scholarly journals P087: Procedural sedation in Canadian emergency departments a national survey of pharmacological agent selection and practice variation

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S87-S87
Author(s):  
E. Leci ◽  
K. Van Aarsen ◽  
A. Shah ◽  
J. W. Yan
Keyword(s):  
Practice Variation ◽  
Procedural Sedation ◽  
Pharmacologic Agent ◽  
Electronic Survey ◽  
Canadian Association ◽  
Institutional Influences ◽  
Agent Selection ◽  
Practice Variability ◽  
American Society ◽  
Question Survey

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients when performing painful procedures through the use of procedural sedation (PS). Examination of the literature suggests that the application of PS appears to be variable with institutional influences and clinician disagreement on pharmacology, airway management, and monitoring. The primary goal of this research project was to describe the variability of practice with respect to pharmacologic choices and clinical applications of PS among Canadian ED physicians. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding PS indications and pharmacology. The primary outcome was the quantification of practice variability among ED physicians with respect to the above listed aspects of PS. The data was presented with simple descriptive statistics. Results: To date, 278 ED physicians responded to our survey (response rate 20.3%). Respondents were primarily academic hospital (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). There was relative agreement on the following interventions requiring PS: 98.4% applied PS for electrical cardioversion and 98.1% for brief (<10 mins) orthopedic manipulations. However, only 36.3% utilized PS for burn debridement in the ED. PS was utilized less frequently (78.1%) for prolonged (>10mins) orthopedic manipulations than brief manipulations. For all procedures aggregated, in hemodynamically stable patients with an American Society of Anesthesiology (ASA) score of 1, ED physicians utilized propofol 76.3% of the time. Additional agents were utilized at the following rates: fentanyl-propofol (7.6%), ketamine (7.6%), and fentanyl (4%). This inclination towards propofol alone appears to be consistent across modality of ER training, type of ER setting (rural vs academic), and volume of PS performed. Conclusion: This study demonstrates that Canadian ED physicians have a clear preference for propofol as a first line pharmacologic agent when administering PS in hemodynamically stable, ASA1 patients. Conversely, there appears to be more variation amongst ED physicians with respect to second line pharmaceutical choices for PS.

scholarly journals P088: Procedural sedation in Canadian emergency departments a national survey of airway management, patient monitoring, and adverse events

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S88-S88
Author(s):  
E. Leci ◽  
K. Van Aarsen ◽  
A. Shah ◽  
J. W. Yan
Keyword(s):  
Adverse Events ◽  
Airway Management ◽  
Clinical Situation ◽  
Procedural Sedation ◽  
Electronic Survey ◽  
Oral Airway ◽  
Canadian Association ◽  
Prolonged Sedation ◽  
Practice Variability ◽  
Airway Equipment

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients undergoing painful procedures through the use of procedural sedation (PS). While, PS is generally safe and effective in the ED, there is institutional variability and clinician disagreement with respect to the bedside equipment required for airway management and the monitoring of adverse events. The primary goal of this research project was to describe the variability of the bedside setup utilized by Canadian ED physicians preforming PS in conjunction with self-reported adverse events. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding bedside setup of airway equipment, and prevalence of self-reported adverse events. The primary outcome was the quantification of variability among ED physicians with respect to the above listed aspects of PS. Data was presented with simple descriptive statistics. Results: 278 ED physicians responded to our survey (response rate 20.9%). Respondents were primarily academic (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). The ED area in which PS was carried out varied; bedside (30.5%), procedure room (37.1%), resuscitation area (31.2%). The basic equipment set utilized appears to be a bag valve mask, suction, and an oral airway. These 3 items were present 95.4%, 95.9%, and 86.3% of the time respectively. The preparation of other items such as capnography and difficult airway equipment is highly variable and appears to be physician specific rather than clinical situation specific. The most common physician self-reported adverse events associated with PS appear to be hypoxia (Spo2<90%), hypotension (sBP<90), and prolonged sedation which occurred in 10.7%, 8.3%, and 8.1% of PS performed. Conclusion: There appears to be significant practice variability with respect to the clinical setting as well as the equipment ED physicians prefer when administering PS. Given that causal relationships cannot be inferred between airway/monitoring equipment preferences and adverse events, future studies should be targeted at identifying optimal bedside set ups which minimize adverse events.

