Unknown Pseudocholinesterase Deficiency in a Patient Undergoing TIVA with Planned Motor Evoked Potential Monitoring: A Case Report.

Pseudocholinesterase abnormalities are a genetic cause of aberrant metabolism of the depolarizing muscle relaxant succinylcholine. This article examines a case where succinylcholine was chosen to facilitate intubation due to its ultra short duration and the request of the surgeon to monitor motor evoked potentials. Following succinylcholine administration the neurophysiologist was unable to obtain motor evoked potentials. This case study highlights the intraoperative and postoperative management of an elderly patient with an unknown pseudocholinesterase deficiency.

Conventional versus neutral positioning in central neurological disease: a multicenter randomized controlled trial.

BACKGROUND: Severe immobility due to lesions of the brain necessitates therapeutic positioning over the long term. There is little scientific evidence concerning the efficacy of different positioning methods. This clinical trial compares the effects of conventional positioning (CON) with those of positioning in neutral (LiN). METHODS: A prospective, multicenter, investigator-blinded, randomized, controlled trial was performed on a total of 218 non-ambulatory patients (underlying disease: stroke, 141 patients; hypoxic brain damage, 28; traumatic brain injury, 20; other, 29). The subjects were randomly assigned to either LiN (105 patients) or CON (113 patients) and stratified within each of these two positioning concepts to five different positions. They remained in the assigned positions for two hours. The primary endpoint was change in the passive range of motion (PROM) of the hip joints. Secondary endpoints were change in the PROM of the shoulder joints and patient comfort. RESULTS: Patients in the LiN group had a significantly better PROM of the hips after positioning than those in the CON group (difference, 12.84°; p<0.001; 95% confidence interval [CI], 5.72°-19.96°). The same was true for PROM of shoulder flexion (11.85°; p<0.001; 95% CI, 4.50°-19.19°) and external rotation (7.08°; p<0.001; 95% CI: 2.70°-11.47°). 81% of patients in the LiN group reported their comfort level as good, compared to only 38% in the CON group (p<0.001). CONCLUSION: Positioning severely immobilized patients in LiN for two hours improved passive hip and shoulder mobility and patient comfort compared to conventional positioning. Further studies are needed to determine whether prolonged LiN positioning might improve rehabilitation and quality of life, prevent pressure sores, or ease nursing care.

SAFE Medication Management for Patients with Physical Impairments of Stroke, Part One.

PURPOSE: This article focuses on the extensive impairments of stroke and their influence on medication management. The impairments of motor skills due to paralysis-loss of mobility and balance, lack of hand-to-mouth coordination, and difficulty swallowing-are discussed. A future article will discuss sensory impairments of vision, hearing, cognition, comprehension, communication, and emotional disorders and how these impairments influence medication management. DESIGN: Each of the impairments are presented and discussed, and possible interventions are proposed. Every patient is an individual and requires variable care plans. METHOD: Intervention strategies that include tools for patient assessment, practice tips, and devices available to assist the patient and family in safe medication management are presented. FINDINGS: Patient outcomes and successes vary, but the strategies outlined will return the patient to as close to previous capabilities as possible. CONCLUSION AND CLINICAL RELEVANCE: Teaching SAFE (Systematic, Accurate, Functional, Effective) medication management to the patient, family, and caregivers will increase medication safety and decrease the number of adverse effects. The rehabilitation nurse is charged with evaluating the patients' needs and developing strategies to assist them to manage their medications.

The body trap.

Locked-in syndrome is a devastating result of brain injury. It is rare and specialist care is crucial to help patients have a meaningful life.

Prolonged paralysis and apnea after receiving a neuromuscular blocking agent: what nurses should know.

After receiving mivacurium, a short-acting neuromuscular blocking agent used for intubation before surgery, a patient experienced prolonged paralysis and prolonged apnea that required ventilator support. Although this complication is rare, all critical care nurses should be aware of it so they can be competent in managing and providing holistic and comprehensive nursing care to the patient and the patient's family. Although this complication has been documented in the anesthesia literature, it has received little mention in critical care nursing journals.

