Type 2 Diabetes Mellitus: Relationships Between Preoperative Physiologic Stress, Gastric Content Volume and Quality, and Risk of Pulmonary Aspiration.

Pulmonary aspiration is a potentially fatal anesthetic complication occurring when gastric contents enter the respiratory system. Fasting guidelines aim to decrease the risk of pulmonary aspiration by recommending a timeframe in which patients abstain from food and drink before surgery. Fasting guidelines recommended for healthy individuals fail to account for patients with type 2 diabetes mellitus (T2DM). Gastroparesis, a common condition associated with T2DM, is exacerbated during stress such as an impending surgery. This study sought to determine whether a relationship exists between stress levels and gastric contents in fasting patients with T2DM presenting for an elective surgical or diagnostic procedure. The quality and quantity of gastric contents and preoperative stress were evaluated using gastric ultrasonography and salivary α-amylase levels. No relationship existed between preoperative stress and gastric contents; however, glycated hemoglobin levels of 7% or greater were associated with increased gastric fluid, which was the most significant finding in this study. In addition, there was a significant difference between the mean gastric volume in healthy individuals and patients with T2DM. Performance of gastric ultrasonography preoperatively provides objective data that could influence the anesthetic plan and decrease the risk of pulmonary aspiration in patients with T2DM.

Critical Events Leading to Endotracheal Reintubation in the Postanesthesia Care Unit: A Retrospective Inquiry of Contributory Factors.

The tracheal reintubation of a surgical patient in the postanesthesia care unit (PACU) is a critical event that increases patient morbidity and mortality, cost, and staff demands. We performed a descriptive retrospective cohort study to identify the incidence of reintubation after planned extubation (RAP) in the PACU from 2010 to 2017. The incidence of RAP was 0.00083% (89/107,845) for the entire study period, an incidence range from 0.00014% to 0.00172% (1/7,407 to 26/15,139) with a steady decline from 2011 to 2017. A post hoc application of published prediction tools demonstrated that most RAP cases could be predicted preoperatively when the RAP predictive risk index (described in 2013) was applied to patients over the age of 64 years. Preoperative attention to increased risk of RAP decreases the incidence of RAP. Neuromuscular blockade (NMB) must be monitored, and reversal must be ensured. Attempting to reverse moderate to deep NMB with increased dosing of neostigmine should be avoided, and NMB reversal with sugammadex should be used in these cases and when residual weakness is observed. Hypothermia must be avoided, and a multimodal pain management regimen must be adopted.

No bacterial growth found in spiked intravenous fluids over an 8-hour period.

Protocol changes prompted by the Joint Commission mandating intravenous (IV) fluid bags to be used within 1 hour of spiking because of possible bacterial contamination have sparked clinical and economic concerns. This study investigated the degree of bacterial growth in which samples were obtained from spiked IV fluid bags at the time of spiking and 1, 2, 4, and 8 hours after spiking. No bacterial growth occurred in any of the 80 bags of Lactated Ringer's (LR) IV solutions sampled. This study demonstrated that LR IV bags do not support any bacterial growth for up to 8 hours after spiking.

Refractory Hypotension in a Patient with a History of Anabolic Steroid Abuse Taking an Angiotensin-II Receptor Blocker: A Case Report.

The renin-angiotensin-aldosterone system (RAAS) is a key component of blood pressure regulation. Patients who take RAAS antagonists on the morning of surgery are at risk of developing hypotension under anesthesia that is refractory to treatment with fluid boluses and conventional vasopressors. This case report describes a unique case of refractory hypotension in a patient with a history of anabolic steroid abuse taking an angiotensin II receptor blocker. An understanding of the role of the RAAS in blood pressure regulation is essential for managing refractory hypotension in the patient under general anesthesia. A scarcity of data on the anesthetic implications of anabolic steroid abuse exists, but an understanding of the physiologic implications of anabolic steroid abuse can help guide management for these patients.

Evidence-based screening for low bone mineral density in HIV-infected men.

