Nurse-managed basal-bolus versus sliding-scale insulin regimen in subjects with hyperglycemia at admission for orthopedic surgery: a propensity score approach.

AIMS: A sliding-scale (SS) regimen is discouraged to correct hyperglycemia in hospital patients, but there is resistance to adoption of basal-bolus (BB) treatment in surgical units. We tested the feasibility and the effects of a nurse-based BB regimen in orthopedic surgery. METHODS: Following an intense training to implement a protocol amenable by nurses, a group of patients admitted with hyperglycemia in an orthopedic institute were prospectively followed according to a basal-bolus insulin regimen (BB, n = 80). They were compared with a hyperglycemic group eventually treated by sliding-scale insulin on demand (SS, n = 122). Diabetes was present in 196 cases. Metabolic control was assessed during the first 3 days of surgery; outcome data were tested by logistic regression, after adjusting for propensity score. RESULT: Average blood glucose and glucose variability were lower in BB versus SS (P < 0.001), in the presence of similar 3-day insulin doses. Complications were recorded in 68 cases (16.2% vs. 45.1% in BB and SS, respectively). BB regimen was associated with propensity-adjusted reduction in all adverse events [odds ratio (OR) 0.36; 95% confidence interval (CI) 0.17-0.76] and of systemic infections (OR 0.18; 95% CI 0.07-0.50) and with shorter hospital stay (8.8 ± SD 5.2 days vs. 12.5 ± 7.4; P < 0.01). The superiority of BB regimen was confirmed in the pair-matched analysis. CONCLUSIONS: The study proves the feasibility and the superiority of nurse-based BB versus SS treatment in metabolic control and on the risk of adverse events in orthopedic surgery patients with hyperglycemia.

Development of a software for intraoperatory nursing assistance.

OBJECTIVE: to develop a software that allows the nurse of the surgical center to plan intraoperative nursing care through electronic access to the work routines of his/her team. METHOD: the methodological course was carried out according to systems development theory, which guides five basic activities: communication, planning, modeling, developing and delivery of the product. RESULTS: the activities and functions of the software were arranged in five modules, containing information regarding the inputs and the step-by-step involving the assembly, circulation and disassembly of the operating room to perform the various anesthetic and surgical procedures. FINAL CONSIDERATIONS: The developed software will allow the surgical center's nursing team to access its intraoperative routines in a fast and systematic way, since this allowed to concentrate all the routines of assembly, circulation and disassembly of operating room in a safe space and accessible.

The Danish Gynecological Cancer Nursing Database: Creating Evidence for Quality Improvements in Preoperative and Postoperative Cancer Care.

OBJECTIVE: Quality of preoperative and postoperative care is crucial to improve postoperative outcome of cancer surgery and to ensure that neither complications nor a poor general condition delays any subsequent radiochemotherapy or recovery. On this background, the Danish Gynecological Cancer Database (DGCD) established a nursing database in 2011. The aim of DGCD Nursing is to monitor the quality of preoperative and postoperative care and to generate data for research. MATERIAL AND METHODS: In accordance with the current data protection legislation, real-time data are entered by clinical nurses at all national cancer centers. The DGCD Nursing includes data of preoperative and postoperative care, and nurses are independently represented in the steering committee. The aim of the present article is to present the first results from DGCD Nursing and the national care improvements that have followed. RESULTS: With national coverage of an average of 94%, 5726 patients have been registered since 2011. In patients undergoing surgery for ovarian, endometrial, and cervical cancer, 436 different variables monitor central preoperative and postoperative care elements within mobilization, nutritional status, pain score, vital functions, and psychosocial support. CONCLUSIONS: At national level, DGCD offers a comprehensive overview of the total patient pathway within gynecological cancer surgery. The DGCD Nursing has added to the quality and implementation of evidence-based preoperative and postoperative care and in addition supported formation of professional networks. With a continued validation of data, DGCD Nursing now constitutes a sound and unique basis for research within the field of preoperative and postoperative cancer care.

Impact of Trauma-Certified Registered Nurse Anesthetists Team on Intra-Operative Resuscitation and Postoperative Outcomes of Trauma Patients.

