Intravenous Tubing Research Articles

Infusion Pump in UH60L/M Flight in Afghanistan: Why Failures Occur

The ALARIS MSIII Infusion Pump (CareFusion, San Diego, CA) uses 3 separate alarms designed to prevent air emboli: “check air sensor,” “air in lower tubing,” and “air in line.” It is assumed that ambient pressure changes cause air emboli that lead to pump failure although evidence to support this is limited. In this small study, the MSIII proved to be highly resilient and able to maintain function even after large repetitive emboli. Although unproven, it is more likely that these alarms are usually caused by loosening of the intravenous tubing within the pump’s collar. This disjointing of the tubing and the ultrasonic sensor can be perceived as an air embolus leading to severe consequences. If the user attempts the clear air function, the pump will not resume function. Problems such as this may have been related to at least 1 reported patient death. More research is needed to determine the cause of these alarms and determine the exact cause. Patient safety can potentially be improved at all levels including manufacturer modifications and operator training. It seems reasonable that the manufacturer should design a mode (“transport mode”) that allows the pump to function even with air emboli.

Terminally Ill Taiwanese Cancer Patients' and Family Caregivers' Agreement on Patterns of Life-Sustaining Treatment Preferences Is Poor to Fair and Declines Over a Decade: Results From Two Independent Cross-Sectional Studies

Context/ObjectiveTemporal changes have not been examined in patient-caregiver agreement on life-sustaining treatment (LST) preferences at end of life (EOL). We explored the extent of and changes in patient-caregiver agreement on LST-preference patterns for two independent cohorts of Taiwanese cancer patient-family caregiver dyads recruited a decade apart. MethodsWe surveyed preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis among 1049 and 1901 dyads in 2003–2004 and 2011–2012, respectively. LST-preference patterns were examined by multi-group latent class analysis. Extent of patient-caregiver agreement on LST-preference patterns was determined by percentage agreement and kappa coefficients. ResultsFor both patients and family caregivers, we identified seven distinct LST-preference classes. Patient-caregiver agreement on LST-preference patterns was poor to fair across both study cohorts, indicated by 24.4%–43.5% agreement and kappa values of 0.06 (95% CI: 0.04, 0.09) to 0.27 (0.23, 0.30), and declined significantly over time. Agreement on LST-preference patterns was most likely when both patients and caregivers uniformly rejected LSTs. When patients disagreed with caregivers on LST-preference patterns, discrepancies were most likely when patients totally rejected LSTs but caregivers uniformly preferred LSTs or preferred nutritional support but rejected other treatments. ConclusionPatients and family caregivers had poor-to-fair agreement on LST-preference patterns, and agreement declined significantly over a decade. Encouraging an open dialogue between patients and their family caregivers about desired EOL care would facilitate patient-caregiver agreement on LST-preference patterns, thus honoring terminally ill cancer patients' wishes when they cannot make EOL-care decisions.

Commissurorraphy in the Dog.

Commissurorraphy is a surgical procedure designed to move the lip commissure rostrally. This procedure may be helpful as a unilateral procedure in cases of unilateral mandibulectomy to support tongue function and improve esthetics. Bilateral commissurorraphy is utilized in cases of radical bilateral mandibulectomy and as a salvage procedure for support of bilateral mandibular fractures in cases where rigid surgical fixation is not feasible. Dehiscence is the most likely complication of commissurorraphy. Tension can be reduced at the rostral extent of the incision by utilizing mattress sutures, intravenous fluid tubing, and/or buttons to prevent tearing through sutures.

Y-site Incompatibility Between Premix Concentrations of Vancomycin and Piperacillin-Tazobactam: Do Current Compatibility Testing Methodologies Tell the Whole Story?

