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.

Evaluation and management of apparent life-threatening events in infants.

Apparent life-threatening events (ALTEs) are frightening to caregivers and clinicians alike. This article provides a comprehensive review of the causes, management, and consequences of ALTEs. The information provided was collected from an extensive literature review using the search terms ALTE, sudden infant death syndrome, and apnea. There is a wide array of contributing factors to ALTE syndrome and sequalae for both infants and caregivers of infants experiencing an ALTE.

Can all neonatal resuscitation be managed by nurse practitioners?

AIM: To assess the ability of nurse practitioners to manage the care of all babies requiring resuscitation at birth in a unit without on site medical assistance. METHOD: A prospective review, and selective external audit, of the case records of all 14 572 babies born in a maternity unit in the north of England during the first eight years after nurse practitioners replaced resident paediatric staff in 1996. RESULTS: Every non-malformed baby with an audible heart beat at the start of delivery was successfully resuscitated. Twenty term babies and 41 preterm babies were intubated at birth. Eight term babies only responded after acidosis or hypovolaemia was corrected following umbilical vein catheterisation; in each case the catheter was in place within six minutes of birth. Early grade 2-3 neonatal encephalopathy occurred with much the same frequency (0.12%) as in other recent studies. Independent external cross validated review found no case of substandard care during the first hour of life. CONCLUSION: The practitioners successfully managed all the problems coming their way from the time of appointment. There was no evidence that their skill decreased over time even though, on average, they only found themselves undertaking laryngeal intubation once a year. It remains to be shown that this level of competence can be replicated in other settings.

Apnea frequently persists beyond term gestation in infants delivered at 24 to 28 weeks.

BACKGROUND: Apnea of prematurity remains among the most commonly diagnosed conditions in the Newborn Intensive Care Unit and may prolong hospital stays in some infants. Because survival of extremely premature infants has improved markedly, the natural history of apnea in this population needs to be reassessed. OBJECTIVE: To document the natural history of recurrent apnea and/or bradycardia events in infants delivered at 24 to 28 weeks' gestation. METHODS: Medical records of all infants delivered at 24 to 28 weeks' gestation admitted to the Brigham and Women's Hospital Newborn Intensive Care Unit between January 1989 and March 1994 were reviewed to document the clinical course of apnea of prematurity. Subjects were included in the study sample if they were discharged home from the Brigham and Women's Hospital or after transfer to an affiliated hospital. Recordings of apnea and/or bradycardia events were based on nursing observations of monitor alarms and assessment of the infant's condition. RESULTS: Of 457 eligible infants, 226 were included in the study sample and stratified by gestational age at birth assigned by the attending neonatologist. The time to resolution of recurrent apnea/bradycardia events was longer with lower gestational age at birth. Apnea/bradycardia events were frequently observed beyond 36 weeks' postconceptional age in all gestational age groups. The incidence of apnea persisting beyond 38 weeks postconceptional age was significantly higher in the 24- to 27-week infants combined compared with the 28-week infants. CONCLUSIONS: Apnea of prematurity frequently persists beyond term gestation in infants delivered at 24 to 28 weeks' gestational age. These persistent apnea and/or bradycardia events may contribute to prolonged hospitalization. Programs to promote earlier discharge of premature infants should take into account the variability in resolution of apnea and specifically address management of persistent apnea.

The art and science of home infant apnea monitoring in the 1990s.

The use of home apnea monitoring (HAM) continues as an accepted or recommended intervention for infants with certain signs and symptoms or medical diagnoses. Results of HAM in terms of case outcomes versus cost-effectiveness and efficacy remain matters of controversy in relation to the limited number of studies that show conflicting results. There are no studies that document the effectiveness of apnea monitoring. When an apnea monitor is prescribed, nursing can provide quality care through education and emotional support of families using HAM.

Infantile apnea monitoring and SIDS.

Primary care practitioners are presented with many concerns and questions from families about Sudden Infant Death Syndrome (SIDS), apnea, and monitors. Clinicians need to know which symptoms are of concern, when to ask for consultation from an apnea center, and how to refer the parent for support and counseling. This article reviews the current knowledge of infantile apnea, monitoring, and SIDS. An approach to evaluation and management is presented.

