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Improving Patient Safety in Surgical Care

Amir Ghaferi, MD, MS, FACS
    • Use of sophisticated nonmedical systems approaches to improving surgical patient safety
    • Recognition and implementation of standardization across surgical practices and integrated health systems to improve surgical patient safety
    • National programs aimed at developing grassroots efforts to improve surgical safety at the individual, practice, and health system levels 

Improving Patient Safety in Surgical Care

Amir Ghaferi, MD, MS, FACS
    • Use of sophisticated nonmedical systems approaches to improving surgical patient safety
    • Recognition and implementation of standardization across surgical practices and integrated health systems to improve surgical patient safety
    • National programs aimed at developing grassroots efforts to improve surgical safety at the individual, practice, and health system levels 

Improving Patient Safety in Surgical Care

Amir Ghaferi, MD, MS, FACS
    • Use of sophisticated nonmedical systems approaches to improving surgical patient safety
    • Recognition and implementation of standardization across surgical practices and integrated health systems to improve surgical patient safety
    • National programs aimed at developing grassroots efforts to improve surgical safety at the individual, practice, and health system levels 

Gastrointestinal Bleeding

Romeo Fairley, MD, Truman J. Milling Jr, MD
    • The causes of gastrointestinal bleeding are protean and reflect the fact that many different kinds of lesions can bleed, many of which can be found in multiple locations in the gastrointestinal tract.
    • Patients with gastrointestinal bleeding are critically ill. It is imperative to obtain early expert consultation and definitive care while resuscitation and stabilization begin; consults may include Gastroenterology, Surgery, and Interventional Radiology.
    • Appropriate, early intensive resuscitation has been shown to significantly reduce mortality in patients with upper gastrointestinal bleeding; a mean arterial pressure > 65 mm Hg is the goal.
    • Aggressive airway management is prudent, with early intubation if indicated.
    • Blood transfusions are indicated for patients with hemoglobin < 7 g/dL or < 9 g/dL if there is evidence of end-organ ischemia.
    • Based on the history, physical examination, bedside testing, and laboratory studies, it is usually possible to distinguish between upper and lower gastrointestinal bleeding, and treatments should be initiated accordingly.
    • Endoscopy is the mainstay of diagnosis and treatment for both upper and lower gastrointestinal bleeding.
    • Treatment for variceal bleeding includes octreotide administered as a 50 µg bolus followed by continuous infusion at 50 µg/hr for 72 hours; an appropriate antibiotic (such as ceftriaxone 1 g intravenously four times a day for 7 days) and a promotility agent (such as erythromycin 250 mg IV) should be given prior to endoscopy.
    • Treatment for nonvariceal upper gastrointestinal bleeding includes an intravenous proton pump inhibitor (such as omeprazole 80 mg) and endoscopy.
    • Evidence-based clinical risk scores such as the Blatchford and Rockall scores can guide disposition decisions.
    • Children with gastrointestinal bleeding can have subtle signs of severe illness; serious disease entities such as intussusception and necrotizing enterocolitis must be considered.
    • Both intrinsic and extrinsic factors contribute to patients’ anticoagulation status, and some of these mechanisms can be managed with pharmacologic therapy.

Stroke and Other Cerebrovascular Diseases

Scott E. Kasner, MD, MSCE, FAHA, FAAN, Christina A Wilson, MD, PhD
    • Recent advances in endovascular therapy for acute ischemic stroke
    • Updated guidelines for administration of intravenous recombinant tissue plasminogen activator
    • Recent advances in antithrombotic choice for directed secondary stroke prevention
    • Current recommendations for the management of acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage

Intracerebral Hemorrhage

Opeolu Adeoye, MD, MS, Natalie P. Kreitzer, MD
    • Platelet transfusion is not recommended in the setting of spontaneous ICH for patients who are taking antiplatelet medications. 
    • Moderate blood pressure control may be better than aggressive blood pressure control in the acute treatment of intracerebral hemorrhage. 
    • It is important to provide the appropriate reversal agents to patients with novel oral anticoagulant related ICH. These include idarucizumab for reversal of dabigatran, and andexanet alfa for reversal of factor Xa inhibitors such as rivaroxaban, apixaban, and edoxaban. 

Seronegative Spondyloarthritis: Epidemiology, Pathogenesis, And Pathology

Walter P Maksymowych, MB, ChB, FRCP (UK), FRCPC, FACP
    • Disease association with the IL23R gene and the key role of IL-23 in the activation and expansion of a distinct phenotype of T helper (Th) cell characterized by expression of IL-17, the Th17 cell, represents a major advance in our understanding of spondyloarthritis.
    • Increasing evidence supports a role for innate lymphoid cells (ICLs) in the pathogenesis of spondyloarthritis, especially group 3 ILCs that produce IL‑17 and IL‑22.
    • New genetic associations have been described with three new aminopeptidases (ERAP2, LNPEPP, and NPEPPS), protective variants having reduced rates of peptide cleavage, thereby changing both the length and amino acid composition of peptides available for binding to B27.  

Understanding Patient Safety in Surgical Care

Amir Ghaferi, MD, MS, FACS
    • The widespread adoption of a systems-based approach to surgical patient safety across healthcare systems
    • Public reporting and ongoing critical evaluation of surgical quality measures with an emphasis on ensuring surgeons are more aware of these measures and their implications
    • Increased emphasis on the education of future surgeons and healthcare leaders on quality measurement and evaluation has resulted in significant gains in the understanding of surgical safety
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