Abstract Background: Alarms alert healthcare professionals of deviations from normal/physiologic status. However, alarm fatigue may occur when their high pitch and diversity overwhelm clinicians, possibly leading to alarms being disabled, paused, and/or ignored. We aimed to determine whether a staff educational program on customizing alarm settings of bedside monitors may decrease inconsistent alarms in the Post-Anesthesia Care Unit (PACU). Methods: This is a prospective, analytic, quantitative, pragmatic, open-label, single-arm study. The outcome was evaluated on PACU admission before (P1) and after (P2) the implementation of the educational program. The heart rate, blood pressure, and oxygen saturation alarms were selected for clinical consistency. Results: A total of 260 patients were included and 344 clinical alarms collected, with 270 (78.4%) before (P1), and 74 (21.6%) after (P2) the intervention. Among the 270 alarms in P1, 45.2% were inconsistent (i.e., false alarms), compared to 9.4% of the 74 in P2. Patients with consistent alarms occurred in 30% in the P1 and 27% in the P2 (p = 0.08). Patients with inconsistent alarms occurred in 25.4% in the P1 and in 3.8% in the P2. Ignored consistent alarms were reduced from 21.5% to 2.6% (p = 0.004) in the P2 group. The educational program was a protective factor for the inconsistent clinical alarm (OR = 0.11 [95% CI 0.04-0.3]; p < 0.001) after adjustments for age, gender, and ASA physical status. Conclusion: Customizing alarm settings on PACU admission proved to be a protective factor against inconsistent alarm notifications of multiparametric monitors. Background normalphysiologic normal physiologic status However clinicians disabled paused andor or ignored PostAnesthesia Post Anesthesia PACU. . (PACU) Methods prospective analytic quantitative pragmatic openlabel, openlabel open label, label open-label singlearm single arm study P (P1 (P2 rate pressure consistency Results 26 34 collected 27 78.4% 784 78 4 (78.4% , 7 21.6% 216 21 6 (21.6% intervention 452 45 2 45.2 i.e., ie i e (i.e. alarms, alarms) 94 9 9.4 30 0.08. 008 0.08 0 08 0.08) 254 25 25.4 38 3 8 3.8 215 5 21.5 2.6 0.004 0004 004 group OR 011 11 0.1 95% 95 [95 0.040.3 00403 0.04 0.3 04 0.04-0.3] 0.001 0001 001 age gender Conclusion (PACU (P 78.4 (78.4 21.6 (21.6 45. i.e. (i.e 9. 00 0.0 25. 3. 21. 2. 0.00 000 01 1 0. [9 040 0.040. 0040 03 0.04-0.3 78. (78. (21. i.e [ 0.040 0.04-0. (78 (21 0.04-0 (7 (2 0.04- (

Abstract Introduction and objectives Multimodal Analgesia (MMA) has shown promising results in postoperative outcomes across a broad spectrum of surgeries, including bariatric surgery. We compared the analgesic effect immediately after Laparoscopic Bariatric Surgery (LBS) of the combined effect of MMA and methadone against two techniques that were based mainly on the use of high-potency medium-acting opioids. Methods Two hundred seventy-one patients were retrospectively reviewed. The primary outcome was postoperative pain score > 3/10 measured by the Verbal Numeric Scale (VNS) during the Postanesthetic Care Unit (PACU) stay. The three protocols of intraoperative analgesia were: (P1) sufentanil at anesthetic induction followed by remifentanil infusion; (P2) sufentanil at induction followed by dexmedetomidine infusion; and (P3) remifentanil at induction followed by MMA including dexmedetomidine, magnesium, lidocaine, and methadone. Only P1 and P2 patients received morphine toward the end of surgery. Poisson regression was used to adjust confounding factors and calculate Prevalence Ratio (PR). Results Postoperative VNS > 3 was recorded in 135 (49.81%) patients, of which 93 (68.89%) were subjected to P1, 25 (18.56%) to P2, and 17 (12.59%) to P3. In the final adjusted model, both anesthetic techniques (P3) (PR = 0.10; 95% CI [0.03-0.28]), and (P2) (PR = 0.42%; 95% CI [0.20-0.90]) were associated with lower occurrence of VNS > 3, whereas age range 20-29 was associated to higher occurrence of VNS > 3 (PR = 3.21; 95% CI [1.22-8.44]) in PACU. Postoperative Nausea and Vomiting (PONV) was distributed as follows: (P1) 20.3%, (P2) 31.25% and (P3) 6.77%; (P3 < P1, P2; p< 0.05). Intraoperative hypotension occurred more often in P3 (39%) compared to P2 (20.31%) and P1 (17.46%) (p< 0.05). Conclusion MMA + methadone was associated with higher incidence of intraoperative hypotension and lower incidence of moderate/severe pain in PACU after LBS.

