Factores asociados a la extubación temprana en pacientes con cirugía correctora de tetralogía de Fallot / Factors associated with early extubation of patients after corrective tetralogy of Fallot

Objetivo: Analizar el manejo intraquirúrgico y los resultados posquirúrgicos asociados a la extubación temprana en los pacientes sometidos a cirugía reparadora de tetralogía de Fallot en un hospital público argentino. Métodos: Se realizó una revisión retrospectiva de los expedientes clínicos de los pacientes a quienes se les practicó cirugía para corrección de tetralogía de Fallot. Se incluyeron en el análisis un total de 38 expedientes que cumplieron con los criterios de inclusión establecidos en el protocolo para la revisión retrospectiva. Resultados: El 16% fue extubado de manera temprana. Milrinona fue la única droga que mostró diferencias en los pacientes a quienes se extubó de manera temprana (p = 0,01). El tiempo de circulación extracorpórea, el de clampaje aórtico, la transfusión con crioprecipitados, la saturación de la presión de oxígeno, y el hematocrito al finalizar el procedimiento quirúrgico no evidenciaron diferencias (p > 0,05). En el período posquirúrgico, la estadía en UTI fue más corta en los pacientes que fueron extubados de manera temprana (p = 0,0007), pero no hubo diferencias en la estadía hospitalaria total (p = 0,26). Conclusiones: La extubación temprana en la institución si bien resultó de baja frecuencia ha demostrado ser una alternativa segura y eficaz para disminuir la estancia en UTI de estos pacientes

Objective: To assess surgical management and postoperative results associated with early extubation in patients undergoing tetralogy of Fallot corrective surgery at a public hospital in Argentina. Methods: A retrospective review was made from clinical records from patients who underwent corrective surgery for tetralogy of Fallot. A total of 38 clinical records that met the inclusion criteria for the retrospective review were included in the analysis. Results: 16% were extubated early. Milrinone was the only drug that showed differences in patients who were extubated early (p = 0.01). Extracorporeal circulation time, aortic clamping time, transfusion with cryoprecipitates, saturation of oxygen pressure, and haematocrit at the end of the surgical procedure showed no differences (p > .05). In the postoperative period, the ICU stay was shorter for the patients who were extubated early (p = 0.0007), but there were no differences in the total hospital stay (p = 0.26). Conclusions: Early extubation in the institution, although found to be low frequency, has proved as a safe and effective alternative to shorten these patients’ stay in ICU

Evaluating a Quality Improvement Initiative to Increase Anesthesia Providers' Use of and Understanding of Quantitative Neuromuscular Monitors.

Improved understanding of the monitoring and dosing practices of anesthesia providers regarding neuromuscular blockade is necessary. The use of subjective methods such as peripheral nerve stimulation and clinical assessment tests can increase the risk of residual neuromuscular blockade and adverse postoperative outcomes. Quantitative monitoring of neuromuscular blockade is an alternative tool to peripheral nerve stimulation to guide neuromuscular blockade; however, it is rarely used by providers. We developed an initiative to improve anesthesia providers' knowledge of neuromuscular blockade pharmacology, physiology, monitoring, and management. After the initiative, an analysis assessed for practice change regarding the use of quantitative monitoring and dosing of neuromuscular blocking agents and neostigmine. The use of quantitative monitoring increased significantly from 14.0% in the preinitiative group to 48.0% after the initiative (P < .001). The least squares mean 95% effective dose (ED95) neuromuscular blocking agents dose was compared between pre-initiative and postinitiative groups, and case length was a significant predictor for patients receiving the highest neuromuscular blocking agents doses. Neostigmine doses were compared between preinitiative and postinitiative groups, and body mass index was a significant predictor of the least squares mean neostigmine dose (P = .002) and the likelihood of receiving a high neostigmine dose (odds ratio = 0.911, 95% CI = 0.870-0.955).

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.

Reexamining traditional intraoperative fluid administration: evolving views in the age of goal-directed therapy.

Intraoperative volume administration has long been a topic of debate in the field of anesthesia. Only recently, however, has the conversation shifted to a discussion of appropriate intraoperative volume. A thorough review of the literature explores the history of today's widely accepted fluid administration equation and discusses possible explanations and consequences of iatrogenically induced hypervolemia. Current studies exploring various volume administration techniques are reviewed, as are emerging technologies available to help guide anesthesia providers with intraoperative fluid management.

