Evaluation of nursing process competencies, nursing quality, and patient safety using virtual simulation with debriefing: A quasi-experimental study.

Background: Investing in clinical education is important for adult urgent and emergency surgery and traumatology as it promotes registered nurses' competencies by providing professional development training to respond to urgent or emergency surgeries. Objective: To examine registered nurses' self-assessment of the effects of virtual video simulation with an immediate debriefing approach on nursing process competencies, nursing care quality, incomplete care, and patient safety in surgical units. Methods: This study used a quasi-experimental two-group pre- and post-test design. The study was conducted at two provincial hospitals in Cambodia. Participants included registered nurses employed in surgical units. The experimental group (n = 46) completed a virtual video simulation and immediate debriefing. The control group (n = 35) completed virtual training on the nursing process. Data were collected two months after a successful second-week follow-up using Competency of Nursing Process, Cambodian Nursing Care Quality, Care Left Undone, and Patient Safety scales. Wilcoxon signed-rank test and Mann-Whitney U test were used to evaluate the differences before and after the sessions. Generalized linear model was used to compare the differences between the two groups. Results: The results showed statistically significant improvements in the experimental group on competency, nursing care quality, patient safety, and reducing care left undone after the intervention. However, the control group revealed statistically insignificant differences. In addition, the experimental group provided positive feedback, such as experiencing a real patient scenario, developing critical-thinking, improving communication skills, and having an opportunity to ask questions. Conclusion: Our study showed that VVS and immediate debriefing have the potential to support in-service training of RNs from diverse backgrounds. Particularly, integrating virtual video simulation and immediate debriefing may to promote competency in the nursing process and improve care outcomes.

Perioperative management of obstructive sleep apnea in lower extremity orthopedic procedures: A review of evidence to inform the development of a clinical pathway.

Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed.

Donating Dantrolene: Development and Implementation of a Malignant Hyperthermia Program in a Scarce Resource Setting.

Intravenous dantrolene is the first-line treatment of malignant hyperthermia (MH), however, it is not always accessible in lower-middle income countries (LMICs). Facilities in the United States are in a transition period where dantrolene is being replaced with Ryanodex, therefore, there is an opportunity for excess dantrolene to be utilized in LMICs where neither dantrolene nor Ryanodex exist. Thirty-six vials of recently expired, unused dantrolene were obtained for a hospital in a LMIC and an MH program was developed in conjunction with the Lao Friends Hospital for Children (LFHC) anesthesia providers, LFHC liaison, LFHC leadership team, and an expert in the field of MH. Components of the MH program included developing a facility-specific protocol, treatment guidelines, supply list, and educational tools. A designated MH drawer was also created in preparation for an MH event. By procuring dantrolene and implementing an MH program in a facility where no MH protocol, treatment guidelines, supply list, or educational tools existed, LFHC is better equipped to handle a potentially lethal scenario.

Decreasing the Incidence of Hypoxia and Airway Maneuvers During GI Procedures.

Many outpatient gastrointestinal procedures are completed with propofol anesthesia. A side effect of propofol is airway obstruction and subsequent hypoxia. This study was designed to determine whether the use of a high-flow nasal cannula is associated with a decreased incidence of hypoxia or airway obstruction in patients undergoing propofol sedation in the gastrointestinal laboratory with a STOP-BANG score ≥5. High-flow nasal cannula was administered at 70 L/min on 27 patients with a STOP-BANG score ≥5 receiving monitored anesthesia care sedation for an esophagogastroduodenoscopy, endoscopic ultrasound, or colonoscopy procedure. Patients were compared to a group from a previous project without the use of high-flow nasal cannula assessing whether hypoxia, apnea, or the need for airway maneuvers occurred. The non-high-flow nasal cannula group required an airway maneuver 53.3% (n = 8) whereas the high-flow nasal cannula group required an airway maneuver 18.5% (n = 5) (p = .021). High-flow nasal cannula was associated with a reduced need for airway maneuvers in patients with a high risk of obstructive sleep apnea undergoing propofol-assisted procedures.

Predictors of severe postoperative pain after orthopedic surgery in the immediate postoperative period.

