Current management of patients taking herbal medicines: a survey of anaesthetic practice in the UK.

BACKGROUND AND OBJECTIVES: Increasing numbers of patients taking herbal medicine products are presenting for anaesthesia and surgery. Anaesthetists need to consider the perioperative implications of herbal medicines and should, therefore, have some knowledge of this subject. METHODS: A postal questionnaire survey was sent to a random 5% of practising members of the Association of Anaesthetists of Great Britain and Ireland residing in the UK, to identify attitudes, practice and knowledge regarding herbal medicines. RESULTS: From 341 questionnaires there were 221 replies, a 65% response rate. Ninety per cent stated that they seldom or never asked patients about herbal medicine usage, yet 65% felt that there could be potentially harmful effects of herbal medicines in the perioperative period. There was a very poor level of knowledge with respect to the current management of 10 well-known herbal medicines. However, 75% agreed that information about perioperative usage of herbal medicines is important, and 77% felt that herbal medicines should be in the undergraduate medical curriculum. Reading was the usual source of herbal medicine product information. Most (82%) felt their knowledge of herbal medicine products and the implications in patient care were inadequate. CONCLUSIONS: This sample of anaesthetists require education on herbal medicines. Suggestions for remedial action are given.

Fundal pressure during the second stage of labor.

The role of fundal pressure during the second stage of labor is controversial and can result in clinical disagreements between nurses and physicians. Clearly the time for resolution of this issue is not when there is a physician request at the bedside in front of the patient. A prospectively agreed upon plan specifying how this request will be addressed is ideal. In order to develop this plan, risks, benefits, and alternative approaches to the use of fundal pressure should be reviewed by an interdisciplinary perinatal team. Much of the data about maternal-fetal injuries related to fundal pressure are not published for medical-legal reasons; however, anecdotal reports suggest that these risks exist. Unfortunately, it is therefore difficult to quantify with any degree of accuracy the exact number of maternal-fetal injuries that are directly related to use of fundal pressure to shorten an otherwise normal second stage of labor. However, there is enough evidence to suggest that if injury does occur when fundal pressure is used, there are significant medical-legal implications for the health care providers involved. This article will review what is currently known about fundal pressure including risks, benefits, and alternative approaches. In that context, suggestions will be offered for a safe approach to managing the second stage of labor.

A critical evaluation of the past 25 years of perinatal nursing practice: opportunities for improvement.

Changes in perinatal nursing over the past 25 years have been abundant. Nursing advocacy has contributed to the introduction of innovations such as single-room maternity care and family-centered care, and to the end of restrictive practices such as the use of hand and leg restraints during birth, routine use of episiotomy, and routine general anesthesia for normal births. Perinatal nursing involves complex clinical interventions, intensive patient and family education, empathetic support and evaluation of family dynamics, and a wide range of opportunities to make a difference in the lives of mothers, babies, and families. The strengths and weaknesses of perinatal nursing practice at the beginning of the new century are chronicled, and suggestions for improvements are made.

Risk management and electronic fetal monitoring: decreasing risk of adverse outcomes and liability exposure.

Electronic fetal monitoring (EFM) has the potential to promote fetal health and improve neonatal status at birth; however, EFM as a stand-alone tool is ineffective in avoiding preventable adverse outcomes. It is effective only when used in accordance with published standards and guidelines by professionals skilled in correct interpretation and when appropriate timely intervention is based on that interpretation. Interpretation and intervention are best accomplished as a collaborative perinatal team rather than individual activity. Only in these circumstances can EFM optimally contribute to fetal well-being and subsequent neonatal health. Risk management strategies to decrease potential liability are presented that can be accomplished with careful planning and collaboration among perinatal team members.

Shoulder dystocia. Nursing interventions and risk-management strategies.

Shoulder dystocia is unpredictable; however, once identified there are reasonable steps that perinatal providers will be expected to take to attempt to dislodge the impacted shoulder. Be aware of these interventions and have a plan for what to do should dystocia occur. Stay calm and help the woman and physician or CNM through the crisis. Call for additional help as appropriate. Provide emotional support to the woman and her family. Ensure that the medical record reflects the events as accurately as possible. If an injury results, the nurse can then be sure that the team did the best they could to intervene during the emergency.

High reliability perinatal units: an approach to the prevention of patient injury and medical malpractice claims.

Perinatal units differ in their ability to prevent patient injury and medical malpractice litigation. Obstetrical units with favorable performance are distinguished by common organizational and clinical features. Organizationally, they resemble what behavioral scientists define as "high-reliability organizations" (i.e., the ability to operate technologically complex systems essentially without error over long periods). Clinically, practices are based on nationally recognized guidelines and/or an operational philosophy of "safety first." These organizational and clinical features are described so that physicians, nurses, and administrators might view their own clinical environments in the context of this perspective.

Strategies for developing an evidence-based approach to perinatal care.

Today more than ever perinatal care providers must work together to develop practice patterns that will contribute to the best possible outcomes for women and newborns. Financial and human resource allocation are under intense scrutiny in most hospitals. Although the fundamental goals of health care institutions are to maximize health while conserving resources, unfortunately, these goals are often in conflict. Perinatal practice must be based on the combined weight of all available evidence rather than "the way we've always done it." Health care institutions that continue doing business as usual are not likely to survive. Using both clinical and financial data, routine perinatal practices without a scientific basis that establish a contribution to improved outcomes can be reevaluated, while practices that have been shown to be beneficial can be enhanced and supported. The first step in developing a standards and evidence-based approach to perinatal care is the establishment of a practice committee in which communication is open and direct and there exists a respect for the contributions of members from all related disciplines. True collaboration and communication between physicians and nurses is the foundation for establishing and implementing best practices. Fortunately, a growing body of research regarding the pros and cons of various perinatal practices is beginning to emerge; this research can be used by knowledgeable, informed perinatal professionals to advocate for a clinically appropriate approach to fiscal prudence. Commitment to practice based on standards and evidence is an ongoing process and may require substantial changes and more professional energy than the usual methods of implementing and evaluating changes in patient care routines. However, the initial investment in time to collaborate and become oriented to this process is worth the effort.