A Trauma Certified Registered Nurse Anesthetists Team (TCT) was created and trained to provide trauma-focused anesthesia and resuscitation. The purpose of this study was to examine patient outcomes after implementation of TCT. We conducted retrospective analyses of trauma patients managed with surgical intervention from March to December 2015. During the first five months, patients managed before the development of TCT were grouped No-TCT, patients managed after were grouped TCT. To assess outcomes, we used hospital and intensive care unit length of stay, ventilator days, and a validated 10-point intraoperative Apgar score (IOAS). IOAS is calculated using the estimated blood loss, lowest heart rate, and lowest mean arterial pressure during surgery. Higher IOAS are associated with significantly decreased complications and mortality after surgery. We used t test and nonparametric tests for analyses. Fifty two patients were included (mean age 39 years, 75% male; 46.2% managed with TCT). Patients in the No-TCT group had significantly lower use of vasopressors (0.019), lower mean IOAS (P = 0.02), and spent more days on ventilator (P = 0.005) than patients in the TCT. These results suggest that trauma centers should take into consideration implementation of TCT to improve intraoperative and overall outcomes.

Anesthetic Considerations of Stiff-Person Syndrome: A Case Report.

Stiff-person syndrome (SPS) is a neurologic disorder characterized by painful involuntary episodes of severe muscle rigidity affecting the axial muscles and extremities. Although the etiology of SPS is unknown, it is suspected to involve the synthesis of γ-aminobutyric acid (GABA). Symptoms of SPS are precipitated by sudden unexpected movements, noises, and stress. Additionally, SPS has been linked with various autoimmune disorders, including diabetes mellitus, thyroid disease, pernicious anemia, and certain cancers. Because of the effect of SPS and SPS medications, inhalational agents and neuromuscular blockers have the potential to cause prolonged hypotonia following anesthesia, resulting in respiratory failure despite full reversal of neuromuscular blockade. In documented case reports, the outcomes of using general anesthesia with inhalational agents and neuromuscular blockers in patients with SPS varied. This case report highlights the anesthetic management of a 56-year-old woman with diagnosed SPS undergoing a hemicolectomy for a colon mass using total intravenous anesthesia.

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.

[Surgical treatment of ulcerative colitis]. / Prise en charge chirurgicale de la rectocolite hémorragique.

Surgery for patients suffering from inflammatory bowel diseases is an option when medication-based treatment fails. Sometimes complex and carried out in several stages, the procedures require the nurses to be involved in the education of the patient, monitoring prevention and identification of complications.

Traffic in the operating room: a review of factors influencing air flow and surgical wound contamination.

Surgical wound contamination leading to surgical site infection can result from disruption of the intended airflow in the operating room (OR). When personnel enter and exit the OR, or create unnecessary movement and traffic during the procedure, the intended airflow in the vicinity of the open wound becomes disrupted and does not adequately remove airborne contaminants from the sterile field. An increase in the bacterial counts of airborne microorganisms is noted during increased activity levels within the OR. Researchers have studied OR traffic and door openings as a determinant of air contamination. During a surgical procedure the door to the operating room may be open as long as 20 minutes out of each surgical hour during critical procedures involving implants. Interventions into limiting excessive movement and traffic in the OR may lead to reductions in surgical site infections in select populations.

Intraoperative stress and anxiety reduction with music therapy: a controlled randomized clinical trial of efficacy and safety.

