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.

Influences on length of stay in an enhanced recovery programme after colonic surgery.

AIM: Enhanced recovery after surgery (ERAS) programmes have been shown to accelerate and enhance functional recovery after colonic surgery. We analysed prospectively collected data to investigate potentially modifiable factors that may influence the length of stay (LOS) in the ERAS setting at a single institution. METHOD: Between October 2005 and November 2008, prospective data were collected on consecutive patients who underwent elective colonic surgery without a stoma. Patients with rectal cancer, those unable to participate in preoperative ERAS components because of their inability to communicate effectively in English, those with cognitive impairment and those with an American Society of Anesthesiologists (ASA) grade of ≥ 4 were excluded. Statistical analyses were performed using the Mann-Whitney U-test and Cox regression modelling. RESULTS: A total of 100 (79 malignancies) patients underwent elective colon resection during the study period. There were 57 right-sided, 41 left-sided and two total colectomies. The median age of the patients was 67.5 (range 31-92) years and the median day stay was 4 (range 3-46) days. Factors with significant correlations for reduced LOS were female gender, the surgeon, operative severity, high-dependency unit (HDU) admission and incision type favouring laparoscopic and transverse approaches. Age, operation site, indication for surgery and body mass index were not significant predictors of hospital stay. Gender, operative severity, HDU admission and surgeon did not have any independent correlation with LOS; in contrast to the ASA score and the type of incision, which did. CONCLUSION: Lower ASA score, transverse incision laparotomy and laparoscopy correlated independently with reduced postoperative LOS within the ERAS setting.

The nursing and financial implications of laparoscopic colorectal surgery: data from a randomized controlled trial.

AIM: The issue of cost effectiveness of laparoscopic surgery remains uncertain and its impact on the ward nursing staff is unaddressed. This study investigated these issues using patients from a single centre admitted to a randomized controlled trial. METHOD: All patients recruited into the Australasian Laparoscopic Colon Cancer Study (ALCCaS) from The Queen Elizabeth Hospital between January 1999 and March 2005 were included in this study. Data relating to hospital cost were collated from the Hospital Patient Costing System. Nursing interventions were calculated in minutes per patient, using the excelcare Software database. RESULTS: Data from 97 patients were analysed (laparoscopy, 53; open surgery, 44). The median number of hours of nursing input per patient was 80 (27.5-907) h in the open surgery group and 58.5 (15-684.5) h in the laparoscopy group. This difference was further increased after exclusion of patients converted from laparoscopy to open surgery. The median total cost of the procedure was AUS $9698/£ 5631 (AUS $3862-90,397) in the open surgery group and AUS $10,951/£ 6219 (AUS$2337-66,237) in the laparoscopy group. CONCLUSION: These data suggest that laparoscopic colorectal surgery is equivalent in price to open surgery and there may be added benefits in reduced nursing intensity.

A quality committee's evaluation of surgical intervention for Clostridium difficile infection.

Clostridium difficile (C diff) is an anaerobic bacterium that causes antibiotic-associated colitis, which can progress to a life-threatening illness for some patients. Clostridium difficile is highly transmissible in health care settings and has high morbidity and mortality rates. The increased prevalence of this bacterium and the consequences of infection necessitate an understanding of its transmission and use of stringent infection control practices. A two-year retrospective evaluation was performed to examine the effectiveness of a screening tool for patients requiring surgical intervention for C diff and to determine whether treatment was timely and effective. Early, aggressive surgical intervention appears to bel the single most effective treatment for fulminant C diff colitis.

Development of abdominal wound dehiscence after a colectomy: a nursing challenge.

Abdominal wound dehiscence is associated with prolonged hospitalization, high morbidity and mortality rates, an increase in health care costs, and risk of further surgery. A case of wound dehiscence in a patient following major abdominal surgery is reviewed and a framework for understanding wound complication as a challenge to nursing care is provided.

Readmissions attributable to skilled nursing facility use after a colectomy: Evidence using propensity scores matching.

