The image of the children's nurse: a study of the qualities required by families of children's nurses' uniform.

Traditional views of the nurse see 'her' in a nurse's uniform, whether she be a 'sex symbol', 'angel of mercy' or 'battle axe'. Children's nursing has, over recent years, moved away from the idea of the uniform into more child friendly clothes, though the traditional uniform is still presented to the public by the media. The staff members of a Children's Outpatients Department (COPD) of a large acute hospital requested knowledge of the qualities families required from the uniform of nurses caring for them, prior to any change in uniform. This study aimed to develop an understanding of these qualities via the use of a survey presented to those attending the COPD. The findings indicate that there is a complex relationship between the qualities that families wish the uniform to present. A balance is needed between presenting a professional authority figure, providing security for families and suggesting an approachable figure, to allow effective communication between staff and families.

The effect of nitric oxide on platelets when delivered to the cardiopulmonary bypass circuit.

UNLABELLED: Nitric oxide (NO) decreases platelet adhesion to foreign surfaces in the in vitro models of cardiopulmonary bypass (CPB). We hypothesized that NO, delivered into the membrane oxygenator (MO), would exert a platelet-sparing effect after CPB. Forty-seven patients scheduled for coronary artery surgery were randomized to either a NO group, in which NO (100 ppm) was delivered into the MO, or a control group, in which CPB was conducted without NO. Platelet numbers, platelet aggregation response to 2.5-20 microM adenosine diphosphate, and beta-thromboglobulin levels were measured after induction of anesthesia, after 1 h on CPB and 2 h after the end of CPB. Met-hemoglobin levels were measured during CPB. The amount of blood products administered and chest tube drainage were measured in the first postoperative 18 h. NO delivered into the MO for up to 180 min did not increase met-hemoglobin levels above 4%. NO inhibited the platelet aggregation response to 2.5 microM ADP during CPB, otherwise NO had no other detectable effect on the aggregation responses or the levels of beta-thromboglobulin. Platelet numbers were not significantly altered by NO. NO did not alter the use of blood products or chest tube drainage. In conclusion, this study suggests that NO delivered into the MO of the CPB circuit does not significantly alter platelet aggregation and numbers, and does not affect bleeding. IMPLICATIONS: Nitric oxide affects platelet function. We demonstrated that nitric oxide delivered into the gas inflow of the cardiopulmonary bypass circuit membrane oxygenator does not significantly alter platelet numbers or function.

High-frequency oscillatory ventilation can be effective as rescue therapy for refractory acute lung dysfunction.

High-frequency oscillatory ventilation (HFOV) is a technique with limited use in adult patients. The main purpose of this pilot study was to evaluate HFOV on adult trauma patients with refractory lung dysfunction. Refractory lung dysfunction was defined as a PaO2:FiO2 ratio <75 for 1 hour despite maximum support via conventional mechanical ventilation (CMV). Five patients were placed on HFOV after failing CMV between May 1998 and December 1998. The mean PaO2:FiO2 ratio at the time of initiation (52.2+/-4.73) of HFOV increased significantly (P<0.05) by 2 hours (126.8 +21) and was still significantly increased (P<0.01) after 48 hours (181 +26.1) on HFOV. The mean airway pressures (MAPs) and peak pressures were significantly lower (P<0.01) after HFOV. The average MAP of the five patients was 34.6 +1.6 cm H2O at time zero and 25.2 cm H2O after 48 hours of HFOV. The mean peak pressure was 52.4 +3.0 cm H2O at time zero and was 35.8+/-3.01 after termination of HFOV. Survival was 80.0 per cent (four of five patients). In conclusion, all patients improved after initiation of HFOV, and HFOV should be considered in the treatment of patients with acute refractory lung dysfunction.

Adjuncts to analgesia. Sedation and neuromuscular blockade.

This article provides an overview of some of the current issues involved in sedation and anxiolysis in the intensive care unit. The problems involved in trying to monitor sedation levels are discussed, as are some of the newer options available for physiologic monitoring of the central nervous system. The problem of abnormal mental states in the intensive care unit and the range of antidepressant therapy now available are also covered. The importance of sleep deprivation and the properties of the neuromuscular blockers are also discussed.

Endotoxin alters hypoxic pulmonary vasoconstriction in isolated rat lungs.

