European guidelines on perioperative venous thromboembolism prophylaxis: Surgery during pregnancy and the immediate postpartum period.

: Thromboembolic events in the pregnant and postpartum patient remain rare but potentially fatal complications. The aim of this section was to analyse the few prospective studies addressing the issue of thromboprophylaxis following a surgical procedure during and immediately after pregnancy, as well as national guidelines, and to propose European guidelines on this specific condition. Thromboprophylaxis is broadly recommended due to the combined risks of surgery and pregnancy or the postpartum period, regardless of the mode of delivery. We recommend prophylactic thromboprophylaxis following surgery during pregnancy or the postpartum period when they imply, as a consequence, bed rest, until full mobility is recovered (Grade 1C). Similarly, thromboprophylaxis should be used in cases of perioperative infection during pregnancy or the postpartum period. Concerning thromboprophylaxis following a caesarean section, it seems avoidable only in elective procedures in low-risk patients, after a normal pregnancy, and with an early rehabilitation protocol. The duration of thromboprophylaxis following caesarean section should be at least 6 weeks for high-risk patients, and at least 7 days for the other patients requiring anticoagulation (Grade 1C).

Atypical spontaneous intracranial hypotension with a head-shaking headache.

Spontaneous intracranial hypotension (SIH) is typically characterized by orthostatic headache; however, various atypical manifestations of SIH have been reported recently. We report here the case of a 46-year-old man with headache secondary to SIH, which was nonorthostatic, triggered only when the patient shook his head. We suggest that SIH should be suspected in patients with headache induced by head-shaking, even without orthostatic features, especially when the headache is accompanied by other symptoms commonly associated with SIH.

Bed rest: outdated following traumatic solid organ injury?

INTRODUCTION: This systematic review aimed to evaluate early ambulation protocols implemented for traumatic solid organ injury. METHODS: The electronic databases PubMed, Medline (Ovid), Embase and Cochrane Library were searched without time constraint to identify prospective and retrospective analyses, randomised controlled trials, cohort studies, and case series that investigated early ambulation in solid organ trauma. RESULTS: Six studies met the predefined inclusion criteria and were reviewed. Three studies investigated early ambulation protocols in direct comparison with bed rest. The remaining three studies were early ambulation case series. In all studies there was no convincing evidence to suggest differences in clinical outcomes between early ambulation and bed rest protocols. In all studies early ambulation resulted in a reduced length of hospitalisation and decreased cost to national healthcare services. CONCLUSIONS: This systematic review has found preliminary evidence that suggests bed rest has no clinical benefit in those with low-grade to mid-grade (grades 1-2) solid organ injury. Further studies are required to inform guidance to improve trauma patient outcomes.

The effectiveness of early position change postcardiac catheterization on patient's outcomes: A randomized controlled trial.

BACKGROUND: Nurses play a substantial role in maintaining patient homeostasis postcardiac catheterization. Patients frequently complain of back pain and discomfort as a result of the prolonged bed rest postcatheterization. AIM: This study aims to evaluate the effectiveness of early position change postcardiac catheterization on reducing patients' pain and discomfort. SETTINGS: The study was conducted at two cardiac units in a university hospital in Jordan. PARTICIPANTS: A total of 120 patients were used in the study, 60 patients in each of the two groups-control and intervention. METHODS: The randomized controlled trial design was used. Data were initially collected 1 hour after sheath removal postcardiac catheterization. After that, the protocol was applied to the interventional group. RESULTS: Early position change 1 hour after sheath removal after cardiac catheterization was found to be effective in reducing back pain as compared with the control group (P < .001). Also, the study intervention was found to be effective in reducing urinary discomfort (X2 = 50.83, P < .001), and increasing comfort level (X2 = 120, P < .001). However, although participants in the intervention group were less likely to have constipation and hematoma than those in the control group, this outcome was not statistically significant at P > .05. CONCLUSION: Early position change 1 hour after sheath removal postcardiac catheterization has significant positive effects on patient outcomes by reducing the intensity of back pain and urination problems and increasing patients' comfort level without increasing incidents of vascular complications such as bleeding and hematoma.