AIM: Severe pain in the immediate postoperative period can negatively affect patients' quality of recovery, prolong hospital stay, and increase the risk of developing persistent pain. This study aimed to examine the predictors of severe postoperative pain in the immediate postoperative period among orthopedic trauma patients. METHODS: A prospective observational study design was used. Data were collected from 153 patients that underwent orthopedic surgery procedures. Pain scores were assessed by a numeric pain scale at 45 min in the Post Anesthesia Care Unit. Physical health status was measured by the American Society of Anesthesiologists Status Classification System, and total dose of opioids (converted to morphine equivalents) and other demographic and clinical characteristics were recorded from medical records. RESULTS: Preoperative smoking and physical health status were statistically significant predictors of severe postoperative pain in the immediate postoperative period. The odds of severe postoperative pain for smokers were 2.42 times the odds of nonsmokers. Patients with severe systemic disease showed 4.27 times lower odds of severe pain than more healthy patients. CONCLUSION: Preoperative predictors of severe postoperative pain should be considered when assessing and treating orthopedic patients postoperatively to assure adequate pain relief.

The impact of preoperative pain-related psychological factors on pain intensity post-surgery in Jordan.

This study aimed to investigate the impact of preoperative psychological factors on postoperative pain. We included 300 postoperative patients who underwent open reduction and internal fixation surgery. Pain Scale, Pain Catastrophizing Scale, and Depression, Anxiety, and Stress Scale were completed by patients preoperatively and at 24 hours after surgery. Clinical characteristics were obtained from medical records. Data were analyzed using multiple linear regression. Postoperative pain was predicted by pain catastrophizing and anxiety symptoms. High preoperative catastrophizing and anxiety levels were associated with increased pain postoperatively. However, the relationships between preoperative depressive and stress symptoms and postoperative pain were not significant.

Bayesian modeling to predict malignant hyperthermia susceptibility and pathogenicity of RYR1, CACNA1S and STAC3 variants.

Aim: Identify variants in RYR1, CACNA1S and STAC3, and predict malignant hyperthermia (MH) pathogenicity using Bayesian statistics in individuals clinically treated as MH susceptible (MHS). Materials & methods: Whole exome sequencing including RYR1, CACNA1S and STAC3 performed on 64 subjects with: MHS; suspected MH event or first-degree relative; and MH negative. Variant pathogenicity was estimated using in silico analysis, allele frequency and prior data to calculate Bayesian posterior probabilities. Results: Bayesian statistics predicted CACNA1S variant p.Thr1009Lys and RYR1 variants p.Ser1728Phe and p.Leu4824Pro are likely pathogenic, and novel STAC3 variant p.Met187Thr has uncertain significance. Nearly a third of MHS subjects had only benign variants. Conclusion: Bayesian method provides new approach to predict MH pathogenicity of genetic variants.

Perianesthesia Measurement During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Procedure: A Case Report and Review of the Literature.

PURPOSE: This purpose of this case study and review was to understand perianesthesia care of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy surgery (CRS+HIPEC). DESIGN: Case study. METHODS: The perianesthesiaa medical record of a patient under CRS+HIPEC was analyzed to study the characteristics of perianestheia care for CRS+HIPEC. The literature of perianestheisa care for CRS+HIPEC was reviewed. FINDINGS: The challenges that perianesthesia care for CRS+HIPEC include-but are not limited to-electrolyte abnormalities, hemodynamic instabilities, and temperature fluctuation. Optimal perianesthesia management of a patient treated with CRS+HIPEC requires control of a complex interplay of physiologic mechanisms. CONCLUSIONS: Besides maintenance of clinical and laboratory parameters, and recognition and treatment of any changes, evidenced-based guidelines are needed, not only for the optimal perianesthesia management of these patients, but also to avoid potential life threatening intraoperative and postoperative complications. The standardization of perianesthesia management for CRS+HIPEC is a necessary step in meeting these goals.

Development of a Unifying Target and Consensus Indicators for Global Surgical Systems Strengthening: Proposed by the Global Alliance for Surgery, Obstetric, Trauma, and Anaesthesia Care (The G4 Alliance).

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.

Perioperative glucose monitoring and treatment of patients undergoing vascular surgery in a community hospital setting.