Hypoxic pulmonary vasoconstriction (HPV) is an important mechanism for maintaining oxygenation, which may be altered by endotoxin. We determined that acute endotoxemia alters the HPV response secondary to changes in endothelium-derived vasoactive products. Rats were treated with Salmonella typhimurium lipopolysaccharide (LPS; 15 mg/kg i.p.) either 1 to 6 h before lung isolation and compared with control rats (no LPS). Additional 6-h LPS-treated and control rats were pretreated with either indomethacin (15 mg/kg i.p.), a cyclooxygenase inhibitor, or bosentan (10 mg/kg po), a nonselective endothelin-receptor antagonist. The rats lungs were isolated and challenged with 3% O2 for 10 min to elicit HPV responses before and after nitric oxide (NO) synthase inhibition with N omega-nitro-L-arginine methyl ester (L-NAME; 100 microM). LPS (6 h) significantly increased the peak HPV responses by 108%. L-NAME had no significant effect in LPS-treated lungs but increased the peak HPV response in control lungs to levels equal to LPS-treated lungs. Bosentan increased the peak HPV response in all lungs, and indomethacin increased the peak HPV in LPS-treated lungs. The HPV response was sustained in control lungs at 10 min and in additional 20-min studies. In contrast, in LPS-treated lungs the HPV response faded after 10 min to levels equal to control, and in 20-min studies it faded by 82% to levels significantly less than in control lungs. The 10-min fade in LPS-treated lungs was attenuated by indomethacin (51%) and bosentan (80%) but not by L-NAME. In conclusion, acute endotoxemia with LPS increased the peak HPV response, but this effect was not sustained and by 20 min was nearly abolished. Inhibition of endogenous NO by LPS may explain the increased peak HPV response, but NO is not involved in the fade. The fade is at least partially due to increased vasodilating cyclooxygenase products and endothelins.

The response to varying concentrations of inhaled nitric oxide in patients with acute respiratory distress syndrome.

We investigated the response to varying concentrations of inhaled nitric oxide (NO) in 18 patients with acute respiratory distress syndrome (ARDS). The study was divided into two parts. In Part 1, 5-40 ppm of inhaled NO was evaluated in 10 patients with ARDS. In Part 2, 0.1-10 ppm of inhaled NO was evaluated in eight patients with ARDS. Inhaled NO significantly (P < 0.05) decreased the mean pulmonary artery pressure (MPAP) and pulmonary vascular resistance index (PVRI), and increased the arterial oxygenation (PaO2) at concentrations of 0.1 to 40 ppm. No dose response was detectable for the pulmonary artery pressure (PAP) or PVRI over this dose range. The increase in PaO2 at 10 ppm of NO was significantly greater than that at 0.1 ppm but not 1 ppm. The decrease in PVRI and the increase in PaO2 were both significantly correlated with the baseline PVRI. While the maximum hemodynamic and oxygenation responses to inhaled NO are achieved at approximately 1 ppm, it appears that the maximum hemodynamic response is observed at lower concentrations (0.1 ppm) of inhaled NO than the improvement in oxygenation (1-10 ppm). Higher concentrations of NO do not produce any further change in these variables. It appears that the baseline PVRI may be the best marker predicting a beneficial response to NO.

Pre-emptive versus post-surgical administration of ketorolac for hysterectomy.

Seventy-seven women who underwent routine vaginal or abdominal hysterectomy were randomly allocated to receive intravenous ketorolac 30 mg either 30 min before surgical incision (pre-emptive group, n = 37), or at the end of the surgical procedure (post-surgical group, n = 40). The patients received routine post-operative care, which included morphine by patient-controlled analgesia, 1 mg per demand with a lockout of 6 min and a background infusion of 1 mg h-1. In addition, pain was assessed at 12 and 24 h using a 100 mm visual analogue scale (VAS), both at rest and on coughing. At 24 h, the median VAS at rest was 24 mm (range 0-80) in the pre-emptive group and 28 mm (range 0-100) in the post-surgical group. The average morphine consumption rate over the first 24 h was 1.9 mg h-1 (SD +/- 0.6) in the pre-emptive group, and 2.2 mg hr-1 (SD +/- 1.1) in the post-surgical group. There were no significant differences on univariate testing. Subsidiary stepwise multiple regression modelling identified age, weight, type of hysterectomy, and the timing of ketorolac administration as significant explanators of post-operative morphine consumption. A statistically significant pre-emptive analgesic effect was therefore identifiable, but the clinical significance is uncertain in relation to the other influences on post-operative analgesic requirements.

Epidural infusions of bupivacaine and diamorphine in labour.

Three different concentrations of bupivacaine, 0.125%, 0.062% and 0.031%, all with diamorphine 0.0025%, were given as an epidural infusion at 10 ml.h-1 to 63 mothers in labour. When the three infusions were compared, significant differences were found in maternal requirements for top-ups and the degree of motor block, but there were no differences in the pain scores. The reduced motor block was not associated with a reduction in the instrumental delivery rate.

