Ventilatory management in the postanesthesia care unit

Postoperative ventilatory depression is common in patients who have received intravenous and inhalational anesthetic agents. Prompt assessment and treatment of ventilatory depression are essential to minimize morbidity and mortality.     

Hypoxemic episodes of patients in a postanesthesia care unit

The incidence, degree, and duration of acute hypoxemia were evaluated with continuous arterial hemoglobin oxygen saturation monitoring by pulse oximetry in 100 postoperative patients during 40 percent oxygen administration by aerosol face tent from postanesthetic recovery room admission to discharge. Saturations were recorded by pulse oximeters (Nellcor-N 200) with desaturations of < or = 92 percent for > or = 30 s considered significant. On recovery room admission, 15 percent of patients were experiencing episodes of desaturation. Low admission saturations correlated positively with patient age and body weight, American Society of Anesthesiologists class, patients having received general anesthesia, and with greater volumes of intraoperative intravenous fluids, particularly > 1,500 ml. Later desaturations to 86.7 +/- 4.6 percent (72 to 91 percent) at 32 +/- 54 min after admission for 5.2 +/- 12.6 min occurred in 25 percent of patients and correlated positively with peripheral surgical procedures, low oxygen saturation on admission, duration of anesthesia, and volume of intraoperative intravenous fluids. Desaturation durations were longer for female subjects and correlated positively with body weight and intravenous fluid volume. Significant arterial hemoglobin oxygen desaturations occurred despite prophylactic oxygen administration by aerosol face tent during short-term postoperative recovery room care.     

Comparison of three rewarming methods in a postanesthesia care unit

Postoperative hypothermia is problematic because patients in postanesthesia care units (PACUs) often feel very cold, and unrecognized or prolonged postoperative hypothermia can aggravate patients' underlying cardiovascular disorders. The researchers compared three methods of rewarming PACU patients who had undergone laparotomy procedures. Patients were assigned randomly to three groups. Each patient in group one received the standard PACU rewarming intervention (ie, two warmed thermal blankets and a hospital bedspread). Each patient in group two received the standard PACU rewarming intervention plus a reflective blanket. Each patient in group three received the standard PACU rewarming intervention plus a reflective blanket and a reflective head covering. Nurses measured patients' vital signs on admission to the PACU and every 15 minutes thereafter until patients' sublingual temperatures reached 36 degrees C (96.8 degrees F). No significant temperature differences occurred among patients in the three groups, but an inverse relationship existed between patients' PACU admission temperatures and the time they required to reach normothermia.     

Barbiturate therapy for status epilepticus in the postanesthesia care unit

Although rare, status epilepticus refractory to conventional therapy may require the initiation of pentobarbital anesthesia and intensive monitoring in the PACU. Barbiturate therapy mandates that the nurse be able to perform mechanical ventilation and advanced cardiopulmonary monitoring as well as be familiar with electroencephalographic monitoring. Careful attention to the potential side effects of barbiturate therapy and anticipation of end-organ complications can increase the likelihood of seizure termination and recovery of status epilepticus patients.     

Factors influencing stay in the postanesthesia care unit: a prospective analysis

STUDY OBJECTIVE: To identify indicators of prolonged length of stay (LOS) in the postanesthesia care unit (PACU) and to test the following hypotheses: (1) that patient age, pain medication administration at the time of PACU admission, length of surgery, and cardiovascular, pulmonary, and pain responses postoperatively predict prolonged PACU LOS and (2) that cardiovascular and pulmonary symptoms preoperatively predict cardiovascular and pulmonary symptoms postoperatively. DESIGN: Prospective, observational analysis. SETTING: PACU of a university teaching hospital. PATIENTS: 1,067 patients scheduled for surgery with general anesthesia between February and September 1996, 18 years of age or older. MEASUREMENT AND MAIN RESULTS: 11.2% of the variation in prolonged PACU LOS can be predicted by age, pain medication at the time of PACU admission, and postoperative cardiovascular, pulmonary, and pain symptoms. A significant number of patients who did not report a prior history experienced postoperative cardiovascular and pulmonary symptoms. CONCLUSION: Patient history and postoperative symptoms predict only a small percentage of prolonged PACU stays. Organizational factors may be a more important predictor of prolonged PACU stay. Additionally, assessment of cardiovascular and pulmonary history needs refinement to improve prediction of patient responses postoperatively.     

Postanesthetic care. Respiratory care

The vasopressor response to angiotensin II was found useful in the differential diagnosis of arterial hypertension and for a better understanding of its pathogenesis. Sodium supply was proved to influence significantly the pressor response to angiotensin II and not that to noradrenaline thus implying the presence of arterial receptors which bind angiotensin specifically. Angiotensin caused an increase of the urinary excretion of electrolytes in hypertensive patients and a decreased electrolyte excretion in normotensives. In most hypertensive patients angiotensin was found to decrease the plasma angiotensinogen and to activate the bradykinin-bradykininogen and fibrinolytic systems. In the presence of urinary infection angiotensin increased the platelet adhesiveness and the thrombelastographic changes proved that in this condition angiotensin increases the tendency to thrombosis.     

