A comparison of occupational physical activity and sedentary behavior patterns of nurses working 12-h day and night shifts.

Background: Past studies have reported nurses working day shifts engage in high amounts of light and moderate-intensity occupational physical activity. However, little is known regarding how occupational physical activity and sedentary behavior is accumulated within shifts and/or over consecutive shifts. Objective: This study compared occupational physical activity and sedentary behavior patterns of nurses working 12-h. day vs. 12 -h. night shifts. We hypothesized nurses working day shifts would be more active and less sedentary while at work compared to nurses working night shifts and that within shift and between shift differences would emerge. Design: Prospective-cohort study design. Settings: Midwestern trauma one academic medical center medical units (medical surgical, critical care, pediatrics, mother and baby, and other). Participants: A total of 56 registered nurses working 12-h. day and night shifts participated in this study. Methods: Occupational physical activity and sedentary behaviors (e.g., step count, time spent sitting, standing, and walking) were measured for 14 continuous days using the ActivPAL 3 micro activity monitor. Repeated measures mixed-effects regression models were used to examine the effects of shift type, consecutive shifts, and time within a shift on occupational physical activity and sedentary behaviors. Results: Nurses spent more time standing and walking, and less time sitting overall during day shifts compared to night shifts. Nurses walked less during the third consecutive night shift and stood less and sat more during the second and third consecutive night shifts, compared to day shifts. Nurses tended to walk less and sit more during the middle portion of each night shift compared to day shifts. Conclusions: Our findings suggest nurses spend more than half of each shift either standing or walking and that differential patterns of occupational physical activity and sedentary behavior exist between day and night shifts. These findings should be used to inform future interventions designed to advance the health and work performance of nurses.

[Anesthesia for a patient with superior vena cava syndrome]. / Manejo anestésico del síndrome de vena cava superior.

An 18-year-old male with a history of surgery to correct partial drainage of the pulmonary veins had been experiencing symptoms of superior vena cava syndrome (SVCS) for 2 years. Severe obstruction of the superior vena cava where it joined the right atrium became evident upon cardiac catheterization. Because the catheter could not be inserted into the atrium, angioplasty was ruled out and surgery was scheduled. Surgery was performed with the patient in Fowler's position. Electrocardiographic signals, oxygen saturation (pulse oximetry), temperature, bispectral index, diuresis, and invasive arterial pressure were monitored. A large vein was catheterized in the left foot, and a central venous catheter was inserted through the right femoral vein. Balanced anesthesia without nitrous oxide was provided, and a right axillary artery-inferior vena cava cardiopulmonary bypass was established. Once the defect was repaired, central venous pressure became normal and edema in the upper thoracic region decreased. Anesthesia for surgical correction of SVCS carries considerable risk related to such events as difficult intubation and ventilation, bleeding, and vessel collapse. Extreme precautions must be taken and certain procedures followed in order to avoid life-threatening complications.

Manejo anestésico del síndrome de vena cava superior / Anesthesia for a patient with superior vena cava syndrome

Un varón de 18 años, con antecedente de cirugía curativa de un drenaje venoso anómalo parcial de las venas pulmonares, desde hacía 2 años presentaba clínica característica de síndrome de vena cava superior (SVCS). El cateterismo cardíaco evidenció una obstrucción severa de la vena cava superior en la unión con aurícula derecha (AD); dada la imposibilidad del paso de la guía a la AD se desestimó la angioplastia y se programó para intervención quirúrgica. En quirófano se mantuvo en semisedestación, y monitorizó con ECG, pulsioximetría, temperatura, BIS, diuresis, presión arterial invasiva y se canalizó una vía venosa gruesa en miembros inferiores y una vía venosa central a través de la vena femoral derecha. La técnica anestésica fue balanceada sin N2O. Se entró en derivación por arteria axilar derecha y vena cava inferior. Tras la reparación se normalizó la presión venosa central y disminuyó el edema en la región torácica superior. La anestesia para la resolución quirúrgica del SVCS conlleva importantes riesgos, como la dificultad para la intubación y la ventilación, el sangrado y colapso, debiendo ser muy cuidadosa y seguir unas pautas claves para evitar complicaciones que pueden ser mortales (AU)