Epidural diamorphine infusions with and without 0.167% bupivacaine for post-operative analgesia.

Forty patients who underwent upper or mid-abdominal surgery were randomly allocated to receive a post-operative epidural infusion of 0.083 mg ml-1 of diamorphine in either 0.167% bupivacaine or 0.9% NaCl solution. The nursing staff, who were unaware of which solution was being infused, managed the patients' pain according to a standardized scheme. They adjusted the epidural infusion rates to 3, 5 or 7 ml h-1 according to the patient's hourly reports of pain on a four point verbal rating scale (none, mild, moderate or severe), aiming to use the lowest allowed infusion rate to prevent or reduce any pain that was more than mild. Additional analgesia was given as diclofenac 75 mg intramuscularly if the patients report moderate pain while on the highest infusion rate. The nurses were instructed to summon anaesthetic help if pain relief was still unsatisfactory after diclofenac, but this was never necessary. Diclofenac was needed by six patients receiving diamorphine in saline and one receiving diamorphine in bupivacaine (P < 0.05). The range of average hourly epidural infusion rates was constrained by design to between 3 and 7 ml h-1 but the median of these values was 5 ml h-1 in the diamorphine-saline group and 3.35 ml h-1 in the diamorphine-bupivacaine group (P < 0.02). In patients receiving diamorphine in saline, a median of 6 (range 0-16) of the 24 h reports were of more than mild pain, whereas in the diamorphine-bupivacaine group, the corresponding figures were 2 (range 0-13) (P < 0.02)).(ABSTRACT TRUNCATED AT 250 WORDS)

Inhaled nitric oxide selectively decreases pulmonary vascular resistance without impairing oxygenation during one-lung ventilation in patients undergoing cardiac surgery.

BACKGROUND: Inhaled nitric oxide (NO), an endothelium-derived relaxing factor, is a selective pulmonary vasodilator. The authors investigated whether inhaled NO decreases pulmonary vascular resistance (PVR) while preserving hypoxic pulmonary vasoconstriction and whether it maintains or improves oxygenation in patients during one-lung ventilation. METHODS: In supine cardiac surgical patients with a normal mean pulmonary artery pressure (PAP) (< 25 mmHg, n = 10) or a moderately elevated PAP (25-35 mmHg, n = 10), one-lung ventilation was established with 80% oxygen and 20% nitrogen followed by the same gas mixture containing 20 ppm NO for 6 min. RESULTS: Inhaled NO decreased (P < 0.05) PAP from 30 +/- 2 to 27 +/- 2 mmHg in the patients with moderate pulmonary hypertension. Likewise, PVR decreased (P < 0.05) from 266 +/- 10 to 205 +/- 8 dyn.s.cm-5. The PAP and PVR did not change significantly after NO inhalation in the patients without pulmonary hypertension. All other hemodynamic variables remained unchanged after inhalation of NO in both groups. In the patients with pulmonary hypertension, the PAP and PVR returned to baseline after discontinuation of inhaled NO. Inhaled NO did not significantly change the arterial oxygen tension or venous admixture in either group of patients. Ventilation, airway pressure, tidal volume, and lung compliance also were unaffected by inhaled NO. CONCLUSIONS: This study demonstrates that 20 ppm inhaled NO is a selective pulmonary vasodilator in patients with moderate pulmonary hypertension secondary to cardiac disease who are undergoing one-lung ventilation. In contrast to what would be expected with intravenous vasodilators that inhibit hypoxic pulmonary vasoconstriction, inhaled NO does not increase the venous admixture or impair oxygenation.

Influence of the lumbar interspace chosen for injection on the spread of hyperbaric 0.5% bupivacaine.

Forty patients undergoing elective Caesarean section were allocated randomly to receive hyperbaric 0.5% bupivacaine 2.5 ml at either the L2-3 (n = 20) or L4-5 (n = 20) interspace. Spinal injection was performed with a 29-gauge needle in 38 patients and a 25-gauge needle in two. The onset time to analgesia at T10 and T6 was significantly faster and the level of analgesia at 5 and 10 min after injection significantly higher after injection at L2-3. Maximum height and range of analgesia, the level of analgesia at 15 and 20 min after injection and the number of episodes of hypotension were not significantly different between the two groups. One case of post-dural puncture headache was recorded after use of a 29-gauge needle. Overall, the choice of lumbar interspace influenced the rate of onset of analgesia, but not the final dermatomal level (mean and range) of analgesia achieved.