Downsizing, reengineering and patient safety: numbers, newness and resultant risk.

Downsizing and reengineering are facts of life in contemporary healthcare organizations. In most instances, these organizational changes are undertaken in an attempt to increase productivity or cut operational costs with results measured in these terms. Less often considered are potential detrimental effects on patient safety or strategies, which might be used to minimize these risks.

Acute fatty liver of pregnancy.

Acute fatty liver is a rare but potentially fatal complication of the third trimester of pregnancy. Significant improvements in morbidity and mortality have been reported in the last several years. Despite accumulation of more data about the disease, the exact pathogenesis is unknown. Many women are initially misdiagnosed with other more common causes of liver dysfunction during pregnancy. It is possible that acute fatty liver is an atypical form of preeclampsia because 30% to 40% of women with acute fatty liver also have preeclampsia. Supportive care and expeditious delivery represent the only known treatment. More data are needed about acute fatty liver of pregnancy, but the rare nature of the disease and the likelihood that most cases are not reported in the literature limit the ability systematically to study causation, disease process, and treatment options. Because of the serious condition of most women who develop acute fatty liver of pregnancy, collaboration between critical care and perinatal care providers is essential for optimal maternal-fetal outcomes.

Fetal oxygen saturation monitoring during labor.

Since the discovery of the ability to detect fetal heart tones in the 1980s, there has been ongoing research about how to interpret the meaning of these data. Fetal pulse oximetry, also known as fetal oxygen saturation monitoring, is a new method of assessing fetal status during labor that is under investigation in the United States. The article discusses limitations of current methods of fetal assessment, the potential benefits and limitations of fetal oxygen saturation monitoring, and future possibilities for fetal assessment during labor.

Electronic fetal heart rate monitoring: a primer for the critical care nurse.

Fetal assessment is an essential component of nursing care for a pregnant woman who is critically ill. If the fetus has reached the gestational age for which electronic fetal monitoring (EFM) is possible, intermittent or continuous fetal assessment with EFM may be used. Most nurses who specialize in adult intensive care nursing do not have the education or clinical experience to interpret EFM data. Collaboration with perinatal care providers is necessary to insure that fetal assessments are timely and accurate and that nursing interventions based on the data are appropriate. When perinatal providers participate as members of the team caring for critically ill pregnant women, terminology and physiologic parameters may be used that are not standard or routinely used in the ICU setting. The physiologic and hemodynamic changes that occur during pregnancy add another dimension to the nursing care required. This article reviews common terms used to describe fetal status and appropriate nursing interventions used in caring for the critically ill pregnant woman.

A collaborative approach to fetal assessment in the adult intensive care unit.

When a pregnant woman is admitted to the adult intensive care unit (ICU), responsibility for fetal assessment must be assumed by a nurse who is competent in interpreting data obtained by auscultation of the fetal heart rate or by the electronic fetal monitor. The fetus is a distinct patient requiring assessments, interventions, and evaluation, including documentation of nursing care provided, similar to any patient in the ICU setting. Most ICU nurses do not have adequate knowledge and clinical experience to assume this responsibility. Therefore, in institutions in which critically ill pregnant women are transferred to the adult ICU, a formal plan should be in place that includes care provided by nurses who are competent in fetal assessment. This article describes a collaborative approach to ensure that fetal assessments are performed by nurses who have the experience and education to do so and includes common terminology used to describe fetal status so that ICU nurses are familiar with the language and appropriate nursing intervention.

Photodynamic therapy of actinic keratosis with topical 5-aminolevulinic acid. A pilot dose-ranging study.

OBJECTIVE: To examine the safety and efficacy of photodynamic therapy using topical 5-aminolevulinic acid (ALA) and red light to treat actinic keratoses (AKs). DESIGN: Actinic keratoses were treated with topical ALA (concentrations of 0%, 10%, 20%, or 30%) under occlusion for 3 hours. Before photodynamic therapy, sites were examined for fluorescence. Sites were irradiated with an argon pumped dye laser (630 nm) at fluences of 10 to 150 J/cm2. SETTING: Academic medical center. PATIENTS: Forty patients with 6 clinically typical, previously untreated AKs per patient. MAIN OUTCOME MEASURE: Complete resolution and decrease in lesion area of the AK relative to baseline evaluated at weeks 1, 4, 8, and 16. RESULTS: Three hours after ALA administration, lesions showed moderate red fluorescence. Cutaneous phototoxic effects, localized erythema and edema, peaked at 72 hours. Patients experienced mild burning and stinging during light exposure. Eight weeks after a single treatment using 30% ALA, there was total clearing of 91% of lesions on the face and scalp and 45% of lesions, on the trunk and extremities. No significant differences were observed in clinical responses with treatment using 10%, 20%, or 30% ALA. All concentrations of ALA were more effective than treating AKs with vehicle and light. CONCLUSIONS: Topical photodynamic therapy with ALA is an effective treatment of typical AKs. Complete clearing of nonhypertrophic AKs can be achieved with 10%, 20%, or 30% ALA that is easily tolerated by the patient. Lesions on the face and scalp are more effectively treated than lesions on the trunk and extremities. Hypertrophic AKs did not respond effectively.