Taponamiento cardíaco por pseudoaneurisma aórtico fistulizado a ventrículo derecho / Cardiac tamponade due to aortic pseudoaneurysm with right ventricular fistula

Una mujer de 69 años, portadora de una prótesis valvular aórtica por insuficiencia aórtica de origen reumático, presentó un taponamiento cardíaco súbito provocado por la rotura de un pseudoaneurisma de aorta ascendente originada en la sutura de aortotomía realizada 10 años atrás. El taponamiento cursó con síncope, ausencia de pulso central acompañado de parada ventilatoria. El episodio fue presenciado permitiendo iniciar con rapidez las maniobras de reanimación cardiopulmonar hasta la recuperación hemodinámica. Tras la reposición de volumen intravascular y la perfusión de catecolaminas se realizó una ecocardiografía transesofágica que demostró el derrame pericárdico y la existencia de flujo entre la aorta y el ventrículo derecho. La actuación quirúrgica, mediante esternotomía exploradora urgente, reparó la cavidad aneurismática y una rara fístula al ventrículo derecho. La evolución cardiovascular fue satisfactoria, si bien las complicaciones respiratorias prolongaron la estancia hospitalaria por la presencia de hipoxemia grave, derrame pleural y neumonía con cultivos positivos para Pseudomona aeruginosa, Acinetobacter spp y Aspergillus flavus en aspirado traqueal y lavado broncoalveolar. Resaltamos que la inmediata aplicación de las maniobras de reanimación evitó la instauración de fracasos orgánicos y permitió una recuperación global satisfactoria tras la cirugía, a pesar de la presencia inicial de factores pronósticos de elevada mortalidad (AU)

[Cardiac tamponade caused by aortic pseudoaneurysm with fistula in the right ventricle]. / Taponamiento cardíaco por pseudoaneurisma aórtico fistulizado a ventrículo derecho.

A 69-year-old woman, with an aortic replacement valve for rheumatic aortic insufficiency suffered a sudden cardiac tamponade caused by a ruptured pseudoaneurysm of the ascending aorta which had its origin in the suture of the aorta performed 10 years earlier. The cardiac tamponade presented as syncope, absent central pulse, and respiratory failure. Hemodynamic variables recovered with early detection and start of cardiopulmonary resuscitation maneuvers. After fluids were replaced and following catecholamine treatment, a transesophageal echocardiogram revealed a pseudoaneurysm and continuous flow between the aorta and the right ventricle. The aneurysm and an unusual right ventricular fistula were repaired surgically through an emergency exploratory sternotomy. Cardiovascular recovery was satisfactory although hospital discharge was delayed because of pulmonary complications leading to severe hypoxia, pleural effusion, and pneumonia, with tracheal aspirate and bronchoalveolar lavage cultures positive for Pseudomonas aeruginosa, Acinetobacter spp, and Aspergillus flavus. We stress that immediate start of cardiopulmonary resuscitation prevented multiorgan failure and allowed for satisfactory recovery from surgery in spite of the presence of risk factors for mortality.

Cesárea a una paciente con hemoptisis amenazante por carcinoide traqueal / Cesarean section in a patient with massive hemoptysis caused by tracheal carcinoid tumor

A una gestante, de 29 semanas, en situación de insuficiencia respiratoria aguda y hemoptisis amenazante sin etiología conocida se le practicó una cesárea urgente, bajo anestesia general, para evitar las posibles repercusiones fetales durante los episodios de hipoxemia materna. El cuadro se debió a la inesperada localización endotraqueal de un tumor carcinoide, próximo a la carina, que provocaba la obstrucción distal de la traquea y que por su localización y características histológicas pudo ocasionar complicaciones fatales durante las maniobras de intubación endotraqueal. La respuesta oximétrica a las pautas habituales de ventilación mecánica fue insatisfactoria y precisó un manejo cuidadoso que permitió oxigenar suficientemente a la madre y el feto, aunque provocó yatrogenia en la vía aérea, neumotórax y neumomediastino. La aparición de un carcinoide traqueal durante el embarazo es excepcional. Es recomendable la intubación traqueal, o bronquial, bajo visión endoscópica ante cuadros de hemoptisis que, como en este caso, carezcan de diagnóstico etiológico confirmado (AU)