Background: Published literature has demonstrated commercially available premix vancomycin (5 mg/mL) and piperacillin-tazobactam (67.5 mg/mL) as physically compatible via simulated Y-site methodology. Compatibility via actual Y-site infusion has yet to be established. Objective: To assess and compare the compatibility of commercially available premix concentrations of vancomycin and piperacillin-tazobactam via simulated and actual Y-site evaluation. Methods: Vancomycin and piperacillin-tazobactam were tested using simulated and actual Y-site infusion methodologies. Simulated Y-site compatibility was performed using previously published methods via visual inspection, turbidity evaluation, and pH evaluation. Evaluation occurred immediately, 60 minutes, 120 minutes, and 240 minutes following mixing for each mixture and control. Mixtures were considered physically incompatible if there was visual evidence of precipitation or haze, an absorbance value was greater than 0.01 A, or an absolute change of 1.0 pH unit occurred. Actual Y-site infusion was simulated to mirror antibiotic infusion in the clinical setting by nursing personnel using smart pumps and intravenous tubing. Results: No evidence of physical incompatibility was observed during simulated Y-site testing via visual inspection, turbidity assessment, and pH evaluation. Conversely, physical incompatibility was observed to the unaided eye within 2 minutes during actual Y-site infusion. Conclusions: Despite observed compatibility between vancomycin and piperacillin-tazobactam via simulated Y-site testing, visual evidence of physical incompatibility was observed during actual Y-site infusion. This poses a potential compromise to patient safety if these antibiotics are administered simultaneously in the clinical setting. Actual Y-site testing should be performed prior to clinical adoption of compatibility studies that are based solely on simulated methodologies.

Cutting-Edge Robotic Intravenous Pole: Preliminary Design and Survey in Academic Medical Center in Lebanon

Intravenous poles are biomedical healthcare supportive tools that aide in holding and delivering medications to patients through intravenous injections. Intravenous infusion relies on the weight of the Intravenous tubing fluid. Continuous follow-up of the intravenous bag is required to replace the fluid when emptied. Also, mobilization of the intravenous pole is required from patients and nurses. This leads to discomfort and inconvenience for both patients and hospital staff. Despite the existing intravenous poles have solved their difficulty, however, they were either not feasible, or couldn’t hold a lot of weight in the bag. Moreover, they lack any alarm system which indicates an empty bag. To improve current intravenous poles, we aim to develop a cutting-edge robotic intravenous pole mounted with an alarm system. The robotic intravenous pole comprises motors to hold large weights, sensors and wireless joystick technology. Experimental results dedicated to the design showed that the novel designed pole mobilization is improved by the use of stepper motors, omni wheels, micro-controller, and a joystick. Also, the alarm system has added alert to patients and nurses when the intravenous bags were emptied. Moreover, the robotic intravenous pole moved in all directions and rotated, with a press of a button. This design surpasses the movements and weight tolerance provided by alternative designs, and it is mechanically and electrically safe on the patients. Survey results highlighted the acceptance and motivation of having and using and Robotic IV pole as compared to alternatives.

Abstract: Intermittent Irrigation of the Microvascular Anastomosis Site During the Critical First 72 Hours

