the fewest number of GIB events within 30 d after VAD implantation: PPI, H2RA, or neither.

Perioperative antibiotics should be used for placement of implanted central venous ports: A propensity analysis evaluating risk.

Objective: To quantify risk for CRI based on PABX use in CVAP placement for cancer patients.

Summary Background Data: Central venous access ports (CVAP) are totally implanted devices used for chemotherapy. There is a temporal risk for catheter related infection (CRI) to insertion and perioperative prophylactic antibiotics (PABX) use is a contested issue among practitioners.

Predicting ICU readmission among surgical ICU patients: Development and validation of a clinical nomogram.

Background: Unplanned intensive care unit readmission within 72 hours is an established metric of hospital care quality. However, it is unclear what factors commonly increase the risk of intensive care unit readmission in surgical patients. The objective of this study was to evaluate predictors of readmission among a diverse sample of surgical patients and develop an accurate and clinically applicable nomogram for prospective risk prediction.

Outcomes When Using Adjunct Dexmedetomidine with Propofol Sedation in Mechanically Ventilated Surgical Intensive Care Patients.

Compare the duration of mechanical ventilation between patients receiving sedation with continuous infusions of propofol alone or combination with the use of dexmedetomidine and propofol. Retrospective, propensity matched (1:1) cohort study, employing eight variables chosen a priori for matching. Timing of exposure to dexmedetomidine initiation was incorporated into a matching algorithm.

Single intervention for a reduction in portable chest radiography (pCXR) in cardiovascular and surgical/trauma ICUs and associated outcomes.

Purpose: Studies suggest that "on-demand" radiography is equivalent to daily routine with regard to adverse events. In these studies, provider behavior is controlled. Pragmatic implementation has not been studied.

Hospital wide porcine mesh conversion results in cost savings with equivalent clinical outcomes.

Background: A variety of biologic mesh is available for ventral hernia repair. Despite widely variable costs, there is no data comparing cost of material to clinical outcome.

Methods: Biologic mesh product change was examined.

Enterovaginal or Vesicovaginal Fistula Control Using a Silicone Cup.

Background: An enterovaginal or vesicovaginal fistula is a complication resulting in vaginal discharge of succus, urine, or stool that can lead to significant complications. For low-volume fistulae, tampons or pads may be used. With high-volume fistulae, frequent product change can be painful and unpredictable in terms of efficacy.

When body mass index fails to measure up: perinephric and periumbilical fat as predictors of operative risk.

Background: Obesity has been associated with worse outcomes and increased surgical technical difficulty. Perinephric fat (PNF) and periumbilical fat (PUF) are alternative metrics to body mass index. We hypothesized that PUF and PNF would offer improved prediction of perioperative risk.

Surgical Outcomes for Mastectomy Patients Receiving Neoadjuvant Chemotherapy: A Propensity-Matched Analysis.

Objective: To evaluate the risk of neoadjuvant chemotherapy for surgical morbidity after mastectomy with or without reconstruction using 1:1 matching.

Background: Postoperative surgical complications remain a potentially preventable event for breast cancer patients undergoing mastectomy. Neoadjuvant chemotherapy is among variables identified as contributory to risk, but it has not been rigorously evaluated as a principal causal influence.

Routine endoscopic surveillance for local recurrence of rectal cancer is futile.

Background: National Comprehensive Cancer Network guidelines for rectal adenocarcinoma regarding routine surveillance with proctoscopy for local recurrence have been evolving. The purpose of this study was to examine the utility of rectal surveillance.

Methods: This is a single-center, retrospective review of patients (2004 to 2011) who underwent total mesorectal excision for rectal cancer.

The Barcelona Technique for Ileostomy Reversal.

Introduction: The Barcelona technique for bowel anastomosis is not well described in the currently available literature, but it saves steps when compared to conventional stapled anastomoses. In short, the proximal and distal ends of a resection margin are approximated, small enterotomies made, a stapler is passed into both lumens creating a common channel, and lastly, this same stapler is used to create the anastomosis and amputate the specimen. We report on this technique with ileostomy reversal in terms of cost and complications.