Prolonged paralysis related to mivacurium: a case study.

Pseudocholinesterase deficiency is usually identified when an anesthetized patient has prolonged paralysis after receiving neuromuscular blocking agents dependent on pseudocholinesterase enzymes for hydrolysis. This rare complication, most frequently associated with succinylcholine, can occur with the use of mivacurium, one of the newer nondepolarizing muscle relaxants also hydrolyzed by pseudocholinesterase. Prolonged paralysis has occurred 3 times in the past 2 years at this pediatric hospital after administration of mivacurium. The following case study describes causality and interventions for a patient with prolonged paralysis after receiving mivacurium.

A model for assessing learning readiness for self-direction of care in individuals with spinal cord injuries: a qualitative study.

Methods are needed for assessing and facilitating learning readiness for self-direction of care of individuals with spinal cord injury (SCI). With declining length of stay, self-direction of care is a major learning task for patients with permanent disability. A retrospective study of secondary data gathered from 30 nursing records was used to develop the Rehabilitation Learning Readiness Model for Spinal Cord Injury. The framework evolved from Orem's (1995) self-care deficit nursing theory and two self-directed adult learning models (Grow, 1991; Pratt, 1988). Using qualitative methods of analysis, five stages of learning readiness behavior (Dependent, Involvement, Engagement, Self-Initiation, and Self-Direction) and five corresponding nursing roles (Authority, Guide, Motivator, Mentor, and Consultant), emerged. Expert nurses corroborated the clinical significance of the model. The model is proposed as a conceptual paradigm for use by nurses to assess learning readiness challenges experienced by patients with SCI and to improve teaching roles and practices.

West Nile virus--the eye of the storm: a case study.

West Nile virus (WNV) is an arbovirus that emerged in the United States in 1999 and is migrating westward across the country. It occurs in the late summer or fall when there is an abundance of mosquitoes. Symptoms develop 3-14 days after an infected mosquito bites a person. Most WNV infections are asymptomatic or produce mild symptoms; however, 1 in 150 cases is severe with significant neurological deficits. The virus can attack the anterior horn cells, causing acute flaccid paralysis resulting in a poliomyelitis-like syndrome. Diagnosis is based on history, clinical presentation, and laboratory tests. In the late summer or fall, WNV infections should be suspected in persons with unexplained encephalitis, meningitis, or flaccid paralysis. There is no definitive medical treatment for WNV. Preventive measures are the most effective means to combat the disease.

Nursing judgment: the key to pain assessment in critically ill children.

Pain assessment in critically ill children emphasizes the need to place expert nursing judgment prominently on the list of assessment strategies. The expert nurse is uniquely qualified to identify subtle responses to physiologic and environmental stimuli and to titrate analgesics and other pain relief strategies accordingly. While it is challenging to assess pain with limited verbal and behavioral cues, pain assessment is not only possible, but even more critical, when the available cues are subtle and can be easily overlooked or attributed to other causes. The question that sparked these comments reflects the passion I so often witness in intensive care nurses committed to eliminating pain as an emotional and physiological stressor for these vulnerable children. When that passion is empowered by evidence-based nursing judgment, children receive the best possible care.

[Analysis of relative factors on paralytic patients with pressure sore complications].

In this study, risk factors for bedsore were studied on 100 paralytic patients with neurologic diseases. The patient's assessment scores based on the risk factors for bedsore were evaluated and analyzed. According to the result, the critical point of assessment score for bedsore was established. The patient will be put into the high risk group of bedsore if his/her assessment score is higher than the critical point and special nursing intervention will be given.

Monitoring and preventive care of the paralyzed patient in respiratory failure.

It is our belief, based on our experience with the Dulin-Williams protocol, that the safe use of a continuous-infusion NMBA is optimized when a constant current peripheral nerve stimulator is used to monitor the depth of neuromuscular blockade. This protocol should facilitate the chance of adverse effects, thereby increasing the quality of patient care and outcomes within the critical care setting.