RESUMEN
OBJECTIVE: This study aimed to evaluate whether implementation of an enhanced recovery after surgery (ERAS) protocol is associated with lower maternal opioid use after cesarean delivery (CD). STUDY DESIGN: We performed a pre- and postimplementation (PRE and POST, respectively) study of an ERAS protocol for cesarean deliveries. ERAS is a multimodal, multidisciplinary perioperative approach. The four pillars of our protocol include education, pain management, nutrition, and early ambulation. Patients were counseled by their outpatient providers and given an educational booklet. Pain management included gabapentin and acetaminophen immediately prior to spinal anesthesia. Postoperatively patients received scheduled acetaminophen and ibuprofen. Oxycodone was initiated as needed 24 hours after spinal analgesia. Preoperative diet consisted of clear carbohydrate drink consumed 2 hours prior to scheduled operative time with advancement as tolerated immediately postoperation. Women with a body mass index (BMI) <40 kg/m2 and scheduled CD were eligible for ERAS. PRE patients were randomly selected from repeat cesarean deliveries (RCDs) at a single site from October 2017 to September 2018, BMI <40 kg/m2, without trial of labor. The POST cohort included women who participated in ERAS from October 2018 to June 2019. PRE and POST demographic and clinical characteristics were compared. Primary outcome was total postoperative morphine milligram equivalents (MMEs). Secondary outcomes included length of stay (LOS) and maximum postoperative day 2 (POD2) pain score. RESULTS: All women in PRE (n = 70) had RCD compared with 66.2% (49/74) in POST. Median total postoperative MMEs were 140.0 (interquartile range [IQR]: 87.5-182.5) in PRE compared with 0.0 (IQR: 0.0-72.5) in POST (p < 0.001). Median LOS in PRE was 4.02 days (IQR: 3.26-4.27) compared with 2.37 days (IQR: 2.21-3.26) in POST (p < 0.001). Mean maximum POD2 pain score was 5.28 (standard deviation [SD] = 1.86) in PRE compared with 4.67 (SD = 1.63) in POST (p = 0.04). CONCLUSION: ERAS protocol was associated with decreased postoperative opioid use, shorter LOS, and decreased pain after CD. KEY POINTS: · ERAS protocol was associated with decreased postoperative opioid use after CD.. · ERAS protocol was associated with shorter length of stay after CD.. · ERAS protocol was associated with decreased postoperative pain after CD..
Asunto(s)
Analgésicos Opioides/uso terapéutico , Cesárea/rehabilitación , Recuperación Mejorada Después de la Cirugía/normas , Manejo del Dolor/normas , Mejoramiento de la Calidad , Acetaminofén/uso terapéutico , Adulto , Estudios de Cohortes , Femenino , Implementación de Plan de Salud , Humanos , Ibuprofeno/uso terapéutico , Tiempo de Internación/estadística & datos numéricos , Dolor Postoperatorio/tratamiento farmacológico , Embarazo , Evaluación de Programas y Proyectos de SaludAsunto(s)
Betacoronavirus , Cesárea/métodos , Infecciones por Coronavirus/diagnóstico , Diabetes Mellitus Tipo 1/diagnóstico , Neumonía Viral/diagnóstico , Complicaciones Infecciosas del Embarazo/diagnóstico , Embarazo en Diabéticas/diagnóstico , Adulto , COVID-19 , Cardiotocografía/métodos , Infecciones por Coronavirus/complicaciones , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/virología , Servicios Médicos de Urgencia/métodos , Femenino , Humanos , Recién Nacido , Pandemias , Neumonía Viral/complicaciones , Embarazo , Complicaciones Infecciosas del Embarazo/virología , Embarazo en Diabéticas/virología , SARS-CoV-2RESUMEN
INTRODUCTION: The method used to create a melanoma trainer using simulated back skin is presented. The trainer is intended to be used to teach medical students to identify benign and malignant cutaneous pigmented lesions. METHODS: Non-Hispanic and Hispanic white melanoma trainers were created using flexible polyurethane foam and pigmented silicone rubber. The models were reviewed by board-certified dermatologists and dermatology residents to determine the reliability and fidelity of the models. RESULTS: The models were deemed an accurate representation of the skin of human backs containing multiple normal nevi and clinically suspicious pigmented lesions, which were melanomas. Among 33 dermatologists and dermatology residents, there was good reliability for all clinically suspicious lesions (κ = 0.64), excellent reliability for melanomas (κ = 0.97), and excellent reliability for selecting melanomas for biopsy (κ = 0.96). Reliability in selecting lesions to monitor for change varied depending on the physicians preference to perform biopsy on all melanomas and follow all other clinically suspicious lesions (κ = 0.86) or to perform biopsy on all melanomas and 1 other abnormal nevus and monitor all other abnormal lesions (κ = 0.61). CONCLUSIONS: The melanoma trainer using simulated back skin is a reliable model that can be stored and used frequently over a long period. The trainer will allow students to assess a range of pigmented lesions that would not be found on 1 patient.