Is Vascularized Composite Allograft Transplantation Experimental or an Accepted Surgical Procedure: Results from a National Survey

2020 ◽  
Vol 36 (04) ◽  
pp. 276-280
Author(s):  
Salih Colakoglu ◽  
Seth Tebockhorst ◽  
David Woodbridge Mathes
Keyword(s):  
Clinical Investigation ◽  
The United States ◽  
Representative Sampling ◽  
Electronic Survey ◽  
Internal Review ◽  
Vascularized Composite Allograft ◽  
American Society ◽  
Question Survey ◽  
Internal Review Board

Abstract Background More than 85 patients have received over 100 hand/arm transplants and more than 35 patients have received full or partial face transplants at institutions around the world. Given over two decades of experience in the field and in the light of successful outcomes with up to 17 years follow up time, should we still consider vascularized composite allograft (VCA) as a research/clinical investigation? We present the results of a nationwide electronic survey whose intent was to gather institutional bias with regard to this question. Methods An 11 question survey that was developed by VCA advisory committee of American Society of Transplantation was sent to all identified Internal Review Board chairs or directors in the United States. Results We received a total of 54 responses (25.3%) to the survey. The majority (78%) of responses came from either the chairperson, director, or someone who is administratively responsible for an IRB. Conclusion Though certainly not an exhaustive investigation into each institution's preference, we present a representative sampling. The results of which favor VCA as an accepted clinical procedure given the appropriate setting. Further research is needed to fully ascertain practices at each individual institution.

Assessment of the Implementation of AUC Dosing and Monitoring Practices With Vancomycin at Hospitals Across the United States

2021 ◽  
pp. 089719002110123
Author(s):  
Nicole Bradley ◽  
Yuman Lee ◽  
Muaz Sadeia
Keyword(s):  
The United States ◽  
Descriptive Statistics ◽  
Therapeutic Drug ◽  
User Friendliness ◽  
Electronic Survey ◽  
The Us ◽  
Institutional Adoption ◽  
American Society ◽  
Trough Levels ◽  
Do So

Introduction: The latest vancomycin therapeutic drug monitoring guidelines for serious MRSA infections have made a pivotal change in dosing, switching from targeting trough levels to AUC dosing. Because of these new recommendations, antimicrobial stewardship programs across the country are tasked with implementing AUC based dosing. Objectives: To assess plans for institutional adoption of vancomycin AUC dosing programs and perceptions of currently used programs in hospitals across the US. Methods: An electronic survey was distributed to members of the American College of Clinical Pharmacy IDprn Listserv and American Society of Health-System Pharmacists between May and June 2020 to assess current institutional vancomycin dosing. Institutional program use and multiple software user parameters were analyzed using descriptive statistics. Results: Two hundred two pharmacists responded to the survey with the majority practicing in institutions with 251-500 beds. Most respondents have yet to implement AUC dosing (142/202, 70.3%) with many of them planning to do so in the next year (81/142, 57.0%). Of those that already implemented AUC dosing programs, purchased Bayesian software (23/60, 38.3%) and homemade software (21/60, 35.0%) were the 2 methods most frequently utilized. Purchased Bayesian software users were more likely to recommend their software to other institutions and ranked user friendliness higher compared to non-purchased software. Conclusion: Most respondents have not made the switch to vancomycin AUC dosing, but there is a growing interest with many institutions looking to adopt a program within the next year.

Intermittent, Repetitive Corticosteroid-Induced Upregulation of Platelet Levels After Adenovirus-Mediated Transfer to the Liver of a Chimeric Glucocorticoid-Responsive Promoter Controlling the Thrombopoietin cDNA

Blood ◽  
1998 ◽  
Vol 92 (3) ◽  
pp. 822-833 ◽  
Author(s):  
Ko Narumi ◽  
Motoyoshi Suzuki ◽  
Wenru Song ◽  
Malcolm A.S. Moore ◽  
Ronald G. Crystal
Keyword(s):  
Clinical Medicine ◽  
Intraperitoneal Administration ◽  
Fold Increase ◽  
Inducible Promoter ◽  
Pharmacologic Agent ◽  
Before And After ◽  
American Society ◽  
Pharmacologic Agents

