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The purpose of this quality improvement project was to identify trends in the intraoperative dosing of dexamethasone in type II diabetic patients undergoing genitourinary procedures at a full-service community hospital and to determine impact of dosage level on postoperative glycemic response compared to preoperative blood glucose levels. Dexamethasone is a corticosteroid that has many dose-dependent benefits when administered perioperatively to surgical patients. It is often withheld in the type II diabetic population out of concern for effects on postoperative glycemic control due to the side effect of hyperglycemia.
The method of this quality improvement project consisted of a retrospective chart review of patients with type II diabetes undergoing genitourinary procedures. Data inclusion criteria included patients who: are type II diabetics, had procedures that lasted less than four hours, had a documented preoperative hemoglobin A1C reading within the last twelve months ranging from 6.5-8.9%, are non-pregnant, are not taking oral steroidal medications, and had an ASA classification of I, II, or III.
Forty-nine charts were reviewed and overall there was no significant change in blood glucose in the postoperative period (t = 0.92, p = 0.361). The dose of dexamethasone (4, 8, or 10 mg) had no effect on the change in blood glucose levels (t =-1.14, p = 0.263). Additionally, changes in blood glucose were not found to be associated with age, HbA1C, or ASA status.
Dexamethasone administration for patients undergoing genitourinary procedures had no significant impact on blood glucose levels in the postoperative period. These findings may be a result of the shorter length of surgery, in that all 49 charts in this sample consisted of different cystoscopy procedures and had an average surgery length of 66 minutes. Further study is needed to help facilitate anesthesia provider’s decision-making for dexamethasone dosing in type II diabetics.
Autonomous vehicles have gained huge interest across private industry, academia, government, and the public because they promise higher road efficiency, improved safety, better energy consumption, and improved emissions. However, the widespread adoption of autonomous vehicle technology will likely take place over several years (if not decades) as the technology becomes more widely accepted by the general public and more cost-effective. Therefore, there will be a long period of time when we have both autonomous and human-driven vehicles sharing the same road and it is essential to develop traffic management strategies that take the uncertainty associated with the heterogeneity in the traffic networks into account. Furthermore, it is crucial to understand the extent to which these control strategies improve the performance of the traffic network.
This research aims to develop, enhance, and validate hierarchical infrastructure-based control framework designs for improving the mobility of large-scale heterogeneous traffic networks. In this work, heterogeneity is defined as a multi-vehicle traffic network consisting of Human-Driven Vehicles (HDVs) and Autonomous Vehicles (AVs), distinguished by their operational characteristics and controllability. To capture the realistic nature of large-scale heterogeneous traffic networks, we adopt the heterogeneous (multi-class) METANET model wherein the density and velocity dynamics of each vehicle class in each cell are described mathematically.
Moreover, in this research, we propose a hierarchical distributed infrastructure-based control framework to manage large-scale heterogeneous traffic networks. At the lower-level, we employed the Distributed Filtered Feedback Linearization (D-FFL) controller which only requires limited information from the plant model. The purpose of this controller is to track the desired density of each vehicle class in the target cells which is set by the upper-level controller. D-FFL tracks the reference density by controlling the suggested velocity of vehicles in the target cell and its upstream cell. At the upper-level, in our initial design, a Distributed Extremum-Seeking (D-ES) controller is designed and implemented to find the optimal operating densities of each vehicle class in the target cells over time. Gradient-based D-ES is a model-free, real-time adaptive control algorithm that is useful for adapting control parameters to unknown system dynamics and unknown mappings from control parameters to an objective function. To improve the performance of the designed hierarchical controller and reduce the convergence time, we designed and implemented Lyapunov-based Switch Newton Extremum Seeking (LSNES) at the upper level of the hierarchy to feed the optimal density of each vehicle class in the target cells to the lower-level controller. One of the key distinctions between the Newton algorithm and the gradient algorithm is that the convergence of the former is not solely contingent on the second derivative (Hessian) of the cost map and it is user-assignable.
Finally, we established a MATLAB-VISSIM COM interface that allows closed-loop control of a simulated traffic scenario in PTV-VISSIM to test and validate the effectiveness of the distributed control approaches in large-scale traffic networks. The simulation results show that our control framework design can effectively reduce congestion and prevent congestion back-propagation during peak hours in large-scale traffic networks.
Purpose: Identifying trends in the intraoperative dosing of dexamethasone in type II diabetic patients undergoing bariatric procedures at a community hospital to determine impact of the dose received on perioperative glycemic control.
Background: Dexamethasone is a corticosteroid and despite its many documented benefits when administered perioperatively to surgical patients, it is often withheld in the type II diabetic population out of concern for postoperative hyperglycemia.