Evaluation of benefits related to reduced length of stays in postanesthesia care units

The study's purpose was to estimate the potential economic benefit of the optimization of postanesthesia care units (PACUs). A simulation model was designed and used to test the economic impact of a reduction of length of stay. For the studied PACU, a reduction of 25% of length of stay is required to yield significant economic results.     

A clinical evaluation of an operational postanesthesia care unit source control system

Ossifying fibromyxoid tumor of soft parts is an unusual benign neoplasm, with a tendency for local recurrence. Its typical microscopic appearance is that of a multinodular proliferation of round to spindle shaped cells separated by fibrous bands in which bone formation is often seen. Herein, we present the clinicopathologic features of 17 examples of this tumor with particular emphasis on some unusual histopathologic features that may place pitfalls in the diagnosis of this tumor, including satellite micronodules, mucinous microcysts, absence of myxoid areas, crush artifact, multiple microcalcifications, epidermoid cysts, atypical chondroid differentiation with binucleate lacunar cells, pericytic growth pattern, and malignant change. Awareness of these unusual morphologic features should lead to a search for areas displaying the more typical features of ossifying fibromyxoid tumor to arrive at a correct diagnosis.     

Constant temperature monitoring: a study of temperature patterns in the postanesthesia care unit

Our previous research has demonstrated that with the more aciduric oral bacteria, an acid shock to sub-lethal pH values results in the induction of an acid tolerance response that protects the cells at extremely low pH (pH 3.0-4.0) that kills unadapted control cells maintained at pH 7.5 (Oral Microbiol Immunol 1997: 12: 266-273). In this study, we were interested in comparing the protein profiles of acid-shocked and control cells of nine organisms from three acid-ogenic genera that could be categorized as strong, weak and non-acid responders in an attempt to identify proteins that could be classified as acid-regulated proteins and which may be important in the process of survival at very low pH. For this, log-phase cultures were rapidly acidified from pH 7.5 to 5.5 in the presence of [14C]-amino acids for varying periods up to 2 h, the period previously shown to be required for maximum induction of the acid response. The cells were extracted for total protein and subjected to one-dimensional sodium dodecyl sulfate-polyacrylamide chromatography with comparable control and acid-shocked protein profiles compared by scanning and computer analysis. Of particular interest were the proteins in the acid-shocked cells that showed enhanced labeling (i.e., synthesis) over the control cells, since these were considered acid-regulated proteins of importance in pH homeostasis. Streptococcus mutans LT11 generated the most rapid and complex pattern: a total of 36 acid-regulated proteins showing enhanced synthesis, with 25 appearing within the first 30 min of acid shock. The enhanced synthesis was transient with all proteins, with the exception of two with molecular weights of 50/49 and 33/32 kDa. Within the acid-regulated proteins were proteins having molecular weights comparable to the heat shock proteins and the various subunits of the membrane H+/ATPase. By comparison, the strong responder, Lactobacillus casei 151, showed the enhanced formation of only nine proteins within the first 30 min of the acid shock, with a total of 11 acid-regulated proteins formed during the 2-h adaptation period with enhanced synthesis transient for seven of these proteins. Streptococcus salivarius AT2 and Streptococcus gordonii TH12 had the formation of 6 and 8 proteins enhanced, while the weakly responding organisms, Streptococcus sanguis ATCC 10,556 and Streptococcus oralis ATCC 10,557, exhibited 8 and 6 such proteins, respectively. Even non-responding strains unable to survive at very low pH, such as Streptococcus sobrinus CH125/43, Streptococcus mitis ATCC 12,261 and Actinomyces naeslundii 301-13 showed the initial formation of 3-9 acid-regulated proteins, but protein synthesis was not sustained over the entire adaptation period. Clearly, the survival of oral bacteria at very low pH is related, not to the total number of the acid-regulated proteins induced per se but to the formation of key proteins that function to augment normal pH homeostasis.     

Death in the operating room and postanesthesia care unit: helping nurses to cope

The present paper offers data to suggest an effect of geographic latitude in regard to the frequency of conception in human populations. The birth statistics from eight countries in different parts of the world have been evaluated. A particularly strong minimum appears to occur in almost all regions but is shifted in time with changing latitude.     