BACKGROUND: Postacute care (PAC) is a major driver of the rising health care costs in the United States (US). There is limited evidence on the causal effect of skilled nursing facility (SNF) use on readmission after an inpatient colectomy. STUDY DESIGN: We performed a retrospective analysis of data from the Pennsylvania Health Care Cost Containment Council (PHC4) on 38,635 patients who underwent an inpatient colectomy between 2011 and 2014 in a Pennsylvania hospital. Using propensity scores, we matched patients who were discharged to a SNF to those who were discharged elsewhere. We compared the probability of readmissions within 30 days for the two groups of matched patients in a regression framework. For the subset of patients who were readmitted within 30 days, we assessed whether patients discharged to SNF were readmitted earlier than those discharged to other entities. RESULTS: The use of a SNF after a colectomy significantly raises the patients' chance of readmissions within 30 days, even after controlling for their demographic characteristics and illness severity. Based on our estimates, being discharged to a SNF raises the chance of a readmission by 7.7 percentage points. For patients who were admitted within 30 days, we find no association between discharge to a SNF and the timing of readmission. CONCLUSION: Sending less severe patients to facilities other than a SNF following inpatient colectomy may help hospitals reduce 30-day readmission rates.

Fast-track surgery may reduce complications following major colonic surgery.

PURPOSE: Fast-track (enhanced recovery) care pathways for colonic surgery are becoming increasingly popular; however, there have been concerns regarding protocol compliance, high readmission rates, and also the true impact on morbidity rates with these protocols. This study was conducted to assess the impact of a fast-track program for colonic surgery on hospital stay, complications, and readmission rates. METHODS: From December 2005 to March 2007, consecutive patients undergoing colonic surgery were prospectively studied. The comparison group consisted of a comorbidity-matched group of patients who had undergone similar surgery before establishment of the fast-track program. RESULTS: Fifty patients were included in each group. Groups were comparable at baseline. The fast-track group received significantly smaller amounts of intraoperative and postoperative intravenous fluids, were fed earlier, mobilized earlier, passed flatus earlier, and were discharged earlier than the comparison group (4 vs. 6.5 days, P < 0.001). The numbers of patients with urinary infections (2 vs. 12, P = 0.008), ileus (5 vs. 18, P = 0.005), and cardiopulmonary complications (11 vs. 21, P = 0.032) were significantly lower in the fast-track group. There was no difference in the rate of readmission. CONCLUSION: Fast-track is a safe and effective approach for reducing hospital stay and morbidity following major colonic surgery.

Introducing a patient-focused care map in colorectal surgery: a pilot qualitative study of patients' and surgical oncology nurses' experiences.

Care maps for patient care have been around for many years. Key stakeholders at our institution developed and implemented a care map for patients undergoing surgery for colorectal cancer. The purpose of this descriptive, qualitative pilot study was twofold. First was to understand the lived experience of patients being cared for under a newly-implemented care map utilizing patient diaries and interviews. The second goal was to describe the experiences of surgical oncology nurses caring for these patients using a focus group technique. The results of our small study indicated that patients appreciated having a document that outlines daily activities and goals, and were anxious to get home, but were disappointed in the discharge planning process. Nurses were positive about the care map overall, but felt they could have contributed more in the development and planning stages of the care map. Overall, the implementation of our patient-centred care map was a success.

Laparoscopic bowel surgery.

Bowel surgery is performed on a daily basis in many hospitals around the world. With the introduction of laparoscopic surgery in the 1990s, laparoscopic bowel surgery has become an option for patients to consider. This article will briefly review the anatomy of the large bowel and identify indications, contraindications, preoperative preparations, and intraoperative considerations for laparoscopic bowel surgery. A brief description of the various types of laparoscopic bowel resection procedures will be presented along with the advantages and complications. The future of laparoscopic bowel surgery will also be presented.

Aplicação do cuidado baseado na teoria de Orem ao paciente ostomizado / Aplicación del cuidado basado en la teoría de Orem al paciente ostomizado / Application of care based on Orem's theory to the ostomy patien

Estomia intestinal é realizada para desviar o trânsito intestinal para o exterior do corpo, o autocuidado do sujeito é fundamental para o seu processo de bem-estar físico e psicossocial, visto que ocorre mudança na imagem corporal. OBJETIVO: relatar a experiência da prática da sistematização da assistência de enfermagem, com base nas demandas terapêuticas de autocuidado de acordo com a teoria de Orem. MÉTODO: Trata-se de um estudo descritivo, tipo relato de experiência das residentes do Programa de Residência Multiprofissional em Cuidados continuados integrados na área de concentração em atenção à saúde do idoso no estado de Mato Grosso do Sul (MS). RELATO DE CASO: Cliente 58 anos, branco, casado, profissão vendedor, com diagnóstico médico de choque séptico de foco abdominal. DISCUSSÃO: A equipe multiprofissional nesse âmbito insere no contexto hospitalar uma nova visão do cuidado, tendo como uma das funções costurar o sujeito fragmentado pela medicina, e romper o modelo cartesiano ainda existente no imaginário dos profissionais. CONSIDERAÇOES FINAIS: O conhecimento da equipe multiprofissional acerca da legislação que regulamenta o atendimento das pessoas com estomias é de extrema importância, uma vez que, essa equipe deve desempenhar suas ações com eficiência e eficácia à luz do que a legislação preconiza