INTRODUCTION: Although up to 99 percent of free tissue transfers are eventually successful, the rate of reexploration necessary to achieve this is still high despite advances in technique and monitoring.1 We explore the benefits of intermittent postoperative irrigation of the microvascular anastomosis site with lidocaine. PURPOSE: To share our experience with a simple, safe and effective technique that can be easily adopted at minimal cost. RATIONALE: Blood, vascular manipulation, stretching, hypothermia, vasopressors, increased catecholamine states are some of the local and systemic factors that can lead to vasospasm of both artery and vein. While up to 94 percent of plastic surgeons use an intraoperative vasodilator to counteract this, little has been reported on postoperative use of vasodilators.2,3,4 The vasospasm-inducing noxious stimuli may persist in this period and lead to a cascade of events culminating in flap compromise. Studies have shown that the first 72 hours are the critical period during which overwhelming majority of compromised flaps are recognized.5 TECHNIQUE: The cut end of an intravenous catheter tube is placed in close proximity to the anastomosis avoiding direct contact. The other end of the tube is brought out through the wound edge, fixed to the skin with non-absorbable suture and connected to a 10-milliliter syringe filled with one percent lidocaine. The nurse infuses slowly one milliliter every hour amounting to a total of 240 mg of lidocaine per day. The catheter is removed after 72 hours. RESULTS: The senior author has used this technique in 3698 cases (50 percent of which involved lower extremity reconstruction) over the past 25 years. The 6.6 percent rate of re-exploration corroborates with published literature. None of the cases requiring reexploration demonstrated any evidence of vasospasm. Decreased pain and opioid requirements was an expected favorable outcome. However, an unexpected benefit noted early in the series was the cleansing effect of the gentle irrigation, removing small collections of blood, exudate or saliva from the vicinity of the anastomosis site. No inadvertent disruption of the anastomosis, increased bleeding or systemic sign of lidocaine toxicity was identified. CONCLUSION: A simple intraoperative measure can not only minimize the risk of a potentially disastrous vasospasm, but also provide the additional benefits of better pain control and clean microvascular anastomosis site. DISCLOSURE/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. REFERENCES: 1. Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119:2092–100. 2. Yu JT, Patel AJ, Malata CM. The use of topical vasodilators in microvascular surgery. J Plast Reconstr Aesthet Surg. 2011;64:226–8. 3. Yokoyama T, Tosa Y, Kadomatsu K, Sato K, Hosaka Y. A novel approach for preventing the development of persistent vasospasms after microsurgery for the extremities: intermittent topical lidocaine application. J Reconstr Microsurg. 2010;26:79–85. 4. Gu YD, Yuan W, Gong XY.Value of irrigation with a lidocaine solution in tissue transplantation. Zhonghua Wai Ke Za Zhi. 1987;25:215–7, 253. Chinese. 5. Chen KT, Mardini S, Chuang DC, Lin CH, Cheng MH, Lin YT, Huang WC, Tsao CK, Wei FC. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg. 2007;120:187–95.

P.012 Spinal durotomy repair simulator for deliberate microsurgical practice: integration into a residency training module

Background: Deliberate practice is one aspect of gaining competency in surgical skills. We have previously integrated a vascular microsurgery module into our residency training curriculum, and have recently described our experience with constructing patient-specific spine models for simulating lumbar spinal durotomy repair. The goal of this project is to develop the necessary infrastructure to facilitate practice on the spine model during residency. Methods: A 3D-printed plastic lumbar spine model was created from a patient computed tomography scan. L2 was manually laminectomized, and paraspinal tissues were simulated using Polyvinyl Chloride (PVC) Plastisol. Harvested bovine pericardium was sewn into tubular form as a dural substitute. The pericardial tubes were tied at either end and attached to intravenous tubing to create a closed loop water system. Results: We are developing a video tutorial describing how to setup and use the model. Residents will be recorded while performing a 1.5 cm durotomy and repair using a surgical microscope available in our training laboratory (Drake-Hunterian Neurovascular Laboratory, London, Ontario, Canada). Residents are asked to grade the realism of the model using a questionnaire. Metrics of quality are to be determined. Conclusions: Our proposed model is a cost-effective, easy-to-prepare lumbar spinal simulator that facilitates microsurgical practice during neurosurgical residency.

Novel Technique for Rebubbling DMEK Grafts at the Slit Lamp Using Intravenous Extension Tubing.