A woman 29 weeks pregnant presented with acute respiratory insufficiency and massive hemoptysis of unknown origin. An emergency cesarean section was performed to avoid hypoxic fetal damage during episodes of maternal hypoxemia. BIeeding was due to an unsuspected endotracheal carcinoid tumor located near the carina. The tumor obstructed the distal portion of the trachea, leading lo life-threatening complications during tracheal intubation because of its histological characteristics and placement. Pulse oximetry response to standard mechanical ventilation was unsatisfactory. Special measures to ventilate mother and fetus were successful, in spite of iatrogenic pneumothorax and pneumomediastinum. We report an exceptional case of tracheal carcinoid tumor during the pregnancy and recommend that tracheal or bronchial intubation take place under fiber optic guidance in cases of hemoptysis with no firm etiologic diagnosis (AU)

[Preoperative fasting regimens and premedication to reduce the risk of pulmonary aspiration]. / Pautas de ayuno preoperatorio y premedicación para reducir el riesgo de aspiración pulmonar.

Our greater understanding of gastric physiology and the epidemiology of Mendelson's syndrome has allowed the traditional guidelines for preoperative fasting (nothing by mouth after midnight or 6 hours before surgery) to be changed, based on the results of many scientific studies. The stomach is not emptied of liquids and solids in the same way, and therefore preoperative fasting should not be the same for both. Human milk leaves the stomach more rapidly than infant formulas, and the emptying of non-human milk is similar to that of solids. Fasting does not guarantee that the stomach will be empty or that the pH of gastric juices will be high; moreover, shortening the preoperative fasting period may bring several advantages for the patient. Factors such as premedication, anxiety, age, certain associated diseases or injuries may or may not influence gastric emptying and/or acidity at the time of anesthesia. We review the literature, including the guidelines on fasting of the American Society of Anesthesiologists for application with healthy patients of all ages in elective procedures, excluding, among others, women in childbirth and patients undergoing emergency surgery.

Pautas de ayuno preoperatorio y premedicación para reducir el riesgo de aspiración pulmonar / Guidelines for preoperative fasting and premedication to reduce the risk of pulmonary aspiration

Gracias a un mejor conocimiento de la fisiología gástrica y de la epidemiología del síndrome de Mendelson y a la experiencia de múltiples trabajos científicos, ha sido posible modificar las pautas tradicionales de ayuno preoperatorio de nada por boca a partir de medianoche o de 6 horas antes de la intervención. Los líquidos y los sólidos no son vaciados igualmente del estómago, luego el ayuno preoperatorio no debería ser el mismo para ambos. La leche materna abandona el estómago más rápidamente que las fórmulas para lactantes, y la leche no humana es similar a los sólidos en cuanto al tiempo de vaciamiento gástrico. Ayunar no garantiza que el estómago estará vacío o que el pH del líquido gástrico será alto, y acortar el tiempo de ayuno preoperatorio puede aportar múltiples ventajas al paciente. Factores como la premedicación, la ansiedad, la edad, algunas patologías asociadas o los traumatismos, pueden o no influir sobre el vaciamiento y/o acidez gástrica en el momento de la anestesia. Presentamos una revisión de la literatura sobre el tema, que incluye la guía de la ASA de ayuno preoperatorio y uso de agentes farmacológicos para reducir el riesgo de aspiración pulmonar, para aplicar a pacientes sanos de todas la edades y procedimientos electivos, excluyendo, entre otros, mujeres de parto y cirugía de urgencia (AU)

[Cesarean section in a patient with threatening hemoptysis caused by tracheal carcinoid]. / Cesárea a una paciente con hemoptisis amenazante por carcinoide traqueal.

