Nurses' knowledge and application of evidence-based guidelines for preventing ventilator-associated pneumonia.

AIM: The aim of the study was to evaluate the nurses' knowledge and to highlight the causes that hinder guidelines implementation. EXPERIMENTAL DESIGN: descriptive study. SETTING AND PARTICIPANTS: 106 nurses working in the ICUs of a major Italian hospital of national importance. INTERVENTION: administration of a questionnaire listing 21 non-pharmacological strategies considered the most useful in the literature. RESULTS: Eighty-four nurses responded to the questionnaire. Only 19 (22.6%) declared that their knowledge of ventilation associated pneumonia (VAP) and the strategies used to prevent it were satisfactory, whereas 46 (54.8%) declared that they were poorly informed; 68 nurses (80.9%) said that they applied one or more strategies, and 15 (17.9%) that they applied none. The reasons given for not applying the strategies were: method not foreseen in Department protocols (31.5%), lack of the necessary resources (14.3%), disagreement with the method (3.2%), high costs (2.6%), the possibility of causing discomfort (1%) or side effects (0.6%). CONCLUSIONS: In our experience, VAP preventive strategies are widely applied by nurses, but not in a responsible and informed manner. It is important to ensure that nurses receive continuous training and are involved in drawing up and updating Departmental protocols and guidelines for care and behaviour.

Pancreas transplantation: problems and prospects in intensive care units.

AIM: The aim of this study is to describe personal experience in the intensive management of patients with severe diabetes undergoing pancreas transplantation. METHODS: Clinical records of subjects consecutively undergoing an isolated or combined pancreas transplant have been examinated. RESULTS: During the considered period, 10 patients received an isolated pancreas transplant and 43 a simultaneous kidney-pancreas transplantation (SPKT), including 6 using a kidney from a living donor. The mean stay in the Intensive Care Unit (ICU) was 4.7 days: 52 patients (98.2%) were transferred to the Surgical Department, whereas one (1.8%) belonging to the SPKT group died with a non-functioning graft. Ten patients (18.6%) were re-admitted because of the onset of late complications, including one SPKT who died of sudden cardiac death with functioning grafts. Arterial hypertension appeared in 51% of the recipients, and 5.6% experienced at least one hypotensive episode. Cardiac rhythm alterations were diagnosed in 5 subjects (9.4%), and myocardial ischemia in 9 (17%). CONCLUSIONS: Pancreas transplantation is a therapeutic option that can improve patients' quality of life by also slowing down the evolution of diabetes; however, it is important to bear in mind the associated risks. The best results are obtained in patients in whom the disease has not already seriously impaired the function of the various target organs.

Cardiac evaluation for simultaneous pancreas-kidney transplantation and incidence of cardiac perioperative complications: preliminary study.

Type I diabetes mellitus (IDDM) is associated with an increased cardiovascular risk, and eligibility protocols for simultaneous pancreas-kidney transplantation (SPKT) are consequently accurate for preoperative cardiovascular assessment. According to our algorithm, coronary angiography in SPKT candidates is indicated for patients not only experiencing previous cardiac events or symptoms, but also those with long-standing diabetes (more than 25 years) and/or age over 45 years. Furthermore, a basal transthoracic echocardiographic exam (TTE) is performed to assess cardiac volumes, left ventricular mass, systolic function, and kinesis. The aims of this study were to evaluate perioperative cardiac morbidity and mortality in 18 SPKT-eligible patients, divided into two groups on the basis of the presence/absence of angiographically evident coronary artery disease (CAD), as well as to assess the impact of left ventricular hypertrophy (LVH) on cardiac complications. Cardiac intraoperative morbidity and mortality and postoperative mortality and major morbidity were absent; minor cardiac morbidity consisted only of silent ischemic ECG alterations, without significant differences between groups, although the incidence seemed to be higher in the CAD-positive population. LVH detected preoperatively by TTE exam also failed to correlate with the incidence of such complications. Selection of SPKT candidates by coronary angiography may have positive effects on perioperative cardiac morbidity and mortality. A larger sample size is needed to give the study statistical power. Medium- and long-term follow-up studies are warranted to evaluate the effects of preoperative selection on survival rates.

Control of acute pain after major abdominal surgery in 585 patients given tramadol and ketorolac by intravenous infusion.