To describe a novel technique for rebubbling DMEK grafts at the slit lamp using a cannula coupled to a syringe with intravenous (IV) extension tubing. We present a retrospective case series of eyes that underwent rebubbling using a novel technique at the slit lamp. The rebubbling apparatus is assembled using a standard 43-inch IV extension tube, a 5-cc luer lock syringe, and a 27-gauge cannula. The cannula is screwed onto one end of the extension tubing, and a 5-cc syringe that has been filled with air is screwed onto the opposite end. With the patient seated at the slit lamp, the cannula is positioned in the anterior chamber by the surgeon with one hand while the other hand operates the syringe and the joystick. We performed 5 rebubbling procedures at the slit lamp using a standard syringe and cannula. Despite suboptimal ergonomics with this approach, all of these cases achieved sufficient air fills without any complications. Four rebubbling procedures were subsequently performed at the slit lamp using our novel rebubbling technique. All of these cases also attained sufficient air fills without complications, but they were noted to be much easier to perform by the surgeon. Using IV extension tubing to couple a syringe to a cannula for rebubbling DMEK grafts at the slit lamp is ergonomically superior to the conventional alternative of using a standard cannula on a syringe. The technique is also simple and inexpensive to adopt.

A Decade of Changes in Family Caregivers' Preferences for Life-Sustaining Treatments for Terminally Ill Cancer Patients at End of Life in the Context of a Family-Oriented Society

ContextTemporal changes in different family caregiver cohorts' preferences for life-sustaining treatments (LSTs) at end of life (EOL) have not been examined nor have the concept of whether caregivers' LST preferences represent a homogeneous or heterogeneous construct. Furthermore, LST preferences are frequently assessed from multiple treatments, making clinical applications difficult/infeasible. ObjectivesTo identify parsimonious patterns and changes in the pattern of LST preferences for two independent cohorts of family caregivers for terminally ill Taiwanese cancer patients. MethodsPreferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis were assessed among 1617 and 2056 family caregivers in 2003–2004 and 2011–2012, respectively. Patterns and changes in LST preferences were examined by multigroup latent class analysis. ResultsFive distinct classes were identified: uniformly preferring, uniformly rejecting, uniformly uncertain, and favoring nutritional support but rejecting or uncertain about other treatments. Class probability significantly decreased from 29.3% to 23.7% for the uniformly rejecting class, remained largely unchanged for the uniformly preferring (16.9%–18.6%), and favoring nutritional support but rejecting (37.1%–37.5%) or uncertain about other treatments (8.0%–10.4%) classes, but significantly increased from 7.0% to 11.5% for the uniformly uncertain class over time. ConclusionFamily caregivers' LST preferences for terminally ill cancer patients are a heterogeneous construct and shifted from uniformly rejecting all LSTs toward greater uncertainty. Surrogate EOL-care decision making may be facilitated by earlier and thorough assessments of caregivers' LST preferences and tailoring interventions to the unique needs of caregivers in each class identified in this study.

A clinical combined gadobutrol bolus and slow infusion protocol enabling angiography, inversion recovery whole heart, and late gadolinium enhancement imaging in a single study.

BackgroundThe use of gadolinium contrast agents in cardiovascular magnetic resonance is well-established and serves to improve both vascular imaging as well as enable late gadolinium enhancement (LGE) imaging for tissue characterization. Currently, gadofosveset trisodium, an intravascular contrast agent, combined with a three-dimensional inversion recovery balanced steady state free precession (3D IR bSSFP) sequence, is commonly used in pediatric cardiac imaging and yields excellent vascular imaging, but cannot be used for late gadolinium enhancement. Gadofosveset use remains limited in clinical practice, and manufacture was recently halted, thus an alternative is needed to allow 3D IR bSSFP and LGE in the same study.MethodsHere we propose a protocol to give a bolus of 0.1 mL/kg = 0.1 mmol/kg gadobutrol (GADAVIST/GADOVIST) for time-resolved magnetic resonance angiography (MRA). Subsequently, 0.1 mmol/kg is diluted up to 5 or 7.5 mL with saline and then loaded into intravenous tubing connected to the patient. A 0.5 mL short bolus is infused, then a slow infusion is given at 0.02 or 0.03 mL/s. Image navigated (iNAV) 3D IR bSSFP imaging is initiated 45–60 s after the initiation of the infusion, with a total image acquisition time of ~5 min. If necessary, LGE imaging using phase sensitive inversion recovery reconstruction (PSIR) is performed at 10 min after the infusion is initiated.ResultsWe have successfully performed the above protocol with good image quality on 10 patients with both time-resolved MRA and 3D IR bSSFP iNAV imaging. Our initial attempts to use pencil beam respiratory navigation failed due to signal labeling in the liver by the navigator. We have also performed 2D PSIR LGE successfully, with both LGE positive and LGE negative results.ConclusionA bolus of gadobutrol, followed later by a slow infusion, allows time-resolved MRA, 3D IR bSSFP using the iNAV navigation technique, and LGE imaging, all in a single study with a single contrast agent.