A woman 29 weeks pregnant presented with acute respiratory insufficiency and massive hemoptysis of unknown origin. An emergency cesarean section was performed to avoid hypoxic fetal damage during episodes of maternal hypoxemia. Bleeding was due to an unsuspected endotracheal carcinoid tumor located near the carina. The tumor obstructed the distal portion of the trachea, leading to life-threatening complications during tracheal intubation because of its histological characteristics and placement. Pulse oximetry response to standard mechanical ventilation was unsatisfactory. Special measures to ventilate mother and fetus were successful, in spite of iatrogenic pneumothorax and pneumomediastinum. We report an exceptional case of tracheal carcinoid tumor during the pregnancy and recommend that tracheal or bronchial intubation take place under fiber optic guidance in cases of hemoptysis with no firm etiologic diagnosis.

Vena cava superior izquierda persistente: una localización infrecuente del catéter venoso central / Persistent superior vena cava: a rare location of the central venous catheter

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Effect of pulmonary rehabilitation on quality of life in patients with COPD: the use of SF-36 summary scores as outcomes measures.

PURPOSE: Pulmonary rehabilitation (PR) is an accepted therapy for patients with chronic obstructive pulmonary disease (COPD), improving both exercise capacity and quality of life (QOL). Generic measures of QOL have been criticized as being insensitive to detecting the improvement in QOL after PR in contrast to disease-specific instruments. The authors looked at the Medical Outcomes Survey Short Form 36-item questionnaire (SF-36), a generic QOL measure, to detect changes in QOL in COPD patients after completion of PR. METHODS: Patients with COPD who participated in a PR program completed the QOL questionnaire before and after completion of PR. Exercise tolerance was assessed by the 6-minute walking test. Quality of life was assessed by the SF-36; the authors calculated its eight dimensions as well as mental (MCS) and physical (PCS) component summary scores. RESULTS: The patients realized a significant improvement in exercise tolerance; 6-minute walking test distance increased from 470 +/- 104 m (mean +/- standard deviation) to 536 +/- 133 m (P = 0.0006) after PR. Quality of life also improved in nearly all dimensions and in both summary scores; PCS improved from 26.1 +/- 8.0 before PR to 30.5 +/- 9.0 after PR (P = 0.008) and MCS improved from 27.9 +/- 7.0 before PR to 34.1 +/- 5.0 after PR (P = 0.0002). CONCLUSION: The SF-36 and its summary scores are sensitive instruments to detect improvement in QOL in COPD patients after PR.

Non-invasive mechanical ventilation: the benefits of the BiPAP system.

Many of the complications with endotracheal intubation and invasive mechanical ventilation can be avoided with the use of non-invasive mechanical ventilation (NIMV). This technique has been especially successful in treating patients with acute respiratory failure (ARF). NIMV improves gas exchange, avoids complications caused by endotracheal intubation, and allows patients to talk and take medications orally. This article reviews our experiences treating 27 patients with ARF with a BiPAP (bi-level positive airway pressure) ventilator. This is a portable unit which allows for selection of different modes of ventilation and adjustment of inspiratory and expiratory pressures. Non-invasive mechanical ventilation should be considered in patients presenting with ARF who are hemodynamically stable and in whom spontaneous breathing is preserved.

[Tetanus in a drug addict and HIV carrier patient]. / Tétanos en una paciente con farmacodependencia y portadora de VIH.