Apnea of prematurity: current management and nursing implications.

Apnea is a common occurrence in preterm infants. Neonatal nurses must have a clear understanding of the diagnosis, pathophysiology, and management of apnea of prematurity. In addition, there are many implications for the nurse caring for the preterm infant with apnea. Nurses play an essential role in monitoring for apnea and the effectiveness of its treatment.

Home apnea monitoring. A systems approach to the family's home care needs.

Parents who bring home an infant requiring constant home apnea monitoring often face a stressful situation with their child's medical difficulties and their own financial concerns. The home care nurse must be aware of the difficulties facing these families to offer the necessary support and education.

Sleep measured by polysomnography in patients receiving high-dose chemotherapy for multiple myeloma prior to stem cell transplantation.

PURPOSE/OBJECTIVES: To describe the objective sleep of patients receiving chemotherapy for multiple myeloma (MM) prior to stem cell transplantation. DESIGN: A descriptive study with repeated measures. SETTING: An international referral center in an urban area of the southern United States. SAMPLE: A convenience sample of a subset of 12 patients with MM, recruited from a randomized, controlled trial. METHODS: Objective sleep was assessed using two nights of polysomnography, one obtained before and one after a second cycle of high-dose chemotherapy prior to stem cell transplantation. Demographic and clinical data were obtained through a retrospective chart review. MAIN RESEARCH VARIABLES: Objective sleep including sleep characteristics, sleep-related respiratory events, and periodic limb movements (PLMs) of sleep. FINDINGS: Sleep was characterized by a relatively short sleep time, excessive time spent awake after the onset of sleep, and poor sleep efficiency (objective sleep quality). Patients spent more than the expected percent of time in non-rapid eye movement sleep and less in rapid eye movement sleep. Arterial oxyhemoglobin saturation nadirs reflected episodes of low arterial oxygen saturation. PLMs during sleep were in the mildly elevated range. CONCLUSIONS: Findings suggest that patients had poor sleep efficiency (objective sleep quality) and were slightly better sleepers after receiving a second cycle of high-dose chemotherapy. A number of patients also demonstrated obstructive sleep apnea and frequent PLMs. IMPLICATIONS FOR NURSING: Findings support the need for additional investigation of sleep in patients with MM, particularly poor sleep efficiency and PLMs. Improving sleep may improve quality of life by decreasing associated symptoms such as pain, fatigue, and depression. KNOWLEDGE TRANSLATION: Oncology nurses should consider assessing patients with MM for insomnia symptoms, excessive daytime sleepiness, obstructive sleep apnea, and a history of jerking or kicking their legs when asleep. Those symptoms may suggest the need for additional investigation of a possible sleep disorder, which may negatively influence mood and function.

Prolonged paralysis and apnea after receiving a neuromuscular blocking agent: what nurses should know.

After receiving mivacurium, a short-acting neuromuscular blocking agent used for intubation before surgery, a patient experienced prolonged paralysis and prolonged apnea that required ventilator support. Although this complication is rare, all critical care nurses should be aware of it so they can be competent in managing and providing holistic and comprehensive nursing care to the patient and the patient's family. Although this complication has been documented in the anesthesia literature, it has received little mention in critical care nursing journals.

A primer on Apnea of prematurity.

Apnea, the cessation of respiratory airflow, can begin in many preterm infants in the first week of life and can last until the day of discharge or beyond. This article provides an overview of the complex anatomic, physiological, and developmental mechanisms related to immaturity of both the central nervous system and musculature of the pulmonary system, that contribute to apnea of prematurity. Apnea of prematurity is a diagnosis of exclusion; an array of other conditions and stimuli can also cause apnea, including infections, pulmonary disease, and intracranial pathology. The standard clinical management of apnea, including cutaneous stimulation, methylxanthine therapy, and continuous positive airway pressure or ventilatory support, are discussed as well as newer investigational therapies, such as olfactory stimulation. Emerging evidence on the long-term neurodevelopmental impact of apnea is reviewed. Nursing measures to prevent and manage apnea are reviewed with an emphasis on parent education and preparation for discharge. Apnea resolves in most preterm infants as they approach term corrected gestational age; however, if it does not, options include continued hospitalization or, for infants with stable apnea, discharge with a home apnea monitor.