Is nutritional support needed in late preterm infants?

BackgroundLate preterm birth accounts for 70 % of all preterm births. While the impact of feeding problems in very preterm infants has been widely investigated, data on late preterm infants’ feeding issues are scarce. The aim of the present study was to investigate the need of nutritional support during hospital stay in a cohort of late preterm infants and to identify the factors that most contribute to its occurrence.MethodsWe analyzed the medical records of late preterm infants, born 2011–2013, admitted to a single institution. Neonatal data, the need for nutritional support, defined as the need for parenteral nutrition or intravenous fluids or tube feeding, and the feeding status at discharge were retrieved. The occurrence of respiratory distress syndrome, congenital malformations/chromosomal diseases, cardiac diseases, sepsis, hypoglycemia, poor feeding and the need for surgical intervention were also collected.ResultsA total of 1768 late preterm infants were included. Among the 592 infants requiring a nutritional support, 228 developed a respiratory distress syndrome, two developed a sepsis, one presented with a cardiac disease, 24 underwent a surgical intervention, eight had a chromosomal disease/congenital malformation, 80 had hypoglycemia. In addition, 100 infants required nutritional support due to poor feeding and 149 were born small for gestational age. Birth weight ≤2000 g (adjusted OR = 12.2, 95 % CI 7.5-19.9, p < 0.0001), gestational age of 34 weeks (adjusted OR = 4.08, 95 % CI 2.8-5.9, p < 0.0001), being small for gestational age (adjusted OR = 2.17, 95 % CI 2.8-5.9, p=0.001), having a respiratory distress syndrome (adjusted OR = 79.6, 95 % CI 47.2-134.3, p < 0.0001) and the need of surgical intervention (adjusted OR = 49.4, 95 % CI 13.9-174.5, p < 0.0001) were associated with a higher risk of need of nutritional support during hospital stay.ConclusionsLate preterm infants are at relatively high risk of requiring nutritional support during hospital stay, especially if they have a birth weight ≤2000 g, a gestational age of 34 weeks, are born small for gestational age, develop a respiratory distress syndrome and require a surgical intervention. The present findings add to the knowledge of late preterm infants’ feeding issues and may contribute to tailoring nutritional approaches for these infants.

Synergy of ambroxol with vancomycin in elimination of catheter-related Staphylococcus epidermidis biofilm in vitro and in vivo

Central venous catheters are widely used in neonatal intensive care units (NICUs) nowadays. The commonest cause of catheter-related bloodstream infections (CRBSIs) is coagulase-negative staphylococci (CoNS). Ambroxol, an active metabolite of bromhexine, exhibits antimicrobial activity against strains producing biofilm and enhances the bactericidal effect of some antibiotic by breaking the structure of biofilm. In this study, we aimed to determine the effect of ambroxol with vancomycin on the biofilm of Staphylococcus epidermidis (S. epidermidis) in vitro and in vivo. In the in vitro study, the biofilm of S. epidermidis was assessed by XTT reduction assay and analysed by confocal laser scanning microscopy (CLSM). In the in vivo study, a rabbit model of CRBSIs was created by intravenous intubation with a tube covered with S. epidermidis biofilm. The rabbits received one of the following four treatments by means of antibiotic lock therapy: normal heparin, ambroxol, vancomycin, or vancomycin plus ambroxol each for 3 days. The microstructure of the biofilm was assessed by scanning electron microscopy (SEM). The number of bacterial colonies in the organs (liver, heart, and kidney) and on the intravenous tubes was measured on agar plates. Pathological changes in the organs (liver, heart, and kidney) were observed with Hematoxylin-Eosin staining. The ambroxol exhibits significant efficacy to potentiate the bactericidal effect of vancomycin on S. epidermidis biofilm both in vitro and in vivo. The antibiotic lock therapy using a combination of ambroxol and vancomycin reveals a high ability to eradicate S. epidermidis biofilms in vivo. These results provide the basis of a useful anti-infection strategy for the treatment of CRBSIs.

