A comparison between lecture and videotape inservice for certified nursing assistants in skilled nursing facilities.

OBJECTIVE: Certified Nursing Assistants (CNA) provide most of the direct patient care in skilled nursing facilities (SNF). CNAs undergo mandatory inservice education regarding a variety of clinical conditions, but high CNA turnover and diverse cultural and educational backgrounds are persistent obstacles to overall staff education. A standardized, easily administered, highly reproducible training intervention would be valuable. We compared the efficacy of videotape versus standard lecture for inservice education relating to topics of dementia care, restraint use, and falls. DESIGN: A prospective randomized study. SETTING: Certified Nursing Assistants were recruited from three SNFs in San Diego County California between November 1997 and August 1998. PARTICIPANTS: The 82 CNAs who participated in the study were all CNA certified in California, employees of the study SNFs, and provided direct clinical care to SNF residents. All participants received regular inservice training. INTERVENTIONS: (1) Standard inservice lecture, (2) Videotape of inservice lecture material supplemented with brief clinical video vignettes. MAIN OUTCOME MEASURES: Scores on a 72-item multiple choice/true-false examination. MAIN RESULTS: Both lecture and video inservice education were effective in this CNA population. Test scores were significantly higher for both inservice groups compared with the control group (P < 0.001). There was no statistically significant difference between test scores for the two intervention groups (control = 63.1 +/- 8.2%, lecture = 78.2 +/- 8.9%, video = 77.9 +/- 11.2%). Knowledge retention was similar between the two intervention groups at 4 months. Lecture subjects who scored highest were more likely to have family members with dementia (P = 0.037), and video subjects who scored highest were younger (P = 0.007). CNA video subjects who scored highest on the examination were more likely to have English as their primary language compared with the highest scoring CNA lecture subjects (P = 0.012). CONCLUSIONS: Compared with control group scores, videotape and lecture inservice interventions were equally effective at increasing and maintaining test scores. The ease of frequent video intervention and the identification of learner characteristics most suited to the video format make audiovisual education a potentially powerful medium for CNA training. These data have important implications for future educational interventions in the SNF.

Time to peak effect of neostigmine at antagonism of atracurium- or vecuronium-induced neuromuscular block.

STUDY OBJECTIVE: (1) To determine the time to peak effect of neostigmine (time to peak antagonism) during atracurium- or vecuronium-induced neuromuscular block; and (2) to determine the effect on time to peak effect of neostigmine during atracurium-induced neuromuscular block, when the dose of neostigmine is increased from 35 micrograms/kg to 70 micrograms/kg. DESIGN: Prospective, randomized clinical study. SETTING: Gynecologic operating room suite at a university hospital. PATIENTS: 45 ASA I and II women admitted for gynecologic laparotomy. INTERVENTIONS: Anesthesia was performed with thiopental sodium, fentanyl, halothane, nitrous oxide, and atracurium or vecuronium. Train-of-four (TOF) stimulation and mechanomyography were used to monitor neuromuscular transmission. Neostigmine was administered while a constant degree of neuromuscular block was maintained at a twitch height at a point between 4% and 11% of the control twitch height, using a continuous infusion of atracurium or vecuronium. The patients were randomized to three groups, with 15 patients in each group. Group 1 received atracurium block antagonized with neostigmine 35 micrograms/kg; group 2 received vecuronium block antagonized with neostigmine 35 micrograms/kg; and group 3 received atracurium block antagonized with neostigmine 70 micrograms/kg. MEASUREMENTS AND MAIN RESULTS: The degree of neuromuscular block at antagonism was similar in the three groups. Time to peak effect (mean +/- SD) on TOF ratio was significantly longer in Group 1 (9.7 +/- 3.0 minutes) versus Group 2 (6.6 +/- 1.4 minutes; (p < 0.05). The time to peak effect on TOF ratio during atracurium-induced block was reduced from 9.7 +/- 3.0 minutes to 6.3 +/- 2.0 minutes when the dose of neostigmine was increased from 35 micrograms/kg to 70 micrograms/kg (p < 0.05). The peak effect on TOF ratio was significantly greater in Group 3 compared with Group 1 (p < 0.05), while it was similar in groups 1 and 2. CONCLUSION: The time to peak effect of neostigmine 35 micrograms/kg is about 6 to 10 minutes when antagonizing a constant degree of atracurium- or vecuronium-induced neuromuscular block at a twitch height at a point between 4% and 11%. Even though the time to peak effect was longer with atracurium than with vecuronium, clinically significant differences between the antagonizing effect of atracurium versus vecuronium block were not demonstrated. The time to peak effect during atracurium-induced block decreased when the dose of neostigmine was increased from 35 micrograms/kg to 70 micrograms/kg.

