How an audit of epidural patients in a community hospital setting resulted in the development of a formal acute pain management service.

PURPOSE: To describe the results of an audit of patients who received epidural analgesics postoperatively and the subsequent development of a formal acute pain management service in a community hospital. METHODS: To understand how epidural analgesia was being used to treat postoperative pain at the Peterborough Regional Health Centre, Peterborough, Ontario, a retrospective chart review was performed. Audits were performed on 178 patients who had received epidural analgesia postoperatively from October 1994 to May 1995. Data pertaining to demographics, epidural analgesia, pain scores and side effects were collected. RESULTS: Sixty-one per cent of patients received bupivacaine/ fentanyl infusions, and 39% received epidural morphine boluses. More than 60% of patients reported no pain postoperatively. Patients who received bupivacaine/fentanyl were more likely than those who received epidural morphine to also receive co-analgesia and transitional analgesia. Patients who received epidural morphine were more likely than those who received bupivacaine fentanyl to experience respiratory depression, hypotension and pruritus. Patients were followed by the anesthesiologist who provided the anesthetic. Anesthesiologists practised independently, and formal policies and procedures did not exist. CONCLUSIONS: As a result of the audit, an acute pain management service was developed. This included a team that did daily rounds and consisted of a nurse clinician and an anesthesiologist who was assigned to the service on a weekly basis. A committee was created, and formalized policies and procedures were established. Standardized order sheets, data sheets and a computerized database were developed. Reports for administrative and quality improvement purposes were generated monthly. Education programs were developed. Co-analgesia and transitional analgesia are now part of routine care, and epidural catheter placement close to the site of incision is encouraged. A postoperative nausea and vomiting algorithm, and a treatment regimen for pruritus have also been implemented.

Mueller matrix dual-rotating retarder polarimeter.

A computer-controlled Mueller matrix polarimeter with dual rotating retarders is described. Bulk properties of optical materials are determined by controlling the input-polarization state and measuring the output-polarization state. The Mueller matrix of a sample is obtained from polarimetric measurements, and polarization properties, i.e., diattenuation and retardance as well as depolarization, are extracted from the Mueller matrix. Further, fundamental electro- and magneto-optical material properties such as the electro-optical tensor coefficients may be obtained from Mueller matrices measured with applied fields. The polarimeter is currently configured to operate over the 3- to 12-microm spectral region.

A survey of resuscitation training in Canadian undergraduate medical programs.

OBJECTIVES: To establish a national profile of undergraduate training in resuscitation at Canadian medical schools, to compare the resuscitation training programs of the schools and to determine the cost of teaching seven resuscitation courses. DESIGN: Mail survey in 1989 and follow-up telephone interviews in 1991 to update and verify the information. SUBJECTS: The undergraduate deans of the 16 Canadian medical schools. INTERVENTION: The mail survey asked five questions: (a) Is completion of a standard first aid or cardiopulmonary resuscitation (CPR) course a requirement for admission to medical school? (b) Are these courses and those in basic and advanced cardiac, trauma and neurologic life support for children and adults provided to undergraduate students? (c) During which undergraduate year are these courses offered? (d) Is their successful completion required for graduation? and (e) Who funds the training courses? RESULTS: The medical schools placed emphasis on the seven courses differently. More than half the schools required the completion of courses before admission or taught some courses but did not require the completion of the courses for graduation. On average, fewer than three of the seven courses were taught, and the completion of fewer than two was required for graduation. About half of the courses were funded by the universities. The annual projected maximum cost of teaching the seven courses was $1790 per medical student. CONCLUSION: The seven resuscitation courses have not been fully implemented at the undergraduate level in Canadian medical schools.

Treatment of radiation or cyclophosphamide induced hemorrhagic cystitis using conjugated estrogen.

Five patients with severe hemorrhagic cystitis induced by radiation and/or cyclophosphamide were systematically treated with conjugated estrogen. Two patients received conjugated estrogen twice each day (1 mg. per kg.) intravenously, followed on day 3 and thereafter by 5 mg. per day orally. Hematuria decreased markedly 6 to 8 hours after the initial dose and urine color became light yellow within 1 to 3 days. The other 3 patients received 5 mg. conjugated estrogen per day orally and urine color became clear within 4 to 7 days. Hematuria did not recur during 12 to 22 months in 4 patients who received daily conjugated estrogen (1.25 mg.). However, transient episodes of mild hematuria persisted in 1 patient during the 3-month followup despite a higher dose of conjugated estrogen (10 mg. per day). Complications, including thromboembolism and other side effects associated with conjugated estrogen, were not observed in these patients. We postulate that conjugated estrogen controls hematuria in hemorrhagic cystitis by decreasing the fragility of the mucosal microvasculature of the bladder.

Effectiveness of a non-amalgamated ambulance service on out-of-hospital sudden cardiac death.

Many Canadian communities rely on non-amalgamated ambulance services to respond to out-of-hospital sudden cardiac arrest victims. These pre-hospital care systems lack a central coordinating and dispatching facility, a publicized, easily-accessible telephone number (911) and vehicles equipped with monitor-defibrillators, and are generally staffed by personnel trained only in basic cardiac life support. To receive definitive care, the victim of a cardiac arrest in these communities must be successfully transported to a hospital. In the study area, 114 victims of out-of-hospital sudden death were identified in a community served by a non-amalgamated ambulance service over a 12-month period for an annual incidence rate of 6.1/10,000. The mean age was 64 +/- 11.5 years with the majority (78%) of arrests occurring in the home. The collapse to CPR time was 10.2 +/- 6.7 minutes and the ambulance response time was 5.2 +/- 3.9 minutes. The estimated time from collapse to the victims receiving definitive care was 36.4 +/- 19.1 minutes. Overall, only 8 victims (8.8%) survived and were discharged from hospital. Based on the data presented, survival rate for cardiac arrest victims treated by a non-amalgamated ambulance system are inferior to those reported for pre-hospital care services capable of providing advanced cardiac life support at the scene. Whether all of the components of an established paramedic program are required to improve survival rates in individual communities remains undetermined.