OBJECTIVE: The purpose of this study was to investigate the music therapy (MT) effect in levels of intraoperative anxiety in patients undergoing crossectomy with stripping of the great saphenous vein and to assess the efficacy, safety, and feasibility of this alternative therapy as a complement of standard intraoperative care. MATERIAL AND METHODS: The study is a simple blind, controlled, parallel groups, prospective randomized clinical trial. Patients were allocated by means of randomized controlled sampling. The study was performed in the surgery room of Getafe University Hospital in Madrid. The study was carried out in 40 patients, 20 randomized to the experimental group and 20 randomized to the control group, with an age range from 27 to 70 years. The control group was given intraoperative routine attention, and the experimental group was given an MT passive intervention that consisted of audition of musical fragments during varicose veins surgery. These pieces previously showed relaxing actions on the cardiovascular system. The anxiety levels were measured by means of pre- and postsurgical questionnaires by a blinded investigator for the study arm to which the patients had been randomized. Heart rate and systolic and diastolic blood pressures were determined during the intervention, and adrenaline and noradrenaline plasma levels were determined before and after the surgical procedure. RESULTS: The majority of the patients in the MT group (95%) and standard care group (90%) completed the study. There were no statistical differences between the control and experimental groups in heart rate gradient or systolic and diastolic blood pressures measured after the intervention. The anxiety state and the stress feeling scale score after surgery were significantly inferior in the MT group (94.7% vs 57.9% decrease in anxiety levels, P < .05, and stress score of 1.31 vs 2.36, P < .05, respectively). The adverse events ratio was low and occurred with similar frequency in both groups. CONCLUSIONS: The MT intervention was easily implemented in the context of nursing care received during varicose vein surgery and was positively accepted and valued by the majority of the patients. MT is a safe procedure that is proved to reduce anxiety and stress in the study patients.

[Intraoperative nursing in bariatric surgery: integrative review]. / Enfermagem transoperatória nas cirurgias de redução de peso: revisão integrativa da literatura.

Integrative review of scientific literature study to identify and analyze the production of knowledge about clinical advances in security needs of patients during the intraoperative period of bariatric surgery. It was based on 12 selected studies in electronic databases, with descriptors previously defined. Except for two studies, the specific content of this production was composed of the general context of perioperative care. The studies highlight the possible state of the art of nursing activities on these needs, which are well established, including recommendations by several guidelines. However, they are fundamentally based on the science of traditional clinical practice through the development of rational judgments issued by experts. It concludes for the relevance of primary studies to evaluate the impact and resolution of the identified resources to answer those needs, as well as improving or generating other innovative features and identification of new needs.

Enfermagem transoperatória nas cirurgias de redução de peso: revisão integrativa da literatura / Intraoperative nursing in bariatric surgery: integrative review / Enfermería intraoperatoria en cirugía bariátrica: revisión integradora de la literatura

Estudo de revisão integrativa da literatura científica com a finalidade de identificar e analisar a produção de conhecimento sobre avanços clínicos em necessidades de segurança de pacientes no período transoperatório de cirurgia bariátrica, baseada em 12 estudos selecionados em bases eletrônicas, a partir de descritores previamente definidos. Com exceção de dois estudos, o conteúdo específico dessa produção compunha o contexto geral da assistência perioperatória. A análise dos estudos possibilitou evidenciar o estado da arte da atuação da enfermagem sobre essas necessidades, as quais já estão bem estabelecidas, inclusive por vários guias de recomendações, contudo, fundamentalmente baseadas na ciência da prática clínica tradicional, por meio da elaboração de juízos racionais teóricos de especialistas. Conclui-se pela pertinência de realização de estudos primários para avaliar, principalmente, impacto e resolutividade dos recursos identificados para atendimento dessas necessidades, assim como melhoria ou geração de outros recursos inovadores e identificação de novas necessidades.

Integrative review of scientific literature study to identify and analyze the production of knowledge about clinical advances in security needs of patients during the intraoperative period of bariatric surgery. It was based on 12 selected studies in electronic databases, with descriptors previously defined. Except for two studies, the specific content of this production was composed of the general context of perioperative care. The studies highlight the possible state of the art of nursing activities on these needs, which are well established, including recommendations by several guidelines. However, they are fundamentally based on the science of traditional clinical practice through the development of rational judgments issued by experts. It concludes for the relevance of primary studies to evaluate the impact and resolution of the identified resources to answer those needs, as well as improving or generating other innovative features and identification of new needs.

Investigación de revisión integradora de la literatura con el fin de identificar y analizar la producción del conocimiento sobre los avances clínicos en las necesidades de seguridad de los pacientes durante el período transoperatorio de la cirugía bariátrica. Está basado en 12 estudios seleccionados en bases de datos electrónicas, con descriptores definidos. A excepción de dos estudios, el contenido de esta producción se compuso por el contexto general de los cuidados perioperatorios. El análisis de los estudios ha puesto en evidencia el estado del arte de la actuación de enfermería sobre esas necesidades, que ya están bien establecidas. Sin embargo, este análisis está basado principalmente en la ciencia de la práctica clínica tradicional a través de la elaboración de juicios teóricos de expertos. Se concluye que estudios primarios son necesarios para evaluar el impacto y la resolución de los recursos identificados para satisfacer las necesidades de seguridad de estos pacientes.