RESUMO JUSTIFICATIVA E OBJETIVOS: O manejo da dor pela equipe multidisciplinar continua como um desafio na saúde. O objetivo deste estudo foi analisar o impacto de estratégias educacionais para efetivação da dor como 5º sinal vital e seu gerenciamento em um hospital de alta complexidade. MÉTODOS: Estudo não controlado de intervenção por meio de análise de três diferentes estratégias educativas sequenciais: Semana de treinamentos sobre Dor (SD), visitas educacionais pelo enfermeiro da dor para orientar os profissionais em relação à dor e treinamento eletrônico virtual de revisão. A análise do impacto das estratégias educativas foi realizada por meio de indicadores em relação à dor como 5º sinal vital e tratamento adequado da dor. RESULTADOS: Na avaliação da dor como 5° sinal vital, a auditoria prévia à SD mostrou mediana de conformidade de 46,4% na unidade de internação, de 53,1% na maternidade e de 16,7% no Pronto Socorro. Nas avaliações após a SD, a mediana de conformidade na unidade de internação foi de 78,4%, na maternidade de 79,62% e no pronto atendimento de 32,9% (p<0,05). Houve melhora no tratamento da dor em todos os setores após avaliações subsequentes aos treinamentos (p<0,05). CONCLUSÃO: A implantação de um programa de educação continuada se mostrou efetivo em promover melhora na assistência no cuidado ao paciente com dor e dos resultados dos indicadores assistenciais em relação ao protocolo de dor institucional.

ABSTRACT BACKGROUND AND OBJECTIVES: Pain management by the multidisciplinary team remains a challenge in the health field. The aim of this study was to analyze the impact of educational strategies for the implementation of pain as the fifth vital sign and its management in a highly complex hospital. METHODS: An interventional non-controlled study analyzed three different sequential educational processes: Pain training week (PW), educational visits by the pain nurse to guide professionals in relation to pain management and e-learning. The impact of the educational strategy was assessed through pain as the 5th vital sign and adequate pain management. RESULTS: For pain as the 5th vital sign, the audit previous to PW showed a median of compliance of 46.4% at the inpatient unit, 53.1% at the maternity ward and 16.7% at the emergency room. In the evaluations after PW, the median of compliance at the inpatient unit was 78.4%, at the maternity ward 79.62% and at the emergency room 32.9% (p<0.05). There was an improvement in pain management in all hospital sectors after subsequent training (p<0.05). CONCLUSION: The implementation of a continuing education program has improved pain care assistance and increased compliance to the institutional pain protocol.

RESUMO JUSTIFICATIVA E OBJETIVOS: O objetivo deste estudo foi comparar técnicas anestésicas com sufentanil em diferentes doses na indução anestésica e infusão contínua de remifentanil ou dex medetomidina no intraoperatório para manutenção da anestesia, relacionando tais fatores à incidência de dor, náuseas e vômitos no pós-operatório e demais complicações na sala de recuperação pós-anestésica. MÉTODOS: Estudo observacional analítico retrospectivo reali zado em pacientes obesos (n=120). Os pacientes incluídos foram selecionados aleatoriamente e constituíram 4 grupos de 30 pa cientes cada: G1 - indução com sufentanil 0,5 µg.kg-1 associado à infusão continua de remifentanil; G2 - indução com sufentanil 0,7 µg.kg-1 associado à infusão contínua de remifentanil; G3 - indução com sufentanil 0,5 µg.kg-1 associado à infusão contínua de dexmedetomidina; G4 - indução com sufentanil 0,7 µg.kg-1 associado à infusão contínua de dexmedetomidina. Considerou -se como critério de significância valor de p<0,05. RESULTADOS: A incidência de dor na sala de recuperação pós -anestésica foi de 52,5% (n=63) e, entre esses, em 36,11% dos casos foi considerada intensa. A incidência de dor foi menor nos pacientes que receberam infusão de dexmedetomidina compara do àqueles que receberam infusão de remifentanil. A dose de su fentanil na indução anestésica não influenciou na incidência de dor (G1=G2>G3=G4) (p<0,05). A ocorrência de complicações respiratórias não apresentou diferença estatisticamente significa tiva entre os grupos. CONCLUSÃO: O uso de dexmedetomidina apresentou vanta gem em relação à analgesia na sala de recuperação pós-anestésica, sem aumento no risco de complicações respiratórias, quando comparado à infusão contínua de remifentanil, independente mente da dose de sulfentanil utilizada na indução.

ABSTRACT BACKGROUND AND OBJECTIVES: Compare anesthesia techniques with sufentanil and intraoperative infusion of remifentanil or dexmedetomidine, and to then analyze their associations with the incidence of pain and other complications in the post-anesthesia care unit. METHODS: A retrospective analytical observational study conducted in a reference center for bariatric surgery in São Paulo, São Paulo State, Brazil. Patients (n=120) included in the study were randomly selected using this site’s anesthesia records for bariatric surgery. Four 30-patient groups were established: G1 - induction with 0.5 µg.kg-1 sufentanil associated with the continuous infusion of remifentanil; G2 - induction with 0.7 µg.kg-1 sufentanil associated with the continuous infusion of remifentanil; G3 - induction with 0.5 µg.kg-1 sufentanil associated with the continuous infusion of dexmedetomidine; and G4 - induction with 0.7 µg.kg-1 sufentanil associated with the continuous infusion of dexmedetomidine. Significance was set at p<0.05. RESULTS: The incidence of pain in the post-anesthesia care unit was 52.5% (n=63). It was considered intense in 36.11% of these cases. The incidence of pain in the post-anesthesia care unit was lower in patients receiving a continuous infusion of dexmedetomidine relative to those who received remifentanil infusion. Sufentanil dosage in anesthesia induction did not influence the incidence of pain (G1=G2>G3=G4; p<0.05). The occurrence of respiratory complications did not differ significantly between the groups. CONCLUSION: The use of dexmedetomidine proved to be better for analgesia in the post-anesthesia care unit, and it did not increase the risk of respiratory complications when compared to the continuous infusion of remifentanil, regardless of the sufentanil dose used for induction.