Observer variability of radionuclide left ventricular volume determination at rest and during exercise.

The reproducibility expressed as the intra- and interobserver variation in the determination of cardiac left ventricular (LV) volumes by the radionuclide multigated equilibrium technique in the upright position is presented. No systematic difference was found in the reproducibility between LV volumes determined in healthy subjects and cardiac patients or between examinations performed at rest and during exercise. The intra- and interobserver variation were of the same magnitude. SD of the difference was 8 to 9 ml for LV end-diastolic volume, 4 to 7 ml for LV end-systolic volume, and 2 to 5% for LV ejection fraction. Thus, there is a 95% probability that repeat measurements, either by the same observer or by 2 independent observers, will result in the same LV end-diastolic volume within 18 ml, LV end-systolic volume within 11 ml, and LV ejection fraction within 8%. Only 15% of the variation can be ascribed to determination of the attenuation correction factor.

The effect of topical lignocaine on intubating conditions after propofol-alfentanil induction.

BACKGROUND: Recent studies have found satisfactory conditions for intubation of the trachea without using muscle relaxants using an intravenous technique combining propofol and alfentanil. In this study we evaluate intubating conditions with this method and either lignocaine applied topically in the larynx and trachea or placebo. METHODS: Sixty adult patients of ASA class I were premedicated with diazepam 15-20 mg and randomly allocated to one of two groups. For induction of anaesthesia both groups were given propofol 2.5 mg/kg and alfentanil 30 micrograms/kg. One group received 4 ml of lignocaine 40 mg/ml (< or = 3 mg/kg) topically into the larynx and trachea (group L), the other group an equal amount of isotonic saline (group S) in a double-blind design. Intubation conditions were assessed as excellent, good, moderately good, poor or impossible, scored on the basis of jaw relaxation, ease of insertion of the tube and coughing on intubation. RESULTS: The total score for group L was significantly better than the score for group S (P < 0.0001) with significant differences with respect to ease of intubation and coughing after intubation. CONCLUSIONS: Induction of anaesthesia with propofol 2.5 mg/kg and alfentanil 30 micrograms/kg combined with 4 ml of lignocainespray 40 mg/ml into the larynx and trachea offered consistent and satisfactory intubation conditions. We thus recommend this method for tracheal intubation, where the use of muscle relaxants is not indicated.

Changes in volume of trapped gas in the lungs during provoked asthma followed by beta-2 receptor stimulation.

The volume of trapped gas (VTG) that could be mobilized by maximal breaths at the end of a nitrogen washout to 2% N2 was measured in 11 subjects with a history of asthma before and after provocation with specific allergens. The change after salbutamol was also measured. VTG was found to be more specific and sensitive for demonstrating early bronchospasm than changes in FEV1, VC or nitrogen washout. Salbutamol relieved all symptoms of bronchospasm.

Plasma level and broncholytic effect of choline theophyllinate after a single dose of a press-coated tablet formulation.

The broncholytic effect and plasma concentrations of theophylline in 10 asthmatic patients were studied for 8 hours after a single dose of 600 mg choline theophyllinate in press-coated 200 mg tablets. Therapeutic concentrations of theophylline were rapidly achieved and the plasma peak averaged 10.4 mug/ml after 2 hours. The broncholytic effect was closely related to the plasma level of theophylline. The largest change was in FEV1, which was significantly increased 1 to 6 hours after the dose. No patient complained of adverse effects. A theophylline concentration of 7 mug/ml plasma was adequate for a broncholytic effect, but a higher level was required for a maximal response. The results provide a basis for further studies to establish a dosage schedule suitable for prolonged therapy.

Plasma theophylline level and ventilatory function in chronic obstructive pulmonary disease during prolonged oral treatment with choline theophyllinate.