Influence of bedrest or ambulation in the clinical treatment of acute deep vein thrombosis on patient outcomes: a review and synthesis of the literature.

A thorough review of current and classic literature was completed to distinguish the influence of bedrest or ambulation on patient treatment outcomes with confirmed deep vein thrombosis.

What is the evidence for using bed rest as part of hospital treatment of severe anorexia nervosa?

Bed rest is commonly used on medical and paediatric wards as part of nursing management of the physically compromised patient with severe anorexia nervosa. The aim of this study was to review the evidence base of bed rest as an intervention in the management of severe anorexia nervosa. We searched MEDLINE, PubMed, Embase, PsychInfo, CINAHL, HMIC, AMED, HBE, BNI and guidelines written in English until April 2018 using the following terms: bed rest and anorexia nervosa. After exclusion of duplicates, three guidelines and eight articles were included. The papers were methodologically heterogeneous, and therefore, quantitative summary was not possible. There have been no randomised controlled trials to compare the benefits and harms of bed rest as the focus of intervention in the treatment of anorexia nervosa. Several papers showed that patients have a strong preference for less restrictive approaches. These are also less intensive in nursing time. Negative physical consequences were described in a number of studies: these included lower heart rate, impaired bone turn over and increased risk of infection. We found no evidence to support bed rest in hospital treatment of anorexia nervosa. The risks associated with bed rest are significant and include both physical and psychological harm, and these can be avoided by early mobilisation. Given the established complications of bed rest in other critically ill patient populations, it is difficult to recommend the enforcement of bed rest for patients with anorexia nervosa. Future research should focus on safe early mobilisation, which would reduce complications and improve patient satisfaction.

Immobilization versus immediate mobilization after intrauterine insemination: A systematic review and meta-analysis.

INTRODUCTION: The objective of this systematic review and meta-analysis was to investigate a possible association between immobilization and pregnancy rate in patients undergoing intrauterine insemination. MATERIAL AND METHODS: To ensure the quality of the methodology, the PRISMA criteria were met at all stages of the development of this meta-analysis. We searched the Cochrane Library, EMBASE, PubMed MEDLINE, ScienceDirect and reference lists of eligible studies from inception to March 2017, without any restriction. We also interviewed the ClinicalTrials.gov database for unpublished articles. Finally, we sought potentially eligible studies in meeting abstracts. Two reviewers independently extracted study characteristics and outcome data. Estimates were pooled using random effects models and sensitivity analyses. We selected studies that compared bed rest to immediate mobilization after intrauterine insemination. The primary outcome was the ongoing pregnancy rate per couple. RESULTS: Of 176 identified abstracts, four primary studies, all of them randomized controlled trials, met the inclusion criteria, including 1361 couples. The overall relative risk of ongoing pregnancy rate in bed rest versus immediate immobilization was 1.67 95% CI [0.86; 3.22]. The overall relative risk of the live birth rate was 1.11 95% CI [0.56; 2.20]. CONCLUSION: This systematic review and meta-analysis was not able to demonstrate that bed rest after intrauterine insemination effectively increases in pregnancy rate. For everyday practice, no specific strategy, bed rest or immediate mobilization, can be recommended at this time.

Multiple gestation: side effects of antepartum bed rest.