Tube Anchor: development of a small medical device from concept to market

Experts probably have to immerse themselves in their discipline for at least a decade before they have the knowledge and insights needed to produce world-class work. Medical practitioners with long...

Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-way stopcock on central line–associated bloodstream infection rates in India: a randomized clinical trial conducted by the International Nosocomial Infection Control Consortium (INICC)

Three-way stopcocks (3WSCs) are open systems used on intravenous tubing. Split septums (SSs) are closed systems with prepierced septums. Single-use prefilled flushing devices (SUFs) carry a lower risk of contamination than standard intravenous flushing. 3WSC and standard flushing are widely used in developing countries. This is the first randomized clinical trial (RCT) to compare rates of central line-associated bloodstream infection (CLABSI) between patients using an SS+SUF and those using a 3WSC. An RCT with 1096 patients in 5 adult intensive care units was conducted between April 2012 and August 2014 to evaluate their impact on CLABSI rates. Centers for Disease Control and Prevention/National Healthcare Safety Network definitions were applied and International Nosocomial Infection Control Consortium methodology were followed. The study cohort included 547 patients and 3619 central line (CL)-days for the SS+SUF group, and 549 patients and 4061 CL-days for the 3WSC group. CLABSI rates were 2.21 per 1000 CL-days for SS+SUF and 6.40 per 1000 CL-days for 3WSC (relative risk, 0.35; 95% confidence interval [CI], 0.16-0.76; P= .006). The SS+SUF group had significantly better cumulative infection-free catheter survival compared with the 3WSC group (hazard ration,0.33; 95% CI, 0.15-0.73; P=.006). Using an SS+SUF represents savings of $402.88 and an increase in quality-adjusted life years of 0.0008 per patient. For each extra dollar invested in an SS+SUF, $124 was saved. The use of SS+SUF is cost-effective and associated with a significantly lower CLABSI rate compared with the use of 3WSC.

A Chemical Heat Pack–Based Method For Consistent Heating of Intravenous Fluids

Transfusion of cold intravenous fluids (IVF) can exacerbate hypothermia. Civilian and military guidelines recommend heated IVF for hypothermic patients; however, there is currently no ideal IVF heating system for use in resource-limited settings. Development of a system that uses flameless ration heaters (FRH) and an insulated sleeve for the consistent delivery of IVF at physiologically appropriate temperatures (40°-42°C) over the range of ambient conditions typical of the prehospital and wilderness environments. The temperatures of 0.9% normal saline (NS) 1-L bags were measured under 3 ambient conditions: 3°C, 10°C, and 20°C. The IVF was placed in an insulated pouch along with a predetermined number of activated FRH (5 FRH for 3°C, 4 FRH for 10°C, and 3 FRH for 20°C) for 10 minutes before removing the FRHs. The insulated IVF bag was drained through 280 cm of intravenous tubing at a flow rate of 77 mL/min. Raw temperature data for internal and delivery temperatures were collected and analyzed. The temperature of the IVF throughout the delivery of 1 L of NS under the 3 ambient conditions was as follows (mean ± SD): at 3°C ambient, 47° ± 2.1°C internal and 42.6°C ± 1.4°C at delivery; at 10°C ambient, 52.3° ± 2.7°C and 45.2° ± 1.6°C; and at 20°C ambient, 45.5° ± 1°C and 39.7° ± 0.7°C. The IVF heating system described here reliably delivered physiologically appropriate temperature intravenous fluids in 2 of the 3 ambient treatment conditions. With the appropriate number of FRH for the ambient conditions, this system enables the delivery of warmed IVF to provide active warming, which may be clinically beneficial in the prevention and treatment of hypothermia.