Diagnósticos e intervenciones enfermeras intraoperatorias en pacientes intervenidos de nefrectomía simple / No disponible

A través del presente artículo pretendemos dar difusión a un protocolo de actuación creado en la unidad quirúrgica del Hospital Alto Guadalquivir de Andújar para los pacientes intervenidos de nefrectomía simple. A la misma vez que podemos poner de manifiesto que la labor de enfermería en el área quirúrgica y las actividades que realiza, pueden ser tipificadas con las taxonomías NANDA-NIC, consiguiendo que los cuidados que se presten a este tipo de pacientes sean de calidad y estandarizados, debido a la necesidad de evitar complicaciones y garantizar una asistencia adecuada en este tipo de intervención. Este hecho aporta mayor seguridad al paciente y a los propios profesionales, así como una reducción de la variabilidad en la práctica asistencial enfermera (AU)

Through this article we try to disseminate a protocol established in the surgical unit of the Hospital Alto Guadalquivir Andujar, for patients who underwent simple nephrectomy. At the same time we are able to show that the work of nurses in the surgical area and the activities can be typified with NANDA-NIC Taxonomies, getting the care that is appropriate for this type of patients are of quality and standardized, due to the need to avoid complications and ensure appropriate assistance in this type of intervention. This provides greater patient safety and the professionals as well as a reduction of the variability in clinical practice nurse (AU)

Pautas prácticas de enfermería en cirugía urológica laparoscópica / No disponible

Hemos realizado una revisión sobre la actividad enfermera intraoperatoria en estos procesos, elaborando una guía práctica de fácil manejo, que ayude a adquirir los conocimientos y habilidades necesarios que capaciten unos cuidados enfermeros de calidad. Principales diagnósticos enfermeros: ansiedad, temor, riesgo de infección, aspiración, lesiones perioperatorias y caídas. 96 cirugías laparoscópicas justifican la necesidad de adquirir los conocimientos y habilidades necesarios para la correcta actuación enfermera. Hemos realizado un plan de cui dados enfermeros estandarizado. La alta especialización de estos procesos precisa un personal altamente cualificado, enfermería es clave en el desarrollo de estas técnicas, pues influye de forma activa en el buen desarrollo de las mismas, favoreciendo el trabajo en equipo, minimizando los tiempos quirúrgicos y asegurando una atención de calidad (AU)

We have carried out a revision about the intraoperatory nurse activity in these processes, elaborating a practical guide of easy handling, which helps to acquire the necessary knowledge and skills that enable quality nurse care. Main nurse diagnoses: anxiety, fear, risk of infection, aspiration, perioperatory injuries and falls. 96 laparoscopic surgeries justify the need to acquire knowledge and necessary skills to the correct nursing performance. We have carried out a standardized nursing care plan. The high specialization of these processes needs highly qualified staff, nursing is key in the development of these techniques as it is influential actively in the correct development of them, favoring the teamwork, minimizing surgical time and guaranteeing attention of quality (AU)

Anesthesia awareness-induced posttraumatic stress disorder.

While the incidence of anesthesia awareness has been well documented, information related to posttraumatic stress disorder (PTSD) symptoms resulting from anesthesia awareness is limited. Particularly scarce are descriptions of specific techniques to treat anesthesia awareness-induced PTSD. This article reviews an individual example of a woman who was experiencing anesthesia awareness-induced PTSD symptoms for 10 years. Treatment included supportive psychotherapy, psychoeducation, psychopharmacology, and group therapy with other individuals experiencing PTSD symptoms. Although this patient responded to these treatment approaches, additional studies are needed to identify optimal treatment options for patients with anesthesia awareness-induced PTSD.

Combined spinal/general anesthesia with postoperative femoral nerve block for total knee replacement in a patient with familial hyperkalemic periodic paralysis: a case report.

Familial hyperkalemic periodic paralysis (HYPP) is a rare genetic disorder in which the sodium channels in skeletal muscle cells have altered structure and function. Small elevations in serum potassium lead to inactivation of sodium channels, causing episodic weakness or paralysis. Exposure to cold, anesthesia, fasting, emotional stress, potassium ingestion, and rest after exercise can stimulate an attack. This case report describes a 65-year-old man with HYPP who was admitted for a right total knee arthroplasty. He had a history of arteriosclerotic heart disease and stenting 8 years earlier, previous inferior wall myocardial infarction with ejection fraction of 65%, anxiety, degenerative joint disease, well-controlled type 2 diabetes mellitus, and a body mass index of 53.3 kg/m2. A combined spinal/general anesthetic with a femoral nerve block for postoperative pain control was chosen. Careful attention was given to monitoring and maintenance of core temperature, use of insulin and glucose to maintain normokalemia, and carbohydrate loading the night before surgery. The patient recovered from the anesthetic without complication and had pain relief for approximately 22 hours postoperatively because of the femoral nerve block. The patient was without weakness or paralysis related to HYPP in the postanesthesia care unit or throughout his hospitalization.

Caudal anesthesia in a patient with severe pulmonary hypertension.