Methods: Retrospective chart reviews of 36 type II diabetics receiving dexamethasone undergoing bariatric procedures was completed. Inclusion criteria: type II diabetics, procedures <4 hours, patients with a HbA1C reading 6.5-8.9%, patients who are non-pregnant, patients with an ASA classification of I, II, or III, and who are not taking chronic steroids.
Results: Of the 36 perioperative glycemic trends reviewed, there was a significant increase (t = 8.72, p<0.001) between the preoperative and immediate postoperative blood glucose readings for dexamethasone doses 4-10 mg (p <0.011). This increase was not associated with age, HbA1C, or surgery length. The dose level itself did not influence actual BG level changes (t = -.87, p = .390).
Conclusion: Dexamethasone increases postoperative BG significantly in DMII patients undergoing bariatric surgery in the immediate postoperative period. However, it should be noted that there was not a significant difference between preoperative BG and the 24-hour postoperative BG level. Two patients who did not receive dexamethasone also showed an increase in BG that approached significance (p = .060). These results suggest that further study on the effects of dexamethasone dosing and perioperative glycemic control is necessary.
Key words: Hemoglobin A1C (HbA1C), dexamethasone, diabetic II, type 2, bariatric, intraoperative
Corneal abrasions are one of the most common anesthesia-related adverse events. There is limited evidence about the effect of virtual education on anesthesia providers’ knowledge regarding corneal abrasion prevention. The purpose of this study project was to assess if a web-based educational module effectively improved anesthesia providers’ awareness of evidence-based preventative measures of corneal abrasions. This was a quasi-experimental pretest-posttest study design. All participants completed a questionnaire regarding their knowledge of corneal abrasion prevention before and after the educational module. A student T-test was used to compare the differences in pre- and post-education knowledge scores. There were 55 participants in the study. Among them, 23.6% were anesthesiologists and 76.4% were certified registered nurse anesthetists. There was a significant pretest-posttest difference in the total knowledge score (6.49±1.23 vs. 8.24± 1.08, p< .001). The average number of correct answers increased from 6.49 ± 1.23 to 8.24 ± 1.108 (t = 9.94, p < .001) Overall, the web-based educational module was effective in enhancing anesthesia providers’ knowledge in preventing surgical-induced corneal abrasions. The finding may add evidence for developing effective guidelines and standardizing provider education in corneal abrasion prevention.
Background
Sugammadex is one of the most used agents to reverse surgery induced neuromuscular blockade. It also reduces hormonal contraceptive effectiveness. There is limited evidence about developing effective education of the interaction between Sugammadex and birth control pills in post anesthesia care unit (PACU) nurses who are responsible to provide discharge education to patients taking hormonal contraceptives.
Purpose
The purpose of the project is to examine the effect of a web-based education on PACU nurses’ awareness and knowledge about the interaction between Sugammadex and hormonal contraceptives.
Methodology
A quasi-experimental study with pretest posttest design was conducted in a southeast healthcare facility. An animated educational video was designed to enhance the knowledge about the interaction between Sugammadex and hormonal contraceptives. An online survey was performed to assess the change of pre and post education knowledge score.
Results
The study included 27 PACU nurses. Age was associated with pretest score (b = 0.04, p = .010). Older participants were likely to have higher pre-intervention score. There was a significant pretest -posttest difference on Question 1 (the mechanism of action of Sugammadex) (χ2 = 7.72, p = .005) and total score (3.93± 1.00 vs. 4.55 ± 0.67, t = 2.81, p = .011).
Conclusion
The web-based education is effective to improve PACU nurses’ knowledge of the drug interaction between Sugammadex and hormonal contraceptives. The finding may help the development of discharge teaching in surgical patients taking hormonal contraceptives.
Background
Sugammadex is a useful reversal agent of neuromuscular blockade during surgery. However, its interaction with hormonal contraceptives could lead to undesirable outcomes in surgical patients using birth control pills. The feasibility and effectiveness of web-based education targeting post-anesthesia care unit (PACU) nurses are limited. PACU nurses are responsible for patient education related to the interaction between Sugammadex and hormonal contraceptives.
Purpose
The purpose of the project is to examine the effect of a web-based education on PACU nurses’ awareness and knowledge about the interaction between Sugammadex and hormonal contraceptives.
Methods
A quantitative, quasi-experimental, pre-/post-test design study was conducted among PACU nurses who work at a healthcare facility located in the southeast region of the United States. An online survey was used to investigate the effect of web-based education on PACU nurses’ knowledge about the interaction between Sugammadex and hormonal contraceptives.