Initial Misdiagnosis of Proximal Pancreatic Adenocarcinoma Is Associated with Delay in Diagnosis and Advanced Stage at Presentation.

Introduction: Delay in diagnosis of pancreatic ductal adenocarcinoma (PDAC) is associated with decreased survival. The effect of an initial misdiagnosis on delay in diagnosis and stage of PDAC is unknown.

Methods: This study is a retrospective review (2000-2010) from a University-based cancer center of new diagnoses of proximal PDAC.

Should we operate for an intra-abdominal emergency in the setting of disseminated cancer?

Background: Patients with advanced cancer and an abdominal surgical emergency pose a dilemma, because rescue surgery may be futile. This study defines morbidity and mortality rates and identifies preoperative risk factors that may predict outcome.

Methods: The National Surgical Quality Improvement Program database was queried for patients with disseminated cancer undergoing emergent abdominal surgery (2005-2012).

Optimal utilization of a breast care advanced practice clinician.

Background: Incorporation of "lean" business philosophy within health care has the goal of adding value by reducing cost and improving quality. Applying these principles to the role of Advance Practice Clinicians (APCs) is relevant because they have become essential members of the healthcare team.

Methods: An independent surgical breast care clinic directed by an APC was created with measurements of success to include the following: time to obtain an appointment, financial viability, and patient/APC/MD satisfaction.

Image-guided placement of long-term central venous catheters reduces complications and cost.

Background: The goals of this study were to evaluate the complication rate for intraoperative placement of a long-term central venous catheter (CVC) using intraoperative ultrasound (US) and fluoroscopy and to examine the feasibility for eliminating routine postprocedure chest X-ray.

Methods: Retrospective data pertaining to operative insertion of long-term CVC were collected and the rate of procedural complications was determined.

Results: From January 2008 to August 2013, 351 CVCs were placed via the internal jugular vein using US.

Charge Awareness Affects Treatment Choice: Prospective Randomized Trial in Pediatric Appendectomy.

Objective: To determine whether charge awareness affects patient decisions.

Background: Pediatric uncomplicated appendicitis can be treated with open or laparoscopic techniques. These 2 operations are considered to have clinical equipoise.

Propofol is associated with favorable outcomes compared with benzodiazepines in ventilated intensive care unit patients.

Rationale: Mechanically ventilated intensive care unit (ICU) patients are frequently managed using a continuous-infusion sedative. Although recent guidelines suggest avoiding benzodiazepines for sedation, this class of drugs is still widely used. There are limited data comparing sedative agents in terms of clinical outcomes in an ICU setting.

The importance of extended postoperative venous thromboembolism prophylaxis in IBD: a National Surgical Quality Improvement Program analysis.

Background: The National Comprehensive Cancer Network recommends that patients who have colorectal cancer receive up to 4 weeks of postoperative out-of-hospital venous thromboembolism prophylaxis. Patients with IBD are at high risk for venous thromboembolism, but there are no recommendations for routine postdischarge prophylaxis.

Objective: The purpose of this study was to compare the postoperative venous thromboembolism rate in IBD patients versus patients who have colorectal cancer to determine if IBD patients warrant postdischarge thromboembolism prophylaxis.

Does travel distance influence length of stay in elective pancreatic surgery?

Background: Length of stay (LoS) following elective surgery is being reported as an outcomes quality measure. Regional referral centres may care for patients travelling significant distances. The effect of travel distance on LoS in pancreatic surgery patients was examined.

A survey of American College of Surgery fellows evaluating their use of antibiotic prophylaxis in the placement of subcutaneously implanted central venous access ports.

Background: Currently, there is no standard of care for prophylactic antibiotics (PABX) at the time of placement of fully implanted central venous access ports (CVAPs). A survey of fellows of the American College of Surgeons was undertaken to determine the current practice pattern of PABX in CVAP placement.

Methods: A survey was mailed to 5,000 fellows of the American College of Surgeons.