Plasma levels of theophylline and broncholytic activity have been studied in 12 patients with chronic obstructive pulmonary disease during prolonged oral treatment with choline theophyllinate, administered as a press-coated tablet (BrondaxinR). The plasma levels determined immediately before and 80 minutes after each dose showed very good agreement with those calculated on the basis of data from a previous single dose study. The plasma concentration and improvement in ventilatory function were closely correlated throughout the 48 hours of the study. A tendency towards further reduction of bronchial obstruction was observed during the second day, despite essentially unchanged plasma levels of theophylline. The results provide a rational basis for determination of an optimal dose schedule for oral treatment with choline theophyllinate to reduce the symptoms of obstructive bronchial disease.

Predominantly unilateral asthma studied with 133Xe-radiospirometry.

Regional lung function in the supine position was studied with 133Xe-radiospirometry in 10 asthmatic subjects in remission, before and after inhalation of specific allergens in the right lateral decubitus position. Regional ventilation and regional lung volume showed a significant decrease in the right lung. The decrease in ventilation was most pronounced in the diaphragmatic half of the lung. The regional perfusion of the right lung decreased less than the ventilation. The change in perfusion, however, became greater with time, whereas the decrease in ventilation remained the same as shortly after the provocation. Predominantly regional asthma could thus be provoked in the regions that receive most of the allergen in the right lateral position. The asthma was easily controlled and caused little discomfort.

Rectal administration of choline theophyllinate in adult asthmatics on theophylline maintenance therapy.

The relief of bronchial obstruction from theophylline administered intravenously and as retention enema was compared in a controlled double-blind cross-over study in 21 adult patients with reversible bronchial obstruction, who were on continuous treatment with an individually adjusted maintenance dose of oral theophylline. In two sessions the patients received in random order a 10 ml aminophylline infusion intravenously (180 mg theophylline) and the equivalent of 400 mg theophylline rectally in the form of choline theophyllinate, followed by serial determinations of ventilatory function and plasma theophylline levels during the next 8 h. Significant improvement of FEV1 within 1 h was recorded with both treatments and the duration of the effect was very similar for the two routes of administration. The patients were in stable state while taking part in the experiment but the similarity in the outcome suggests that choline theophyllinate administered as retention enema, although slower acting, represents a useful alternative to intravenous aminophylline also in the management of acute episodes of bronchial obstruction.

Effects of fentanyl or alfentanil as supplement to propofol anaesthesia for termination of pregnancy.

One hundred and twenty patients undergoing early legal termination of pregnancy by dilatation and suction curettage before 12 weeks of pregnancy were randomly allocated to receive total intravenous propofol anaesthesia either alone or supplemented with fentanyl 1.5 micrograms.kg-1 or alfentanil 15 micrograms.kg-1. Supplementation with fentanyl or alfentanil improved operating conditions (P < 0.01), reduced total propofol requirements (P < 0.01) and reduced postoperative pain intensity (P < 0.05). Immediate recovery, assessed by the time patients took to open the eyes, to give correct date of birth and by co-operation score, was more rapid in the alfentanil group compared to the control group (P < 0.05), whereas there was no significant difference between the alfentanil and fentanyl groups. The three anaesthetic techniques did not differ with regard to side effects. In conclusion, total intravenous propofol anaesthesia in patients undergoing early termination of pregnancy was improved by supplementation with either fentanyl 1.5 micrograms.kg-1 or alfentanil 15 micrograms.kg-1. The benefit was slightly greater with alfentanil than with fentanyl.

Blood and plasma volumes determined by carbon monoxide gas, 99mTc-labelled erythrocytes, 125I-albumin and the T 1824 technique.