Results
Among 27 PACU nurses, their years of experience ranged from 0 to 26 years (4.43 ± 6.65). There was a significant pretest-posttest difference on Question 1 (the mechanism of action of Sugammadex) (χ 2 (1) = 6.22, p = .013). The average number of correct answers increased from 4.00 ± 0.87 to 4.70 ± 0.54 (t = 3.99, p < .001).
Conclusion
The web-based education was effective in improving PACU nurses’ knowledge of drug interactions. This finding may contribute to the development of a standardized online education program for anesthesia providers, enhancing their skills and competence in providing patient education on anesthetic agents.
Background
Sugammadex is an effective and safe drug to reverse surgery induced neuromuscular blockade. However, the interaction of Sugammadex and hormonal contraceptives may lead to unintended effects in surgical patients who are using hormonal birth control. There is insufficient evidence regarding the effectiveness of online education among post-anesthesia care unit (PACU) nurses, who are responsible for delivering discharge education.
Purpose
The purpose of the project is to examine the effect of a web-based education on PACU nurses’ awareness and knowledge about the interaction between Sugammadex and hormonal contraceptives.
Methods
We conducted a quasi-experimental study with pre-/post-test design. The study was conducted in a surgical center located in the southeastern region of the United States. A digital survey was given both prior to and following the online educational session. The effects of web-based education was examined by comparing the differences of the pre and post-educational survey knowledge scores.
Results
Among 19 PACU nurses, their years of experience ranged from 0 to 33 years (M = 5.67, SD = 8.81, Mdn = 3). There was a significantly increased number of corrections between pre- and post-test from 4.37 ± 0.90 to 4.81 ± 0.40 (t = 2.52, p = .023).
Conclusion
The online education proves to be both feasible and effective in enhancing the knowledge of drug interactions among PACU nurses. This finding could contribute to the development of a standardized educational framework for ongoing drug education in nurses.
Problem Statement: Obese adults having laparoscopic surgery are at increased risk for postoperative pulmonary complications (PPCs) due to the alteration in pulmonary physiology caused by their body habitus, the use of Trendelenburg position, and abdominal insufflation required for this surgical approach.
Background: Current literature recommends utilizing lung protective ventilation (LPV) strategies to reduce the incidence of PPCs, but anesthesia provider implementation of LPV strategies is inconsistent. The purpose of this quality improvement project is to explore anesthesia providers’ knowledge and utilization of lung protective alveolar recruitment maneuvers (ARMs) in obese patients undergoing laparoscopic surgery.
Clinical question: “In a large urban trauma center, what are anesthesia providers’ knowledge and utilization of lung-protective alveolar recruitment maneuvers (ARMs) in obese (BMI>30kg/m2) patients aged 18 and older undergoing laparoscopic surgeries?”
Methods: The descriptive design of this project aimed to investigate anesthesia providers’ knowledge and use of LPV alveolar recruitment maneuvers in obese patients (BMI>30kg/m2) undergoing laparoscopic surgery via an anonymous, quantitative electronic survey consisting of 24 Likert scale questions. A convenience sampling of certified registered nurse anesthetists (CRNAs) and physician anesthesiologists (MDAs) was used. The survey was disseminated via email and available by QR code. Data was evaluated and stratified by role/education, age, and years of experience to evaluate for trends.
Results: Fifty-two providers completed the survey. There were significant differences in likelihood to utilize lung protective ARMs.
Conclusions: Anesthesia provider utilization of LPV strategies remains inconsistent. Education regarding implementation of evidence-based lung protective ARMs in obese patients undergoing laparoscopic surgery is warranted.
Background
Corneal abrasions (CA) are one of the most common anesthesia-related adverse events. There is limited evidence about the effect of virtual education on anesthesia providers’ knowledge regarding CA prevention.
Purpose
The purpose of this study project was to assess if a web based educational module effectively improved anesthesia providers’ awareness of evidence-based preventative measures of CA at a One Day Surgery Center.
Method
This was a quasi-experimental pretest-posttest study design. All participants completed a questionnaire regarding the knowledge on corneal abrasion prevention before and after the educational module. A student T-test was used to compare the differences in pre- and post-education knowledge scores.
Results
Among 26 participants, 15.4% were anesthesiologists, and 84.6% were CRNA. There was a significant pretest-posttest difference on the total knowledge score (6.54±1.14 vs. 8.55± 1.53, p< .001). Overall, the average number of correct answers increased from 6.54 ± 1.14 to 8.55 ± 1.53 ( t = 5.74, p < .001)
Conclusion
The web-based educational module was effectively to enhance anesthesia providers’ knowledge in preventing surgical induced CA. The finding may add evidence on developing the effective guideline and standardizing provider education in CA prevention.