Improving Antibiotic Prophylaxis Prior to Cesarean Birth

Poster Presentation Objective To ensure that antibiotic prophylaxis will occur 100% of the time within the one‐hour window prior to incision for women with scheduled cesarean births at Children's Memorial Hermann Hospital Women's Services by July 30, 2014. Design A quality‐improvement team of anesthesiologists, nurses, and pharmacists used quality‐improvement methods to understand the problem and develop a new process for antibiotic delivery. Sample Women with scheduled cesareans at Children's Memorial Hermann Hospital Women's Services comprised the sample. Methods Baseline data were collected to define the scope of the problem of antibiotics being delivered according to evidence‐based guidelines. A fishbone diagram was developed to understand the potential causes of antibiotic delivery failure in 18% of patients from anesthesiologist and nursing staff perspectives. A waste walk was performed to identify inefficiencies. A map of the current process was created to detect potential stages at which interventions might improve the ability to give antibiotics on time. A spaghetti map was drawn after a nurse wearing a pedometer walked to all areas where nurses must travel to gather intravenous tubing and antibiotics to make a packet for anesthesia. A test of change in one pod was tested with positive results and then the new process was implemented in the entire unit. Postimplementation data were collected. Implementation Strategies Anesthesia, medicine, and nursing leaders approved the project. The new process was taught to all nurses and anesthesiologists with the goal to reduce surgical site infections by delivering antibiotics within one hour prior to incision. Specific resources and supplies needed for the process to work smoothly and efficiently were also implemented. Pyxix MedStations were purchased for operating rooms (ORs). The pharmacy supplied antibiotics and altered practice to support the new process. Information systems collaborated on the implementation of Power Chart Maternity Care4 (PCM), a new electronic charting method, to reduce the incidence of charting in different software and to support the convenience of charting medications in the ORs for the anesthesiologists. Results The goal of 100% compliance was not met, although at 99%, the goal is within reach. The new process is in place and Power Chart Maternity has been implemented. Conclusion/Implications for Nursing Practice A control plan to maintain gains will need to be in place. Implications for nursing practice include the elimination of time wasted in finding tubing and antibiotics and the ability of the nursing staff to focus on laboring women without leaving the bedside.

The night before the first day of school.