Obstetric postanesthesia care unit stays: reevaluation of discharge criteria after regional anesthesia

BACKGROUND: Obstetric patients may have long postanesthesia care unit (OB-PACU) stays after surgery because of residual regional block or other conditions. This study evaluated whether modified discharge criteria might allow for earlier discharge without compromising patient safety. METHODS: Data were prospectively collected for 6 months for all patients (N=358) who underwent cesarean section or tubal ligation and recovered in the OB-PACU. Regional anesthesia was used in 94% of patients. The duration of anesthesia and PACU stays, the presence and treatment of events in the PACU, and the regression of neural blockade were recorded. Discharge from the OB-PACU required a 60-min minimum stay, stable vital signs, adequate analgesia, and ability to flex the knees. After completion of prospective data collection, events that kept patients in the PACU after 60 min were reevaluated as to whether patients needed to stay in the PACU for medical reasons. "Needed to stay" events included bleeding, cardiorespiratory problems, sedation, dizziness, and pain. "Safe to leave" conditions included pruritus, nausea, and residual neural blockade. The cumulative duration of OB-PACU stays not clearly justifiable for medical reasons was calculated. RESULTS: Residual block and spinal opioid side effects accounted for the majority of "unnecessary" stays. Annually, 429 h of PACU time could have been saved using the revised criteria. Complications did not develop subsequently in any patient deemed "safe to leave." CONCLUSIONS: In many obstetric patients, the duration of PACU stays could safely be shortened by continuing observation in a lower-acuity setting. This may result in greater flexibility and more efficient use of nursing personnel.     

Patient, visitor, and nurse evaluations of visitation for adult postanesthesia care unit patients

Mammalian cells contain two distinct types of topoisomerases. They have been mechanistically classified into a type I (topo I) and type II (topo II) enzyme. Anticancer drugs which target topo I include camptothecin, irinotecan, topotecan, and 9-aminocamptothecin. Anticancer drugs which target topo II include etoposide, mitoxantrone, teniposide, and doxorubicin. Much experimental work has indicated that cells with high topoisomerase are drug sensitive, and cells with low topoisomerase are drug resistant. These data suggest that patients whose tumors have abundant topoisomerase might be predicted to respond to topo targeted anticancer drugs. In order to test this hypothesis, immunohistochemical stains have been developed which can recognize the topoisomerases in formalin-fixed, paraffin-embedded, human tissue sections. This may make it feasible to correlate topoisomerase expression in human cancers with clinical response to chemotherapy.     

Using protocols in the context of pharmacists'' patient care responsibilities

A significant weight gain with a mean of 4.4 kg was found between the date of acceptance for bariatric surgery and the date of admission to hospital for the operation.     

Developing and gaining acceptance for patient care protocols

The difficulties students experience in applying theory to practice are well documented and educationalists have employed a variety of techniques in an effort to enhance effective application. This paper describes the utilization of one such teaching/learning strategy in a diploma level course in management for registered nurses and midwives. As problem-solving individual contracts of learning, 'ripple effect' plans enabled course participants to apply general principles of management theory to specific nursing management practice in their everyday world of nursing and midwifery work, making changes in practice and procedure which were visible and real.     

Ovarian hyperstimulation syndrome: protocols for nursing care

One of the few life-threatening conditions encountered by the nurse caring for reproductive endocrinology and infertility patients is ovarian hyperstimulation syndrome (OHS). Having protocols for the nursing care of the patient with OHS enhances patient safety and quality of care. Model OHS protocols for outpatient and inpatient settings are presented. The collaborative nursing role in patient care also is discussed.     

Respiratory care warrants studies for cost-effectiveness

The need for careful cost-effectiveness studies in the field of RCS is apparent. Salaries consume most of the cost, and overtrained and expensive personnel may be saturating the work force. Costs for consumable and nonconsumable supplies have not risen out of proportion to general economic inflationary indixes. Close examination is needed of therapeutic modalities that are expensive and that stand on shaky scientific ground. However, the short-term experience of the medical center's multidisciplinary respiratory rehabilitation program has demonstrated that such programs can be worth the costs involved.     

The effectiveness of skin care protocols for pressure ulcers

Pressure ulcers (PU) remain a serious healthcare problem in the United States. This study investigated the effectiveness of a prevention and early intervention program in reducing the prevalence of pressure ulcers (i.e., the number or the percentage of persons with pressure ulcers at a given time) in a rehabilitation hospital. The Braden Scale for Predicting Pressure Sore Risk was used to assess subjects' PU risk. Protocols were established for PU stages consistent with the National Pressure Ulcer Advisory Panel consensus statement on pressure ulcers. Staff were educated about PUs and the specific protocols for prevention and treatment. Concurrent quarterly prevalence audits on a total of 116 patients were conducted for 1 year. An audit also was done 16 months after protocols had been established. There was a 60% decrease in pressure ulcer prevalence from the 25% baseline to the 10% found at the audit following implementation of the protocols.     

Respiratory monitoring: pulse oximetry and capnography in children during anesthesia and intensive care

Monitoring the critical care patient by pulse oximetry and capnography permits the early diagnosis and follow-up of various clinical events in a precise manner, with considerable safety and with no need for invasive procedures. These techniques have been extensively evaluated in adults, but only recently have they been studied in pediatric patients, including newborn infants. In the present review we discuss the working principles, indications, advantages and limitations of each technique, as well as the interpretation of the results.