The total amount of circulating haemoglobin was measured in 12 subjects using a direct carbon monoxide (CO)-technique. O2 plus 50 ml CO gas was rebreathed in a small closed system for 10 min. Carboxyhaemoglobin (HbCO)% was measured with a diode-array spectrophotometer before and after the rebreathing. delta HBCO% and the amount of CO in moles (nCO) were used to calculate the total amount of circulating haemoglobin. Blood volume was calculated by dividing this figure with the haemoglobin concentration and plasma volume by multiplying the blood volume with 1-haematocrit. The calculated blood and plasma volumes were compared with the simultaneously measured volumes by 99mTc-labelled erythrocytes, 125I-albumin and T 1824 (Evans Blue). Mean blood volume determined with CO was 4557 ml (3251-6576 ml) compared with 4527 ml (3390-6527 ml) with 99mTc-labelled erythrocytes (r = 0.97). Mean plasma volume by T 1824 was 2895 ml (1972-3658 ml) vs 2898 ml (1815-3714) ml using 125I-albumin, (r = 0.99). The plasma volumes calculated from the blood volumes determined by the erythrocyte-labelling methods were 5-10% lower than those measured with labelled albumin. There was a better correlation between the plasma volumes by the albumin methods and by the CO-technique (r = 0.98 and r = 0.97, respectively) than between the plasma volumes by the albumin methods and by 99mTc-erythrocytes (r = 0.90 and r = 0.87, respectively).

A new 99mTc-red blood cell labeling procedure for cardiac blood pool imaging: clinical results.

The first clinical results of a new 99mTc-red blood cell labeling procedure avoiding cell centrifugation are presented. One ml heparinized blood samples were incubated with small amounts of a stannous kit. By titration studies, ideal quantities of sodium hypochlorite for oxidation of extracellular tin and of EDTA as stabilizer of the label were found. The Cl- concentration and pH of the labeled blood were acceptable, and EDTA increased labeling yield and stability determined in vitro by a few percent. The new procedure gave a slightly higher labeling yield than a current technique using centrifugation of cells. Labeling efficiency expressed as cell bound/total activity was 96.6% +/- 1.3% in healthy subjects and 95.5% +/- 2.2% in cardiac patients and remained high for 2 h after reinjection. The biological halflife of labeled cells following the new procedure was 11-12 h rendering it suitable for serial determinations of radionuclide cardiography.

Double burst monitoring during surgical degrees of neuromuscular blockade: a comparison with train-of-four.

UNLABELLED: With double burst stimulation (DBS) it is possible to monitor more profound degrees of neuromuscular blockade than with train-of-four stimulation (TOF). It may therefore be indicated to change between DBS and TOF stimulation during moderate to profound degrees of neuromuscular blockade. Consequently, the aim of the study was to evaluate and compare the twitch height of the first twitch (D1) in DBS and the twitch height of the first twitch (T1) in TOF stimulation during moderate to profound degrees of neuromuscular blockade. Thirty-three patients scheduled for gynaecological laparotomy under general anaesthesia were studied. Mechanomyography was used for neuromuscular monitoring. The T1 twitch height before atracurium was administered served as the control twitch height (T1 control). T1 control was considered as 100%. A constant degree of neuromuscular blockade was maintained at a T1 twitch height at a point between 4 and 11% of T1 control, using a continuous infusion of atracurium. Sequences of 16 DBS and 16 TOF stimulations were given. Two different DBS patterns were examined: DBS3,350/50, (3 stimuli at 50 Hz followed 0.75 sec later by 3 stimuli at 50 Hz), and DBS3,380/40, (3 stimuli at 80 Hz followed 0.75 sec later by 3 stimuli at 40 Hz). The data were analysed by the method described by Bland and Altman. The D1 repeatability coefficients of 1.72% for DBS3,350/50 and 1.20% for DBS3,380/40 were significantly greater than the repeatability coefficient of 1.02% for T1 (p <0.05). The D1 bias of 16.7% for DBS3,350/50 was significantly less than the D1 bias of 25.7% for DBS3,380/40 (p <0.05). The limits of agreement between D1 and T1 were 0.1 to 33.3% for DBS3,350/50 and 2.9 to 48.5% for DBS3,380/40. IN CONCLUSION: The repeatability of responses to DBS and TOF stimulations during moderate to profound degrees of neuromuscular blockade where only one twitch is consistently present is satisfactory. The responses to DBS were greater than responses to TOF as indicated by a positive bias of DBS. The limits of agreement between DBS and TOF responses were so wide that they cannot be used interchangeably.

Response to double-burst appears before response to train-of-four stimulation during recovery from non-depolarizing neuromuscular blockade.