The birth rate for higher order multiples has dramatically increased in recent decades. Multiple gestation pregnancies are considered to be at high obstetric risk. Antepartum bed rest is often prescribed to offset complications despite the lack of evidence for its effectiveness in preventing complications. This longitudinal repeated-measures study identified side effects of antepartum bed rest treatment for 31 hospitalized women with twin or triplet gestation. Maternal weight gain and infant birth weight were recorded. Antepartum stressors were measured by the Antepartum Stressors Hospital Inventory, and depressive symptoms were measured by the Center for Epidemiologic Studies Depression Scale (CES-D). Antepartum and post-partum side effects of bed rest were also assessed by the Antepartum and Postpartum Symptom Checklists. The weekly rate of maternal weight gain during hospitalization was significantly less than recent recommendations for multiple gestation weight gain (t = - 2.14, p = .04). Infant birth weights were appropriate for gestational age. There were fewer than expected small-for-gestational-age infants. Concerns regarding family status and separation from family were the major antepartum stressors. Women reported a high number of symptoms during bed rest (M = 22), which did not significantly change across 2 weeks. CES-D scores for depressive symptoms were high on antepartum hospital admission. Postpartum symptoms were initially high but had significantly declined by 6 weeks: F(1, 27) = 15.68, p = .00. These findings suggest that interventions are needed to reduce antepartum maternal weight loss, stress, physiologic and psychosocial symptoms, and depressive symptoms, as well as reduce postpartum symptoms of maternal morbidity.

Direct observations of nursing home care quality: Does care change when observed?

OBJECTIVES: Recent research demonstrates that care recorded by nursing home (NH) staff is often inaccurate. Direct observations of care may therefore be of critical importance in assessing and improving care in this setting. Unfortunately, despite their apparent use in several types of quality assurance activities, there is little written information about the reliability or accuracy of observational procedures in NHs. This paper provides information about one important measurement issue (reactivity) that is often cited as a limitation of observational procedures in measuring usual care practices accurately. DESIGN: Descriptive. SETTING: Seven nursing homes. PARTICIPANTS: Staff and residents. MEASUREMENTS: Direct observational time in bed; repositioning and feeding assistance. RESULTS: Observational measures of care quality were stable over multiple observation periods and consistently detected quality problems even on the first and last days of observation. CONCLUSION: Direct observations of care provided to residents do not appear to change provider behavior.

Measuring the pressure applied to the skin surrounding pressure ulcers while patients are nursed in the 30 degree position.

The 30 degree laterally inclined and 30 degree head elevated positions (hereafter referred as the 'rule of 30' unless otherwise specified) are widely used as a means of both primary and secondary prevention of pressure ulcers as a result of reductions in localised pressures over bony prominences. However, the authors observed that some some parts of the wound margin were thickened. These thickened edges may be caused by use of the rule of 30 positioning and may also be responsible for a delay in the healing process. This study included five bedbound elderly patients with pressure ulcers located at the sacrum and coccyx. The local pressure was measured at the thickened edges and normal edges of the subjects' wounds by a newly developed sensor while the subjects were positioned according to the rule of 30. The results showed the maximum pressure as well as the average pressure of the thickened edges to be significantly greater than that of the normal edges. Thus, it is suggested that higher pressure on different areas of the wound margin may be responsible for the thickened edges phenomenon, which may consequently delay the healing process. Clinical use of the rule of 30 for patients with pressure ulcers in the sacrum and coccyx regions should be reconsidered.

Axillary subclavian vein thrombosis. Changing patterns of etiology, diagnostic, and therapeutic modalities.

Fifty-two patients with axillary-subclavian vein thrombosis were treated in the last 10 years and were available for follow-up for at least 1 year. Eighteen of these were treated in the first 5 years, Group A, and 34 in the last 5 years, Group B. The causes in both Group A and Group B included respectively: effort or spontaneous 28 per cent and 29 per cent, catheter insertion related 17 per cent and 47 per cent, and malignancy or systemic disease 55 per cent and 24 per cent. None of the patients in Group A had noninvasive vascular testing (NIT). However, 27 patients in Group B had IPG/duplex imaging (NIT). All 18 cases in Group A and 27 cases in Group B were treated conventionally (anticoagulants). Seventy-three per cent of these had residual pain on exertion (venous claudication) and/or swelling. Fourteen of these cases had posttreatment NIT/venography. Four of these showed total resolution of the thrombus and all were symptom free. Ten had no resolution, and nine were symptomatic. Seven cases in Group B were treated with thrombolytic therapy. Five of these had total resolution of thrombus and were symptom free (71%). Two had no resolution with residual symptoms (29%) (statistically significant). In conclusion (1) More patients with axillary-subclavian vein thrombosis seen recently are catheter insertion related; 2) Diagnosis should be initiated with duplex imaging; and (3) Thrombolytic therapy significantly decreased residual symptoms and yielded better resolution than anticoagulants.