La estomía intestinal se realiza para desviar el tránsito intestinal hacia el exterior del cuerpo, el autocuidado del sujeto es fundamental para su proceso de bienestar físico y psicosocial, ya que ocurre un cambio en la imagen corporal. OBJETIVO: relatar la experiencia de la práctica de la sistematización de la asistencia de enfermería, con base en las demandas terapéuticas de autocuidado de acuerdo con la teoría de Orem. MÉTODO: Se trata de un estudio descriptivo, tipo relato de experiencia de las residentes en el Programa de Residencia Multiprofesional en Cuidados continuados integrados en el área de concentración en atención a la salud del paciente en el estado de Mato Grosso do Sul (MS). RELATO DEL CASO: Paciente 58 años, blanco, casado, profesión vendedor, con diagnóstico médico de choque séptico de foco abdominal. DISCUSIÓN: El equipo multiprofesional en ese ámbito inserta en el contexto hospitalario una nueva visión del cuidado, teniendo como una de las funciones coser el sujeto fragmentado por la medicina, y romper el modelo cartesiano aún existente en el imaginario de los profesionales. CONSIDERACIONES FINALES: El conocimiento del equipo multiprofesional acerca de la legislación que regula la atención de las personas con estomias es de extrema importancia, una vez que ese equipo debe desempeñar sus acciones con eficiencia y eficacia a la luz de lo que la legislación indica

Intestinal stomies are performed to divert intestinal transit to the outside of the body, self-care of the subject is fundamental to the process of physical and psychosocial well-being, since there is a change in the body image. OBJECTIVE: to report the experience of the practice of the systematization of nursing care, based on the therapeutic demands of self care according to Orem's theory. METHOD: This is a descriptive study, a experience's report of the experience of the Residents of the Multiprofessional Residency Program in Continuing Care integrated into the area of attention to elderly health care in the state of Mato Grosso do Sul (MS). CASE REPORT: Client, 58 years old, white, married, salesman profession, with medical diagnosis of septic shock of abdominal focus. DISCUSSION: The multiprofessional team in this context inserts in the hospital context a new vision of care, it having as one of the functions to see the subject fragmented by medicine, and to break the Cartesian's model still existing in the professionals' imaginary. FINAL CONSIDERATIONS: The knowledge of the multiprofessional team about the legislation that regulates the care of people with stomies is of extreme importance, since, this team must carry out its actions with efficiency and effectiveness in light of what the law recommends, in addition, it is also the socialization of information with patients and family members about the guarantee of rights

Uncertainty, symptom distress, and information needs after surgery for cancer of the colon.

The purpose of this study was to determine the relationships between uncertainty, symptom distress, and discharge information needs in individuals after a colon resection for cancer. The theoretical framework for the study was derived from Lazarus and Folkman's stress, appraisal, and coping model, and Mishel's theory of uncertainty in illness. Uncertainty was measured by the Mishel Uncertainty Illness Scale (MUIS); symptom distress of pain, fatigue, constipation, diarrhea and loss of appetite by visual analogue scales; and discharge information needs by the Patient Learning Need Scale (PLNS). Forty individuals with a first diagnosis of cancer were interviewed after surgical resection of colon cancer. The study results indicated that they had moderate levels of uncertainty, low levels of symptom distress, and a moderate number of discharge information needs. Information related to treatment, complications, and activities of living were identified as highly important. An increase in uncertainty was significantly associated with an increase in discharge information needs. Increased attention to information needs at discharge may decrease an individual's level of uncertainty and facilitate the transition from hospital to home.

Hirschsprung's disease: diagnosis and management in children.

Hirschsprung's disease is a congenital abnormality of the bowel that results in loss of peristalsis, and is one of the main reasons why an infant may require a stoma soon after birth. Various stages of surgery may be required to resect the affected part of the bowel, including formation and closure of the stoma. Following surgery, the perception of many families is that their child is now "normal" and that all previous problems of managing their child are now resolved. However, there are a variety of postoperative complications and issues relating to bowel control which can affect the child in the long term. This article looks at how potential postoperative long-term problems can be identified early, and thus minimized, by healthcare staff being aware of possible problems, taking a proactive approach to management and advising families about the issues involved.