BACKGROUND: Double-burst stimulation (DBS) it a relatively new nerve stimulation mode introduced for improved manual detection of residual neuromuscular blockade. Previous studies have shown that DBS3,3 50/50 (3 stimuli at 50 Hz followed 0.75 seconds later by 3 stimuli at 50 Hz) can detect deeper degrees of neuromuscular blockade than train-of-four (TOF) stimulation. AIM: The aim of the present study was to examine if DBS3,3 80/40 (3 stimuli at 80 Hz followed 0.750 s later by 3 stimuli at 40 Hz) can detect even deeper degrees of neuromuscular blockade than DBS3,3 50/50 and to determine the time lapse from reappearance of response to each of the two DBS modes until reappearance of response to the TOF mode of nerve stimulation. METHODS: The study comprised 20 women undergoing gynaecological surgery and anaesthetised with fentanyl, thiopentone, halothane, and nitrous oxide. Neuromuscular transmission was monitored by using mechanomyography and stimulation of the ulnar nerve. Atracurium was used for neuromuscular blockade. RESULTS: Elapsed time from reappearance of response to DBS3,3 80/40 and DBS3,3 50/50 to reappearance of response to TOF stimulation was 459 +/- 196 (mean +/- SD) and 360 +/- 150 seconds, respectively, (P < 0.05). CONCLUSIONS: DBS3,3 80/40 is capable of detecting deeper degrees of blockade than DBS3,3 50/50, which again is capable of detecting deeper degrees of blockade than TOF.

Double burst monitoring during recovery from atracurium-induced neuromuscular blockade: a comparison with train-of-four.

BACKGROUND: Double burst stimulation (DBS) was originally introduced for improved manual detection of residual neuromuscular blockade. Previous studies demonstrated a high correlation between mechanomyographical responses to DBS and train-of-four (TOF) stimulation during recovery from neuromuscular blockade. However, repeatability and bias analyses that are recommended when new monitoring devices are introduced into clinical practice [11] have not yet been performed. OBJECT: The object of the present study was to evaluate if DBS3,350/50 (3 stimuli at 50 Hz followed 0.750 sec later by 3 stimulations at 50 Hz) and TOF measurements are in so close agreement that they can be used interchangeably during spontaneous recovery from atracurium blockade. METHODS: The study comprised 20 women undergoing gynaecological laparotomy and anaesthetised with fentanyl, thiopentone, halothane, and nitrous oxide. The neuromuscular blockade was induced and maintained with atracurium. The ulnar nerve was stimulated using DBS or TOF stimulation. Neuromuscular transmission was monitored mechanomyographically. Alternating sequences of 4 DBS and 6 TOF stimulations were applied during the phase of spontaneous recovery. Repeatability, bias (accuracy) and limits of agreement were calculated as proposed by Bland and Altman [11]. RESULTS: The repeatability coefficients before any neuromuscular blocking agent was given were 3.4 and 7.7% for T1 and D1, respectively (P < 0.05), and 3.8 and 3.5% for TOF ratio and DBS ratio, respectively (P > 0.05). The mean difference between duplicated DBS and TOF measurements during recovery (repeatability) differed from zero due to the ongoing recovery process. It was therefore not possible to calculate the repeatability coefficients. The DBS ratio bias decreased from 6.69 to 3.51% (P < 0.05) during recovery. The limits of agreement between the DBS and TOF ratios increased from -2.07 to 15.45%, to -11.93 to 18.95% during recovery, while the limits of agreement between the DBS and TOF twitch heights increased from -5.02 to 10.68%, to -21.02 to 25.26%. CONCLUSION: The limits of agreement between DBS and TOF responses were so wide that DBS and TOF can not be used interchangeably.

Scintigraphic demonstration of subcutaneous abscesses with 99mTc-labeled leukocytes.

Our initial experience with the clinical application of autologous leukocytes labeled in vitro with technetium 99m is reported. An injection of 3.6 X 10(8) leukocytes (83% of which were polymorphonuclear) labeled with 6.4 mCi 99mTc was administered to a patient with subcutaneous abscesses in order to evaluate the in vivo stability of the labeling and cellular function. Scintigraphic examinations demonstrated marked accumulations of radioactivity at the sites of inflammation, suggesting that 99mTc was efficiently bound to the cells and that the migration of polymorphonuclear leukocytes was not disturbed by the labeling procedure.