Diathermy in perioperative practice.

Diathermy has revolutionised modern surgery and is an important tool for efficient and safe surgical practice. It has evolved to become the modern day scalpel, being used for cutting and coagulating tissues. This article addresses the functioning and safe use of diathermy in the perioperative setting. The various precautionary checks before surgery, which are prerequisite for safe usage, are highlighted along with the necessary safety drills during and after operation. A specific note is included about the use of electrical equipment in specialised surgeries like cardiac and laparoscopic surgery. The issues regarding the maintenance and repair of equipment are acknowledged and finally, the anticipation for a future with precise and safer cutting and coagulation devices is addressed.

Optimising patient management before and after surgery.

Enhanced recovery involves the implementation of several evidence-based interventions concurrently in pathways of care for surgery, rather than individually, to ensure they have a greater impact on patient outcomes. This article explains the enhanced recovery pathway and discusses some of its benefits.

Intra-operative hemodialysis during liver transplantation: an expanded role of the nephrology nurse.

Hemodialysis is widely acknowledged as a treatment option to stabilize acute medical conditions where biochemistry management is paramount. One of the most challenging situations is during liver transplantation, when patients with moderate renal dysfunction are likely to become acutely acidotic. For nephrology nurses, this extended role requires increased knowledge, advanced skills, and a high level of communication with unfamiliar team members. With appropriate procedures and a supportive environment, delivering such a service is feasible.

Cystic fibrosis: a systems review.

Cystic fibrosis (CF) is a fatal genetic disorder that affects many organ systems in the body. Historically, few patients with CF lived beyond early childhood, but with continuous improvement in treatment modalities, quality of life and the life span of persons with CF has greatly improved. As the surviving population of people with CF increases, a greater chance of encountering them in anesthesia practice exists. Comorbidities associated with the disease, such as diabetes mellitus and osteopenia, may also contribute to an increased frequency of surgical and anesthetic encounters. An understanding of the pathophysiology of the disease, as well as anesthetic implications and management, is crucial to the safe administration of anesthesia in this population. Cystic fibrosis is traditionally thought of as a childhood disease affecting the lungs and pancreas, which does not accurately describe the disease in its entirety. Many organ systems are affected, from the heart and lungs to the reproductive system, and may warrant alterations in an anesthetic plan. This review highlights the pathologic conditions associated with multiple systems, therapy regimens, and potential complications and suggests anesthetic implications.

The importance of correct patient positioning in theatres and implications of mal-positioning.

Patient positioning in theatre pertains to how a patient is transferred and positioned for a specific procedure. Patient safety is a central focus of care within the NHS and every healthcare practitioner must ensure that patients are protected from harm where possible. Mal-positioning of the patient has important implications in terms of associated problems of pressure sores, nerve compressions, deep vein thrombosis and compartment syndrome, and should be avoided.

Safe handling of chemotherapy in the perioperative setting.

Safe handling of chemotherapeutic agents during administration and disposal is critical. Most antineoplastic agents are toxic compounds that are carcinogenic, mutagenic, or teratogenic. Direct contact may cause irritation of the skin, eyes, and mucous membranes. Perioperative personnel should know how to handle hazardous materials safely to protect the patient, other staff members, and themselves. These safety precautions include appropriately identifying the patient; correctly preparing, verifying, and documenting the chemotherapeutic agents being administered; consistently wearing personal protective equipment; transporting the chemotherapeutic agent in a puncture-resistant container labeled "chemotherapy"; properly disposing of the chemotherapeutic agent and supplies; and handling a spill if one occurs.

Are we doing enough to prevent patient injury caused by positioning for surgery?

Patient positioning is an integral part of perioperative care and yet it is an area of patient care which can easily be compromised as staff try to accommodate surgeons and work through busy operating lists. Inadequate padding and incorrect positioning can cause serious and long term injury and disability, and can result in litigation against perioperative nurses and ODPs.