Canadian ground ambulance services: provincial funding and standards for equipment and training.

There is an increasing demand for improved, up-to-date training and equipment for ground ambulance services across Canada. This paper presents the results of a survey of ambulance operations and their funding by the provinces, as well as a comparison of provincial legislation and recommendations on standards for equipment and the training of ambulance personnel. The training standards were found to be very diverse, and the legislated or recommended equipment standards did not meet those of the American College of Surgeons committee on trauma (ACSCT). The cost of ambulance services per capita and the cost to the user of an average 43-km run varied widely between the provinces. There was no correlation between the second cost and how well the province met the ACSCT's equipment standards.

Emergency therapy of asthma: comparison of the acute effects of parenteral and inhaled sympathomimetics and infused aminophylline.

Forty-eight patients who presented with acute episodes of asthma were randomized to treatment with subcutaneously administered epinephrine, inhaled isoproterenol, or intravenously administered aminophylline. The patients' couses were followed clinically and with spirometry. Although there were no significant differences between the groups before treatment for any measured variable, at the end of 1 hour, the mean improvement inforced expiratory volume in one second (FEV1) was significantly greater for patients treated with epinephrine (0.76 L) or nebulized isoproterenol (0.79 L) than for those given aminophylline (0.23 L). Similarly, the mean duration of therapy required before discharge from the emergency room was significantly longer for patients receiving aminophylline (5.4 h) than for patients treated with either epinephrine (3.5 h) or isisoproeternol (3.0 h). There was no significant differences between the effects of the 2 beta agonists. These results demonstrated that short-acting sympathomimtic agents produce more rapid and potent bronchodilatation in acutely ill asthmatics than that provided by intravenously administered methylxanthines, and that there are no disadvantages to using an inhaled beta agonist rather than one administered parenterally.

Clinically silent pericardial effusions in patients on long-term hemodialysis. Pericardial effusions in hemodialysis.

The danger of cardiac tamponade occurring when pericarditis is accompanied by pericardial effusion, as opposed merely to the presence of a friction rub without effusion, has been unclear. Forty patients on hemodialysis were studied by physical examination, chest x-ray film, and echocardiography for evidence of pericarditis and pericardial effusion. Only two patients developed a friction rub during the study and were placed on regional heparin. Ten of 11 patients who were positive on echocardiogram for pericardial effusion had unremarkable physical examinations. These 11 patients had cardiomegaly as noted on chest x-ray examination. Eighteen of 25 patients without effusion also had cardiomegaly on chest x-ray film. No patient remaining on systemic heparin and having a pericardial effusion developed cardiovascular complications during hemodialysis. This study suggests that while many patients on longterm hemodialysis have pericardial effusion undiagnosed on the basis of physical examination, but noted on echocardiogram, special precautions to prevent tamponade during hemodialysis are not necessary. Also, posterior-anterior chest x-ray film showing a normal-sized heart will usually exclude significant pericardial effusion.

Erythrocytic aminolevulinic acid dehydratase (ALAD) activity as a biologic parameter for determining exposures to lead.

The results of this work demonstrate that a significant exposure to one of several lead compounds can be detected by the ALAD test without a concomitant rapid increase in blood lead concentration. Use of the ALAD test may effectively demonstrate the occurrence of excessive exposure at an earlier time than possible by the accepted blood or urine lead concentration measures. By comparing "early" and "steady state" values of PbB and ALAD, it was possible to derive an equation which can be used to determine an ultimate (steady state) value of PbB from an early (short-term) ALAD measurement. Re-examination of workplace atmospheres would be indicated by findings of depressed ALAD activity in the absence of elevated blood lead values. This could occur when sporadic lead exposures are occurring or upon initiation of a period of continuing elevated exposures. Thus, corrective action can be requested and taken prior to the point at which an excessive blood lead value would be found. Further studies of industrial groups are indicated to confirm the usefulness of the test for the purposes suggested.

Biochemical and toxicological response of infant baboons to lead driers in paint.

In an effort to define the toxicology and disposition of lead compounds that presently exist in paint (i.e., organic driers), a controlled dose feeding study was initiated early this year with the use of 28 infant baboons as experimental animals. The infant baboon, established as a metabolic model for a child ingesting lead, will be used to determine the adequacy of present as well as recently recommended limitations for lead in paint to assure protection from this potential source of lead exposure. To accomplish this goal, research has been designed to determine basic dose-response relationships in animals ingesting constant daily doses of a dried paint, a lead octoate drier, and lead acetate. Doses for these compounds have been chosen to cover a broad range of concentrations including that recommended by the American Academy of Pediatrics from the maximum daily permissible lead ingestion, and associated estimates of paint intake by children with pica. PARAMETERS OF METABOLIC RESPONSE FOR EACH LEAD COMPOUND, INCLUDE: general clinical surveillance, lead concentrations in blood, urine and feces, erythrocytic delta-aminolevulinic acid dehydratase and free erythrocytic porphyrin. The response of several of these measures of lead exposure as a function of time will be discussed for each compound at the several dose levels administered.