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.     

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.     

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.     

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.     

Respiratory care protocols in postanesthesia care

IS1311 is an insertion sequence from Mycobacterium avium and M. avium subsp. paratuberculosis. Using a 180 bp fragment of IS 1311 as a probe, 7-10 copies of IS1311 were revealed in strains of M. avium subsp. paratuberculosis. With a given restriction enzyme, the restriction fragment length polymorphism patterns obtained from isolates of M. avium subsp. paratuberculosis from cattle were all identical, but they differed from those of isolates from sheep, which could be separated into two types. A 1259 bp fragment of IS1311 produced by polymerase chain reaction (PCR) from two isolates of M. avium subsp.paratuberculosis from cattle and two isolates from sheep was sequenced and compared to the sequence known from M. avium. Apart from five point differences the sequences were identical. Restriction endonuclease analysis (REA) of the PCR product was used to distinguish isolates of M. avium subsp. paratuberculosis from M. avium, in addition to the conventional test for IS900. In isolates of M. avium subsp. paratuberculosis from cattle the IS1311 gene was polymorphic at position 223, which enabled isolates from sheep and cattle to be distinguished by PCR-REA. These simple tests will be used to enhance disease control programmes for Johne's disease in ruminants. The findings of this study raise interesting questions about the evolution of M. avium subsp. paratuberculosis.     

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.     

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.     

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.     

Pain management in the pediatric intensive care unit

Control of pain in the pediatric intensive care unit has become increasingly important to intensivists. Improved understanding of the pharmacology of analgesics and the development of new techniques for analgesic administration have greatly enhanced the ability of intensivists to successfully manage patients in pain. The appropriate selection, use, and techniques for administration of analgesics in the treatment of pain in pediatric patients are discussed.     

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.     

Pediatric pain management in an adult critical care unit

Many children every year will be treated in "adult" critical care units because of the limited pediatric trauma centers currently available. Assessment is an integral part of all pain management. Ideally, self-report is the gold standard for assessing pain; however, some children may not have the ability to use these tools. Nonverbal children may be assessed with behavioral tools such as the CHEOPS or FLACC. In children as young as 3 years old, the self-report tool called an OUCHER can be administered to assess their pain. Easy to apply nonpharmacological approaches are discussed with recommendations for nurses to incorporate into their daily care.     

The management of septic abortion in an intensive care unit

Antirheumatic preparations chiefly inhibited (in vitro) the specific microbial stimulation of the reaction of blast transformation of lymphocytes (RBL) in the patients with torpid rheumocarditis caused by addition of streptococcus nucleoproteid into the medium. Specifically stimulated RBL became intensified in healthy donors on addition to the culture medium of amidopyrin and mephenaminic acid; as to delagil, it depressed the specifically stimulated RBL both in healthy donors and in patients.     

The critical care unit. In search of management

Administration of inducing doses of dexamethasone (10 microg/100 g) to adrenalectomized rats results, within 2-5 min, in import of the glucocorticoid receptor from liver cytoplasm into mitochondria, as demonstrated by Western blotting and by electron microscopy. Furthermore, glucocorticoid receptor (GR) synthesized in an in vitro reticulocyte system programmed with the respective mRNA, enters within minutes to added rat liver mitochondria in the form of intact GR, as demonstrated by Western blotting using either monoclonal or polyclonal antibodies against different domains of GR. In vitro studies show that the import is dependent on temperature and/or activation of the hormone-GR complex. These results, in connection with the presence in the human and rodent mitochondrial genome of sequences showing partial homology to the nuclear glucocorticoid response elements, support the hypothesis that the well documented effects of glucocorticoids on mitochondrial functions result from a direct interaction of the GR complex with the mitochondrial genome.     

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.     

Decrease in costs for management of lower airway disease in the pediatric intensive care unit

PURPOSE: Hypertensive patients exhibit exaggerated cardiovascular responses to tracheal extubation. This study was undertaken to examine the inhibitory effects of calcium channel blockers, nicardipine and diltiazem, on haemodynamic changes after tracheal extubation. METHODS: Sixty hypertensive patients (ASA physical status II) undergoing elective orthopaedic (upper and lower extremity) surgery received, in a randomized, double-blind manner, 30 micrograms.kg-1 nicardipine, 0.2 mg.kg-1 diltiazem or saline (as a control) (n = 20 of each) i.v. before tracheal extubation. Changes in heart rate (HR), mean arterial pressure (MAP) and rate-pressure product (RPP) were measured before and after tracheal extubation. RESULTS: The HR, MAP and RPP increased after tracheal extubation in the control group (P < 0.05). The increases in these haemodynamic variables were attenuated with nicardipine or diltiazem. The inhibitory effects of diltiazem on these cardiovascular responses to tracheal extubation were greater than those of nicardipine (HR; 86 +/- 7 vs 101 +/- 10, RPP; 11,437 +/- 1,575 vs 14,675 +/- 2,874, mean +/- SD, P < 0.05). CONCLUSION: Compared with nicardipine, administration of diltiazem produced greater attenuating the circulatory responses to tracheal extubation in hypertensive patients.     

Bronchoscopy in the intensive care unit

With the prevalence of bronchopulmonary disease in the intensive care unit, bronchoscopy has become an essential tool for the management of patients. This article describes the variety of situations in which bronchoscopy can be of assistance in establishing diagnosis, managing the difficult airway, and supporting the patient's suffering of trauma, hemoptysis, atelectasis, and pneumonia.     

The nurse's role in pain assessment and management in a coronary care unit

Nurses play an important role in the assessment and management of pain, but some have many misbeliefs about the pain experience (Watt-Watson & Donovan 1992) and pain management, which may affect their judgment when dealing with a patient's pain. This review of literature on pain assessment and management includes pharmacological and nonpharmacological treatment. A case study highlights the nurse's role in assessment and management of pain in patients admitted to a coronary care unit. Recommendations are made as to how the nursing management of pain can be improved.     

Fungal infection in the intensive care unit

Fungal infection in critically ill patients is an increasingly prevalent problem. Candida spp. cause the majority of these infections in ICU. They occur most commonly in patients with severe underlying illness, multiple courses of antibiotics and intravascular catheters. Clinical diagnosis is difficult due to nonspecific signs and the frequent occurrence of widespread superficial colonization with Candida spp. in ventilated patients. Most patients are diagnosed using inferential evidence of infection, such as persistent pyrexia despite antibiotics, raised serum C-reactive protein and the presence of individual risk factors. Amphotericin B and fluconazole are the most commonly used anti-fungals dependent on the identity of the fungus. Most of these infections are endogenous; however, a proportion may be caused via the hands of healthcare staff or contaminated medical equipment.