Delayed splenic rupture: real or imaginary?

Although splenic injury is the most frequent abdominal injury resulting from blunt trauma, delayed splenic rupture is a rare event. From 1981 to 1990, 75 patients treated at St. Elizabeth Hospital Medical Center (Youngstown, OH) had blunt splenic injury. Splenic rupture was delayed in six of these patients (8%). More severe trauma, such as occurs with motor vehicle accidents, is more likely to lead to immediate rupture. Lesser trauma resulting from minor falls or fights is more likely to lead to delayed rupture. Subcapsular hematoma is the most common etiology for delayed splenic rupture. Although there is no reliable symptom or sign during the latent period, abdominal pain occurs almost uniformly and Kehr's sign is quite common. Peritoneal lavage and abdominal computerized axial tomography scan are accurate in diagnosing splenic rupture. Unfortunately, they are not always reliable in predicting delayed rupture.

Vocational outcome of intervention for low-back pain.

Practical management guidelines for occupational health physicians are needed for the individual support of employees with low-back pain. In this study the level of evidence regarding the efficacy of intervention with vocational outcome parameters was assessed. In a systematic literature search, 40 randomized clinical trials on different types of intervention were retrieved. Their internal validity and statistical power criteria were assessed. The randomization procedure, blinding of patients, and sample size were problematic in most studies. For patients with acute low-back pain limited or moderate evidence was found for the efficacy of no bed rest, a short period of bed rest, and spinal manipulation. For chronic patients limited evidence was found for the efficacy of antidepressants. For the other types of intervention, studies with sufficient statistical power were lacking. Such studies are needed before more-detailed evidence-based guidelines can be formulated for occupational health care.

Evaluation of nursing care after diagnostic coronary angiography.

BACKGROUND: Restricting inpatients who have undergone a cardiac catheterization to 6 hours of flat bed rest to reduce the potential for bleeding from the femoral arteriotomy site is based on tradition rather than on research and is associated with discomfort for the patients. OBJECTIVES: To (1) determine the prevalence of femoral arteriotomy complications after diagnostic coronary angiography among inpatients after implementation of a guideline that included reduced duration of bed rest, elimination of sandbags at the arteriotomy site, and 30 degrees elevation of the head of the bed; (2) compare complication rates in this study with rates in previous studies; and (3) determine patient- or practice-related characteristics associated with complications. METHODS: Records of 306 inpatients were reviewed retrospectively to determine the prevalence of femoral arteriotomy complications and the presence of patient- or practice-related characteristics potentially associated with complications. Associations between each characteristic and the presence of a complication were evaluated by using the Wilcoxon rank sum test for continuous data and the chi 2 or Fisher exact test for nominal data. RESULTS: Prevalences of complications were hematoma, 8.8%; bleeding, 4.5%; pseudoaneurysm, 1%; arteriovenous fistula, 0%; and thrombosis, 0%. No evidence indicated that the occurrence of a complication was related to any patient- or practice-related characteristic. Complication rates were comparable to those of previous studies. CONCLUSIONS: The findings support continuation of the current guideline for patients' care after diagnostic coronary angiography. However, further prospective studies with larger samples of inpatients are warranted.

Effect of backrest position on intracranial pressure and cerebral perfusion pressure in individuals with brain injury: a systematic review.