This article discusses the glucose monitoring and treatment practices of a small community hospital and aims to determine how these practices relate to postoperative complications in patients undergoing vascular surgery. Previous studies in patients undergoing cardiovascular surgery have demonstrated that glucose control directly affects outcomes, including length of stay and incidence of infection, stroke, renal failure, myocardial infarction, and readmissions within 30 days of the initial surgery. A retrospective analysis of 101 patients who underwent vascular surgery was performed. After informed consent was obtained, patient charts were reviewed. Perioperative blood glucose levels, frequency of monitoring, treatment practices, and postoperative complications were collected by review of both electronic and paper medical records. Twenty-seven of the 101 patients had a blood glucose level greater than 140 mg/dL preoperatively. Intraoperative blood glucose levels were monitored for 8 patients. Nine patients had blood glucose levels treated during the perioperative period. The threshold for treatment of preoperative hyperglycemia was a blood glucose level of 236 mg/dL. Increased vigilance of perioperative blood glucose levels is needed so that appropriate interventions can be instituted and outcomes improved. Glucometers must be readily available to anesthesia providers so that intraoperative monitoring of blood glucose levels can occur.

The association of CYP2D6 genotype and postoperative nausea and vomiting in orthopedic trauma patients.

The CYP2D6 gene encodes for an enzyme that is involved in the metabolism of more than 25% of all medications, including many opioids and antiemetics. It may contribute to the risk of postoperative nausea and vomiting (PONV), a common surgical complication. However, little research has been conducted in this area. The purpose of this study was to explore the association of CYP2D6 genotypes with PONV in adult surgical trauma patients. Data from 112 patients (28% female) with single extremity fractures, aged 18-70 years, were analyzed. PONV was defined as present if patients reported nausea, were observed vomiting, or received medication for PONV. Saliva samples collected for DNA extraction and Taqman(®) allele discrimination and quantitative real time polymerase chain reaction (qRT-PCR) were used to collect genotype data that were then used to assign CYP2D6 phenotype classification. The incidence of PONV was 38% in the postanesthesia care unit and increased to 50% when assessed at 48 hr. CYP2D6 classification results were 7 (6%) poor metabolizers, 34 (30%) intermediate metabolizers, and 71 (63%) extensive metabolizers. No ultrarapid metabolizers were identified. Patients who were classified as poor metabolizers had less PONV and higher pain scores. Gender and history of PONV, but not smoking, were also significant risk factors. Findings suggest variability in CYP2D6 impacts susceptibility to PONV.

Ovarian steroids and premenstrual symptoms: a comparison of group differences and intra-individual patterns.

To examine the relationship of gonadal hormone and symptom patterns across the menstrual cycle, women screened for 2-3 cycles completed an intensive study cycle; 26 had a low-severity symptoms (LS), 20, a premenstrual syndrome (PMS), and 26, a premenstrual magnification pattern (PMM). All completed daily symptom diaries and collected late afternoon urine samples which were assayed for pregnanediol and estradiol for that cycle. The PMS and PMM groups had significantly more positive cross-correlations of pregnanediol and symptoms than the LS group. Women in all groups had similar levels of estradiol and pregnanediol. Women with PMS and PMM patterns responded to progesterone differently than women with LS patterns: thus the former groups may not benefit from hormone therapies.

Sleep monitoring in children during neuromuscular blockade in the pediatric intensive care unit: a pilot study.

BACKGROUND: Sleep is an important physiologic process that is known to be disrupted in the intensive care unit. Nevertheless, there is little information on how intensive care unit admission affects sleep in children. Because laryngotracheoplasty is elective but entails 5-7 days of neuromuscular blockade following surgery, children undergoing this procedure present a unique opportunity to analyze sleep during neuromuscular blockade apart from confounding variables resulting from critical illness. OBJECTIVE: To determine the feasibility of using polysomnography to assess sleep patterns in children during neuromuscular blockade. METHODS: Polysomnography recordings were obtained continuously for 4 days (96 hrs) in two children following laryngotracheoplasty. Medication administration (neuromuscular blockades, sedatives) and time of suctioning were also recorded. RESULTS: Both subjects had documented sleep. However, the proportion of time in each stage was markedly different from developmental norms, and a greater proportion of sleep occurred during the day. Furthermore, there was substantial day-night and day-to-day variability. Some rebound of consolidated sleep appeared by day 4. Sedative use varied considerably. However, neither bolus sedation administration nor endotracheal suctioning appeared to affect sleep. Few monitoring difficulties were encountered. CONCLUSIONS: Sleep can be monitored with minimal difficulty in children undergoing neuromuscular blockade in the pediatric intensive care unit. Sleep occurred throughout the day, and there was considerable fragmentation. To fully assess sleep in the intensive care unit, monitoring needs to be continuous over several days, rather than only at night or for < or =24 hrs. Further research is needed in the area to determine typical sleep patterns in children undergoing neuromuscular blockade.