Patient-centered high-technology home care.

High-technology home care is a reality in today's health care system. Nurses, as health professionals, will be involved in high-technology home care for many patients, regardless of age or diagnosis. The nurse's involvement may be in the predischarge setting or in the home actually providing care. High-technology home care cannot and should not merely be care of the technology (the "machines and tubes") at home; rather, it should emphasize the care of the patients and families who are receiving technically complex therapies. To provide care for the patient and entire family, all nurses involved with the patient need to be aware of where the patient and family are developmentally, the structure of family relationships, the expectations with regard to home therapy, and the ability of the patient and family to physically or emotionally manage the therapy. Incorporating this information into a care plan for patient and family teaching can enable the nurse to provide care to the patient and family that surpasses that of merely seeing that the high-technology procedure is done safely and correctly.

Recent advances in home infant apnea monitoring.

Appropriate and effective nursing intervention is an essential element in determining how the family responds to the monitor in the home. Accurate assessment of the family system and dynamics provides the basis for a plan of care. The family's and infant's specific needs must be addressed. Careful implementation of the plan allows for changes and unexpected outcomes. Frequent evaluation of monitoring is necessary to determine if a change in the plan of care is needed. Recent changes in home apnea monitoring technology are rapidly altering the care of infants at risk for apnea and SIDS. The advent of the documented or recording monitor has the potential to demystify the events occurring while the infant is being monitored. Parents can get answers about their infant as quickly as a telephone call. The clinician can differentiate between a true and a false alarm and reassure the parents accordingly. Documenting false events and shallow-breathing alarms will potentially reduce the duration of monitoring, decreasing costs to the entire health care system. Documented monitoring is a valuable tool for nurses. For the staff nurse, clinical observation can be validated through trending and print out of events can be done at the bedside. For the advanced practice nurse, management of care can become more efficient through remote monitoring via modem. Patient teaching can be followed with immediate feedback. Monitors may assist in allaying anxiety in families who have lost children to SIDS or had an unexpected death in a previous sibling. Families may feel less anxious about having an "at risk" child in the home if the events are continuously being recorded. Length of hospital stay may decrease initially, with fewer rehospitalizations. Nursing research in these areas is necessary. Evaluating events occurring in the home may also help shed light on the enigma of SIDS. Several SIDS deaths have been recorded on documented monitors. If we can pinpoint exactly what takes place prior to and immediately after a SIDS episode, the enigma that has had physicians puzzled for so long may finally begin to unravel.

Parenting of at-risk infants in the face of uncertainty: home apnea monitoring of subsibs.

This article describes the experiences of a group of parents in New Zealand who lost infants to sudden infant death syndrome (SIDS) and who monitored their subsequent infants or subsibs (infants born after the death of an infant due to SIDS) at home for signs of apnea. Their caregiving experiences are explored within the framework of the substantive theory developed by Cohen (1993) that describes how another group of parents, those caring for children with chronic life-threatening illnesses, copes with living under conditions of sustained uncertainty. Attention is drawn to the similarities in both the grieving processes and coping strategies used by both groups of parents in these parallel situations.

Patient education and the quality assurance process.

As these three examples suggest, the QA conference at East Tennessee Children's Hospital is an excellent mechanism by which relevant patient education activities can be incorporated into the routine medical management of many patient groups. In this regard, many physicians respond better to the recommendations of their peers than to requests from patient education coordinators, nurses, or others who need physicians' approval and support in providing consistent patient education services. Although most of the medical staff at East Tennessee Children's Hospital readily offer such support, the cooperation of the child life department with the QA conference has helped to identify clearly the important role of patient education in a comprehensive approach to the QA process.