Abstract For many in vivo gene therapy clinical applications, it is desirable to control the expression of the transferred transgene using pharmacologic agents. To evaluate the feasibility of accomplishing this using corticosteroids, pharmacologic agents widely used in clinical medicine, we constructed replication deficient adenoviral (Ad) vectors containing an expression cassette with a chimeric promoter comprised of five glucocorticoid response elements (GRE) and the chloramphenicol acetyltransferase reporter gene (AdGRE.CAT) or the murine thrombopoietin cDNA (AdGRE.mTPO). In vitro studies showed the vectors functioned as expected, with marked glucocorticoid-induced upregulation of the CAT or mTPO transgenes. To evaluate the inducibility of the GRE promoter in vivo, the AdGRE.CAT vector was administered intravenously to C57B1/6 mice, and CAT activity was quantified in liver before and after intraperitoneal administration of dexamethasone. The GRE promoter activity was dependent on the dexamethasone dose, with a 100-fold increase in CAT expression with 50 μg dexamethasone, similar to the levels observed in vivo with the Rous sarcoma virus long terminal repeat constitutive promoter. After dexamethasone administration, maximum CAT activity was observed at day 2, with a slow decline to baseline levels by 2 weeks. Based on these observations, we hypothesized that a single administration of an Ad vector-mediated transfer of the chimeric GRE inducible promoter driving the mTPO cDNA would enable repetitive administration of corticosteroids to repetitively upregulate platelet levels for 1 to 2 weeks. The data show that this occurs, with dexamethasone administration every 3 weeks associated with 1-week elevations (at each 3-week interval) of serum mTPO levels, megakaryocyte numbers in bone marrow, and platelet levels fourfold to sixfold over baseline. Thus, with the appropriate promoter, it is possible to use a commonly used pharmacologic agent to upregulate the expression of a newly transferred gene on demand. © 1998 by The American Society of Hematology.

scholarly journals Practice Variability in Screening and Treating Pediatric Critical Illness Delirium: Survey

2020 ◽  
Author(s):  
Salim Aljabari ◽  
Cara Carter ◽  
Shahzad Waheed ◽  
Jordan E. Anderson
Keyword(s):  
Best Practice ◽  
The United States ◽  
High Variability ◽  
Academic Medical Centers ◽  
Pharmacologic Agent ◽  
Pediatric Critical Care ◽  
Treatment Practices ◽  
Medical Centers ◽  
Academic Medical ◽  
Practice Variability

AbstractThe best practice in pediatric delirium (PD) screening and treatment is still unknown. Current recommendations come from small studies and adult data. We surveyed the Pediatric Critical Care Medicine fellowship directors on PD screening and treatment practices in their centers. We report high variability in the screening and treatment practices for PD in large academic medical centers in the United States. The Cornell Assessment of Pediatric Delirium tool is the most commonly used tool for screening, and quetiapine is the most commonly used pharmacologic agent. A national guideline on PD screening, prevention, and treatment is needed to standardize practice and provide guidance.

scholarly journals P-OGC12 Nasogastric tube drainage and pyloric intervention after oesophageal resection: UK practice variation and effect on outcomes

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Alexander Bull ◽  
Philip Pucher ◽  
Nick Maynard ◽  
Tim Underwood ◽  
Jesper Lagergren ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Nasogastric Tube ◽  
Practice Variation ◽  
Radiological Assessment ◽  
Median Length ◽  
Electronic Survey ◽  
Conflicting Evidence ◽  
Clear Link ◽  
Low Volume ◽  
The Uk

Abstract Background Over 1,500 patients with oesophageal cancer undergo a resection in the UK each year. At surgery, patients commonly have a nasogastric tube (NGT) placed and may undergo a pyloric intervention. There is conflicting evidence on the use of both NGTs and pyloric interventions during oesophageal resections. We performed a national survey of oesophageal centres and assessed practice variation. Methods An electronic survey was distributed to all resection centres in England, Wales and Scotland. Variations in practice regarding NGTs and pyloric intervention were assessed, and compared to nationally reported centre volumes and length-of-stay data Results Most centres (31/39, 79%) responded to the survey. All centres reported routine NGT use. The majority of centres (19/31, 61%) did not perform pyloric interventions. When used, surgical pyloroplasty was the most frequent strategy (8/31, 26%). Routine post-operative radiological assessment was utilised in 9/31 (29%) of centres. Criteria for NGT removal and dietary progression was highly variable, with every centre reporting different protocols. There were no significant differences in practice between high and low volume centres. There were also no trends seen when comparing centres above vs at-or-below the median length-of-stay. The majority (68%) of centres were willing to take part in a trial assessing NGT use and pyloric interventions. Conclusions Pyloric intervention use varies widely, with no clear link to outcomes. NGT use remains standard practice despite evidence for safe omission. Surgeons require and recognise the need for a trial to assess requirement for NGTs and pyloric intervention after oesophageal resection.

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