The aim of this study was to assess the efficacy and safety of postoperative pain relief using tramadol and ketorolac in continuous intravenous infusion. The 585 patients included in the study underwent major surgery according to a protocol involving the parenteral administration of 100 mg tramadol approximately 40 min before the end of surgery. This was followed by the continuous intravenous infusion of 600 mg tramadol and 180 mg ketorolac diluted with physiological solution to a total volume of 96 ml. Delivery was carried out using an elastomeric pump or a syringe pump and administered over a 48-hour period at a constant rate of 2 ml/h. Any further doses consisted of 100 mg tramadol up to a maximum of 300 mg over a 24-h period. Pain was assessed on a verbal numeric scale (VNS). For each patient the intensity of pain was assessed both at rest and on movement (coughing, deep breathing, movement of lower limbs). At the scheduled times (T0-T72, every 6 h), the following parameters were evaluated: hemodynamic stability; respiratory function; the appearance of any side effects; the level of sedation; and the need for any further doses of analgesic. The analysis of the data obtained showed the good quality of postoperative pain relief achieved: pain intensity at rest was, on average, always below VNS level 3, while during movement it always had an average VNS level of 3-4. The only side effects found with any frequency were nausea (22.6%) and vomiting (8.5%); hemodynamic and respiratory parameters remained stable. The method adopted was of limited cost and was well accepted by both patients and staff. On the basis of the data obtained, it is possible to affirm that the post-operative pain protocol proposed is effective, safe, without significant side effects, and of limited cost. Therefore, it is the first choice protocol for our operating unit after major abdominal surgery.

[Early tracheal extubation ofter orthotopic liver transplantation]. / Estubazione tracheale precoce dopo trapianto ortotopico di fegato.

BACKGROUND: To evaluate an early tracheal extubation feasibility in previously unselected orthotopic liver transplantation (OLT) patients. DESIGN: retrospective analysis. SETTING: National Health System Intensive Care Unit. PATIENTS: all the patients who underwent OLT during 1997 at our institution were evaluated. The anesthestic management was the same for all of them and a veno-venous bypass was always used during the anhepatic phase. Tracheal extubation was performed when metabolic and haemodynamic parameters were stable; the following extubation criteria were also considered: no residual curarization, normocarbia, ability to keep the airway patent, good respiratory drive, ability to carry out simple orders. No pre- or intraoperative criteria, as previously reported in the literature for OLT patients, were followed to perform tracheal extubation in the postoperative period. RESULTS: During 1997 forty OLTs were performed in 38 patients. Twenty-eight patients were successfully extubated within 3 hours from the end of the surgical procedure; three patients were extubated within 6 hours and three within 24 hours from the end of surgery; four patients needed more then 24 hours of ventilation or were impossible to wean. No patient was re-intubated. A correlation appeared evident between early extubation and the amount of the transfused red cell units, kidneys and lungs function, cardiovascular efficiency; no correlation emerged with patients age or the pre-transplant severity of the hepatic disease. CONCLUSIONS: To perform a safe early tracheal extubation in previously unselected OLT patients is feasible and it can be carried out in a wide number of them. The previously reported timing characterizing as "early" a tracheal extubation should be moved from 8 to 3 hours.

Dehydration in the elderly: strategies for prevention and management.

Dehydration is the most common fluid and electrolyte disturbance among the elderly population today. It is defined as a state of diminished total body water content and is associated with high morbidity and mortality rates. Such health outcomes highlight the urgent need for effective screening and prevention in the primary care arena. Myriad predisposing factors make the elderly more vulnerable to dehydration. On physical examination, many of the classic signs of dehydration may be present among normally hydrated older populations, highlighting the need for an age-appropriate assessment. In this regard, health care practitioners with a working knowledge of pertinent underlying pathophysiology and relevant predisposing factors will more readily identify high-risk clients and implement successful preventative strategies. Prompt intervention can dramatically affect health care outcomes among high-risk populations and go a long way in providing high-quality, cost-effective health care.

[Axillary block of the brachial plexus and peripheral paresthesia: a technique to refuse at the outset? Clinical experience]. / Il blocco del Plesso Brachiale per via ascellare e ricerca delle parestesie periferiche: una tecnica da rifiutare in partenza? Esperienza clinica.

The axillary brachial plexus blockade by means of stimulating paresthesia and single local anesthetic injection was examined during one year long routine activity in a plastic surgery division. Two-hundred-five blocks were performed evaluating the success percentage, the execution mean time, a sedation utility and the sequelae incidence. The technique was confirmed usefull, easy to perform, well tolerated from the patients. The technique validity, versus the suspiciousness considered by several Authors, is confirmed.