Delivery of anesthesia to patients with severe pulmonary hypertension can be extremely challenging. The profound hemodynamic alterations of the disease can often be exacerbated by alterations in circulatory function brought about by anesthetic and surgical interventions. High perioperative morbidity and mortality rates have been reported. Minimizing adverse outcomes in these patients requires careful perioperative evaluation and planning. Selection of an anesthetic technique suitable for the surgery without causing major hemodynamic alterations, which can lead to cardiac failure and death, is a unique consideration of the anesthesia provider. As shown in this case report, caudal anesthesia, when appropriate, can offer a safe anesthetic for these patients.

Apoptosis: understanding programmed cell death for the CRNA.

Apoptosis, or programmed cell death, is a physiologic mechanism employed by most multicellular organisms to maintain homeostasis of body tissues. In balance with the production of new cells by mitosis, apoptosis provides for the orderly destruction and removal of cells that are no longer needed by the organism. Apoptosis occurs by complex pathways involving multiple biochemical signals and processes. Dysfunctional apoptotic mechanisms are the pathologic basis for many human diseases, including common disorders of the heart, lungs, brain, and endocrine systems. Researchers have demonstrated in animal models that neurodegenerative changes after the administration of anesthetic drugs are related to apoptosis. Anesthesia drugs have been found to induce apoptosis, perhaps through the production of reactive oxygen species. Propofol is a drug used in anesthesia that has unique antioxidant qualities that may be beneficial. The purpose of this article is to review, for nurse anesthesia providers, current information about the process of apoptosis, the role of apoptosis in comorbid diseases, and the implications of the effects of anesthesia drugs on normal apoptotic mechanisms that need to be evaluated as potential sources of risk or benefit to surgical patients.

Use of dexmedetomidine and ketamine infusions during scoliosis repair surgery with somatosensory and motor-evoked potential monitoring: a case report.

Dexmedetomidine and ketamine infusions were the main anesthetic for a 15-year-old girl, who underwent scoliosis repair surgery with intraoperative wake-up test, somatosensory evoked potential (SSEP), and motor-evoked potential (MEP) monitoring. To achieve maintenance of anesthesia, dexmedetomidine and ketamine were administered concomitantly. The dexmedetomidine dose ranged from 0.9 to 1.2 microg/kg per hour throughout the case, and the ketamine dose ranged from 0.4 to 0.6 mg/kg per hour. The analgesic properties of dexmedetomidine and ketamine were complimented by the continuous fentanyl infusion at 1 to 2 microg/kg per hour. The sympatholytic properties of dexmedetomidine were balanced with the sympathomimetic properties of ketamine, and the patient required minimal vasoactive support (only 250 microg of phenylephrine was administered over the course of 12 hours of anesthetic care). This anesthetic regimen, as well as 60% nitrous oxide and 40% oxygen, provided satisfactory conditions for the intraoperative neurophysiologic monitoring. This case report discusses the use of dexmedetomidine and ketamine infusions as an alternative to propofol-based total intravenous anesthesia during scoliosis repair surgery with intraoperative SSEP and MEP monitoring.

Ventricular assist devices and anesthetic implications for noncardiac procedures.

Approximately 5 million Americans experience heart failure, which affects 10 in every 1000 people older than 65 years. Ventricular assist devices (VADs) are a type of mechanical circulatory support that aids in systemic perfusion by maintaining unidirectional flow while reducing the oxygen demand of the failing ventricle. There are 3 generations of VADs in circulation used as a bridge to transplantation, a bridge to recovery, or as destination therapy. Due to the increasing use of these devices, it is likely that anesthetists will encounter patients with these devices more frequently, which requires adequate preoperative discussion with the care team. Intraoperatively, it is important to realize that patients with VADs are at higher risk for aspiration, to recognize electromagnetic interference from surgical devices, to maintain hemodynamic stability, and to monitor coagulation status. With proper knowledge, and adequate preoperative preparation and intraoperative care, anesthetists should be able to achieve safe and successful patient outcomes through anesthesia care.

Code blue: what to do?

Cardiac arrest may occur intraoperatively at any time. The purpose of this article is to help the reader recognize and assist in the management of an intraoperative cardiac arrest. Patients who are at risk for cardiac arrest in the OR are identified and different types of pulseless arrythmias are identified. Roles of perioperative personnel are suggested and documentation during the code is discussed.

Detecting ischemic danger at the source.

Using near-infrared spectroscopy, the INVOS (In-Vivo Optical Spectroscopy) System provides real-time, site-specific cerebral/somatic measurements of de-oxygenated and oxygenated hemoglobin molecules within red blood cells through a noninvasive oximeter. Perioperative professionals can use the vital sign information monitored by this technology to detect and correct site-specific blood oxygenation issues that can lead to complications and poor outcomes. AORN J 90 (September 2009) 431-433. (c) AORN, Inc, 2009.