Head elevation is a conventional nursing procedure for brain-injured individuals with intracranial hypertension; it is performed with the intent of reducing intracranial pressure (ICP) by means of a noninvasive physical intervention. However, in certain circumstances, head elevation puts the brain-injured individual at risk for secondary cerebral injury because of impaired arterial blood pressure and compromised cerebral perfusion pressure (CPP). A systematic literature search was conducted to evaluate existing evidence regarding the effect of changing the backrest position on ICP and CPP in brain-injured individuals. Eleven articles were retrieved. In nine articles it was concluded that ICP significantly decreased at 30 degrees of head elevation compared with a flat position. Five of the nine articles showed no statistical significance in the magnitude of change in CPP from a flat position to 30 degrees of head elevation. Major limitations in the 11 articles were small sample sizes and unclear study protocols, which may have caused a failure to detect the effect of head elevation. In clinical practice, intensive care unit staff members need to cautiously perform head elevation with a thorough understanding of its physiologic effect and potential hazard. Future research should investigate the effects of therapeutic positions on different neurological and neurosurgical populations and explore the combination of head elevation and lateral side-lying positions.

Is bed rest an effective treatment modality for pressure ulcers?

Despite the well-documented medical, physical, and psychological complications associated with this care management option, bed rest remains a frequently prescribed treatment modality for conditions such as pressure ulcers. Cognitive and psychosocial complications of bed rest include depression, learned helplessness, perceptual changes, and fatigue. Physically, complications can include contractures, muscle atrophy, osteoporosis, pathologic fractures, urinary tract infections, decreased cardiac reserve, decreased stroke volume, resting and post-exercise tachycardia, orthostatic hypotension, pulmonary embolism, deep venous thrombosis, pneumonia, anorexia, constipation, and bowel impaction. Furthermore, the literature does not contain evidence supporting the use of bed rest to facilitate healing of pressure ulcers. More suitable approaches to pressure ulcer care include limiting bed rest, initiating occupational therapy, integrating meaningful tasks into daily activities, increasing outside stimulation, involving patients in care decisions and addressing their concerns, optimizing nutritional status, and managing pressure and shear throughout daily activities. Recommendations for implementing alternatives to bed rest are addressed.

Stress fractures of the anterior tibial diaphysis.

Stress fracture of the anterior tibial diaphysis is rare and occurs mostly in leaping athletes. Thirty-six of these fractures in 35 patients have been reported in the literature. These are combined with 15 similar fractures in our experience to provide combined data on 51 anterior tibial stress fractures. Comparison of the various treatments utilized disclosed that there is a high risk of complete fracture if affected patients are allowed full activity, and that treatment by rest alone allowed only 40% to return to full activity even after symptomatic improvement. The treatment recommended for these patients is excision of the fissure, transverse drilling at the fissure site, and cancellous bone grafting of the defect. In those patients who suffer a complete fracture, open reduction and internal fixation is superior to closed treatment.

Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children.

PURPOSE: The aim of this study was to validate the safety, and quantify the impact of, an abbreviated protocol for blunt spleen/liver injury (BSLI), we instituted a prospective study with early ambulation. METHODS: Following institutional review board approval, data were collected prospectively in all patients with BSLI up to 8 weeks after discharge. There were no exclusion criteria, and patient accrual was consecutive. Bedrest was restricted to 1 night for grade I and II injuries and 2 nights for grade III or higher. RESULTS: A total of 131 patients with BSLI were enrolled. Injuries included isolated spleen in 72 (55%), liver only in 55 (42%), and both in 4 (3%). One splenectomy was required for a grade 5 injury. Transfusions were used in 24 patients, with 18 patients undergoing transfusion because of injured solid organ. Bedrest was applicable to 110 patients (84%), for which the mean grade of injury was 2.6 and mean bedrest was 1.6 days. The need for bedrest was the limiting factor for length of stay in 86 patients (66%). There were 2 deaths, and no patients were readmitted. CONCLUSIONS: An abbreviated protocol of 1 night of bedrest for grade I and II injuries and 2 nights for grade III or higher can be safely used, resulting in dramatic decreases in hospitalization compared with the current American Pediatric Surgical Association recommendations.