Low bone mineral density, which leads to osteoporosis and fracture risk, is an emerging clinical problem in HIV-infected patients. Our evidence-based practice project screened a convenience sample of 225 HIV-infected men for low bone mineral density using the Osteoporosis Self-Assessment Tool, and of those men, 173 were also screened by quantitative ultrasound of the calcaneus. One hundred twelve men had low bone mineral density by either or both screening methods. Seventy-one of these 112 men were tested by dual-energy x-ray absorptiometry and 73% had low bone mineral density. The positive protective value of the Osteoporosis Self-Assessment Tool was 73% and for quantitative ultrasound was 88%. These results suggest that routine low bone mineral density screening should be included as standard practice for all HIV-infected patients.

Total knee arthroplasty in a patient with diastrophic dwarfism.

Diastrophic dwarfism is an autosomal recessive disease that predominantly occurs in the Finnish population (1 in 33,000) but has been known to occur worldwide. Affected patients present with multiple cartilaginous anomalies and early degeneration of weight-bearing joints. Once past infancy, life expectancy is favorable and patients may undergo multiple surgical procedures throughout their lifetime to repair .or replace affected joints. The characteristic short trunk of these patients in addition to scoliosis, cervical kyphosis, and involvement of articular cartilages can create unique ventilation and airway challenges for anesthesia providers involved in their care.

The use of discriminant function analysis to predict student success on the NCLEX-RN.

Predicting whether a student will be successful on the National Council Licensure Examination for Registered Nurses (NCLEX-RN) has been an important endeavor for faculty in schools of nursing for the past 2 decades. Extensive documentation exists in the literature concerning research aimed at exploring the academic and nonacademic predictors of success on the NCLEX-RN. Reviews of the findings of these studies indicate that various factors emerge as academic predictors of success. The results of this study suggest that first-time success on the NCLEX-RN can be predicted with a high level of accuracy using existing student data. The findings also support the belief that it is possible to identify students who may be at risk for unsuccessful first time performance on the NCLEX-RN. Early identification of at-risk students will promote timely intervention strategies to optimize the students' potential for success.

Occlusion of a wire-reinforced endotracheal tube in an almost completely edentulous patient.

Wire-reinforced endotracheal tubes have been advocated for use where endotracheal tube kinking is a risk. We report on a 79-year-old nearly edentulous male patient in a weakened state who managed to partially obstruct a wire-reinforced endotracheal tube, despite the presence of a soft bite block. The risk of kinking wire-reinforced endotracheal tubes is not mitigated simply because the patient is edentulous. Good monitoring, vigilance by providers and the use of a solid bite block remains critical in the care of these patients.

Is there postoperative evidence of implicit learning following aural stimuli at moderate hypnotic BIS levels during general anesthesia?

Patients may develop behavioral changes after the administration of a general anesthetic without a triggering stimulus. This phenomenon, referred to as implicit learning, continues to be debated. Some researchers have denied the phenomenon takes place, while others have demonstrated behavioral changes not related to recall. In previous studies it was difficult to determine the effects of taped messages or suggestions, as anesthesia techniques were not standardized, and true depth of anesthesia was impossible to determine. The development of bispectral index (BIS) monitoring allows practitioners to determine the depth of anesthesia based on neuronal activity. In the present study, we compared 2 randomized groups of patients from a convenience sample of patients scheduled to undergo elective spinal surgery at a Department of Veterans Affairs Medical Center. All patients were screened for normal hearing acuity. The control group listened to tapes of white noise, while the experimental group listened to a word list and short story selection. Both groups listened to the tapes at similar BIS levels. A posttest was administered to determine explicit recall, as well as implicit memory formation. No patients had explicit recall. There was no difference in the implicit memory scores between patients in the experimental group and the control group.

Hypotension in the PACU: an algorithmic approach.

Hypotension is a common postoperative complication in the perianesthesia setting and contributes to increased patient morbidity and mortality rates. An understanding of the etiologies, diagnosis, and treatment of this complication is critical to successful treatment of the patient. This article presents an algorithm designed to provide the perianesthesia nurse with a step-by-step guide to the assessment and management of the patient presenting with hypotension.