We report the resuscitation of a woman with a severe tetanic process, dependence on drugs and acquired immunodeficiency syndrome. During her course, the patient presented high hemodynamic lability and supraventricular and ventricular ectopic beats. Impairment of oxygenation and ventilation led to tracheotomy and controlled ventilation for 25 days. Then, intermittent mandatory ventilation was initiated and maintained for 15 days. The patient was extubated. Partial pressure of oxygen in the arterial blood was 73 mmHg and PaO2/FIO2 was 183; she had a sepsis of pulmonary origin. High doses of sedative and analgesic agents (diazepam, 40 mg/hour and morphine, 2.5 mg/hour) were required. We believe the acme of the process was on days 13 and 15 during her stay at the resuscitation unit. We conclude that neither the symptomatology nor her course nor the treatment differed from other severe forms of tetanus treated by us. The infective process did not fit into what would be expected in an immunodeficient background.

[Prevalence of HIV antibody carriers in patients assisted in the recovery room]. / Prevalencia de portadores de anticuerpos VIH en pacientes asistidos en reanimación.

A study has been performed on 200 patients at the Recovery Department of our hospital during 1987. This study was carried out in order to determine patients with human immunodeficiency virus (HIV) antibody. This group was randomized and consisted of 154 men and 46 women, with an average age of 35.6 +/- 3.9, a total weight of 68 +/- 6 kg and a height of 1.69 +/- 0.2 m. The day entered at the Recovery Department we assessed the following parameters: a) addiction to drugs by parenteral way; b) bleeding; c) invasive procedures; d) etiology, and e) blood samples were drawn for plasma antibody to HIV. We detected five patients (2.5%) with antibody anti-HIV and all of these patients were male and they were aged in 20-39 years old. We noticed a close relation between addiction to drugs and HIV (p less than 0.001), nevertheless no relation has been found between invasive procedures, bleeding, etiology and antibody to HIV. We conclude that the number of patients that we detected with antibody from the HIV is similar to those found by other studies that has been carried out in emergency situation, but greater than those found in the screening of the general population.

[Effects of positive end expiratory pressure on oxygen transport]. / Efectos de la presión positiva telespiratoria sobre el transporte de oxígeno.

Fifteen patients admitted at the ICU of our hospital suffering from respiratory failure and submitted to mechanical ventilation were included in a study upon the influence of positive end expiratory pressure (PEEP) on oxygen transport. When the PaO2/FiO2 index was less than 300, 200, and 150, PEEP of +5, +10, and +15 cmH2O respectively was introduced. A Swan-Ganz catheter in the pulmonary artery and a catheter in a radial artery were inserted with the aim to obtain mixed venous blood samples and determine cardiac output, and vascular pulmonary resistances for each PEEP value. When PEEP increased from 5 cmH2O to 15 cmH2O, oxygen supply decreased a 12.4% (p less than 0.05), oxygen extraction from the tissues increased a 21.4% (p less than 0.025) and cardiac output decreased a 7.9% (p less than 0.02) while vascular pulmonary resistances increased a 6.6% (p = NS). We conclude that a PEEP of 5 cmH2O impairs tissue oxygenation when compared with PEEP of 5 cmH2O and that oxygen supply decrease with cardiac output.

[Correlation between the concentration of plasma lactic acid and other cardiorespiratory parameters in hypoxic patients]. / Correlación entre la concentración plasmática de ácido láctico y otros parámetros cardiorrespiratorios en pacientes hipóxicos.

We carried out a study in a group of 20 patients; this group was made up of 16 women and 4 men. All patients were under controlled ventilation and the relation between partial pressure of oxygen and the fraction of oxygen to be inhaled was equal or less than 150. A Swan-Ganz catheter was implanted in the pulmonary artery and another catheter in a radial artery. We determined the cardiac output, oxygen saturation in mixed venous blood and blood levels of lactic acid. We calculated the oxygen supply, oxygen consumption and tissue extraction of oxygen. We could to point out that there is a positive and significative correlation between lactic acid blood levels and cardiac output, oxygen consumption and oxygen extraction (p less than 0.001); negative and significative between acid blood levels and oxygen supply (p less than 0.025) and oxygen saturation in mixed venous blood (p less than 0.001). Finally we observed that when the lactic acid blood levels went up, decrease in oxygen saturation in mixed venous blood is more acute that increase in cardiac output.