DOI: 10.1200/JCO.2014.60.5790 So many years out of school and that feeling returns again. Part nausea, part excitement, part dread, part wonder that another summer is over and another school year begins. It is the night before the first day of school. As a student, the end of summer break somehow became easier to handle with each passing year. Maybe it was maturity or experience or confidence that the school year would be OK. Or maybe I just learned to accept the inevitable. Now, as a parent with that anxiety and opportunity once removed, each school start brings unique perspectives from each of my children. And like so many things, through my children, it is easy to feel school-aged again. I am hoping that the teachers will be nice, wondering if any of my children’s friends will be in home room, and curious about who will have lunch at the same time. And I am more worried than ever that the teachers will give too much homework. As a pediatrician, my patients provide a unique perspective on school. Working in the emergency room many years ago, I was helping a very sick child— getting oxygen for him, putting in an intravenous tube, and handing off my other patients so I could focus on this one sick child. Amid all of the rushing to help him, he turned to me and asked me to get his school bag. He said he needed to study and do his homework. I told him that it would be OK to take the night off, but this 11-year-old boy from the inner city removed his oxygen mask to tell me, “Non scooli sed vitae diskemuse” (Fig 1). I figured he was babbling from too little oxygen going to his brain. But when I looked confused, he said, “You’re a doctor. Don’t you know Latin? It means ‘Not for school but for life we learn.’” If only I had learned that when I was his age. . . It is once again the night before the first day of the new school year. My own children and other kids across the country are clinging to the last hours of summer break. But as a pediatric oncologist, I know one 15-year-old girl is hoping for morning to arrive so she can see her friends, and be a kid, and maybe learn something, not for school, but for life. Christy has a recurrent malignant brain tumor that no one knows how to cure. For patients with the worst types of tumors, we try to set realistic goals. What are some of the things you want to do while you can? Amazingly, most of our patients, even children and teenagers, can answer this question. After her high-grade glioma recurred the first time, Christy danced at the prom party we throw at the hospital for all of our patients. And I mean, she danced. After her tumor recurred a second time, we thought it would be a small blessing if she could be strong enough to make it to see her favorite boy-band in concert. And she did, first class, limo and all, thanks to some great philanthropy. And then her tumor progressed and before she was too weak to get around, we asked what else she was hoping to do. The typical answers are “another trip” or “shopping spree” or “I want to be there for my cousin’s wedding.” But Christy’s great wish was to make it to the first day of school, the first day of 10th grade. So tonight, my boys are tucked in and hopefully looking forward with more excitement than dread to another year of school. And they and I know they will be OK. This year the transition will be easier than last year, and next year will be easier still. But I have never been more anxious before the first day of school than I am right now. I am Fig 1. Photo of Latin quote from 11-year old patient. JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 33 NUMBER 13 MAY 1 2015

Cisatracurium degradation: Intravenous fluid warmer the culprit?

Cisatracurium degradation: Intravenous fluid warmer the culprit?

NOVEL BIOACTIVE AND BIODEGRADABLE MATERIALS FOR MEDICAL APPLICATIONS

Poly(vinyl chloride) (PVC) is the most widely used material for the production of medical devices such as intravenous fluid bags and tubing, enteral feeding, dialysis equipment and catheters. Despite of their numerous advantages, the plastic medical devices are non biodegradable and prone to microbial colonization causing biofilm associated infections which are difficult to treat and tend to chronicisation. A possible solution to surpass these limitations could be the fabrication of new biodegradable polymeric materials with optimized biocompatibility and antimicrobial properties. In this regard, biodegradable polymeric materials, such as poly(e-caprolactone) (PCL), poly(DL-lactic acid) (PLA) etc. have been considered the most desirable solution from the environment management point of view. In this paper, Alg(1%)Zn, Alg(2%)Zn, Alg(3%)Zn compounds were obtained from sodium alginate (AlgNa) crosslinked with ZnCl2. Antimicrobial activity of the AlgZn compounds was assessed by the microdilutions and the diffusion methods, towards Gram-positive and Gram-negative bacterial strains (reference and clinical isolates). The Alg(3%)Zn compound was selected as antimicrobial agent to obtain the biocomposites encoded: PLA/PCL/AlgZn0.1 and PLA/PCL/AlgZn0.3. The PLA/PCL sample was used as control. Antibiofilm activity against Staphylococcus xylosus, cytotoxic effect on mammalian cells and thermal analysis by DSC were investigated for the obtained biocomposites. The obtained results show that the addition of the Alg(3%)Zn compound in the biocomposites decreased the glass transition temperature as well as the degree of crystallinity both of the PCL and PLA components in samples. Although the results suggest that the biocomposites containing Alg(3%)Zn did not inhibit the staphylococcal colonization and mature biofilm formation, the high degree of biocompatibility of blends leads to conclusion that these materials could be used for the development of novel bioactive and biodegradable polymeric materials with medical applications.

Ebola fever: reconciling planning with risk in U.S. hospitals.

The authors of this commentary believe that current recommendations from the Centers for Disease Control and Prevention to prevent transmission of Ebola to health care workers are appropriate. Addi...