A randomized clinical trial of a new perioperative practice model on anxiety and health-related quality of life in arthroplasty patients.

AIMS: To explore the effectiveness of a new perioperative practice model on anxiety and health-related quality of life in patients undergoing total hip arthroplasty and total knee arthroplasty under spinal anaesthesia. DESIGN: A randomized clinical trial. METHODS: Control group participants (N = 222) received standard perioperative care, meaning they were cared for by various nurses during their perioperative process without postoperative visits. Intervention group participants (N = 231) were assigned one named anaesthesia nurse during their entire perioperative process who visited them postoperatively. Both groups responded to two self-reported questionnaires: the generic 15D health-related quality of life instrument and the State-Trait Anxiety Inventory (STAI) measuring anxiety two to three weeks pre-operatively and three months postoperatively. RESULTS: There were no statistically significant differences between the groups at baseline or at follow-up in health-related quality of life or anxiety.

The effect of a new perioperative practice model on length of hospital stay and on the surgical care process in patients undergoing hip and knee arthroplasty under spinal anesthesia: a randomized clinical trial.

BACKGROUND: The shortened length of hospital stays (LOS) requires efficient and patient-participatory perioperative nursing approaches to enable early and safe discharge from hospitals for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). The primary aim of this study was to explore the effect comparative to standard perioperative care of a new perioperative practice model (NPPM) on the LOS and the time points of the surgical care process in patients undergoing THA and TKA under spinal anesthesia. The secondary aim was to find out if any subgroups with different response could be found. METHODS: Patients scheduled for elective, primary THA and TKA were assessed for eligibility. A two-group parallel randomized clinical trial was conducted with an intervention group (n = 230) and control group (n = 220), totaling 450 patients. The patients in the intervention group were each designated with one named anesthesia nurse, who took care of the patient during the entire perioperative process and visited the patient postoperatively. The patients in the control group received standard perioperative care from different nurses during their perioperative processes and without postoperative visits. The surgical care process time points for each study patient were gathered from the operating room management software and hospital information system until hospital discharge. RESULTS: We did not find any statistically significant differences between the intervention and control groups regarding to LOS. Only slight differences in the time points of the surgical care process could be detected. The subgroup examination revealed that higher age, type of arthroplasty and ASA score 3-4 all separately caused prolonged LOS. CONCLUSION: We did not find the new perioperative practice model to shorten either length of hospital stays or the surgical care process in patients undergoing THA and TKA. Further studies at the subgroup level (gender, old age, and ASA score 3 and 4) are needed to recognize the patients who might benefit most from the NPPM. TRIAL REGISTRATION: This study was registered in NIH Clinical.Trials.gov under registration number NCT02906033, retrospectively registered September 19, 2016.

Novel Zero-Heat-Flux Deep Body Temperature Measurement in Lower Extremity Vascular and Cardiac Surgery.

OBJECTIVE: The aim of this study was to compare deep body temperature obtained using a novel noninvasive continuous zero-heat-flux temperature measurement system with core temperatures obtained using conventional methods. DESIGN: A prospective, observational study. SETTING: Operating room of a university hospital. PARTICIPANTS: The study comprised 15 patients undergoing vascular surgery of the lower extremities and 15 patients undergoing cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Zero-heat-flux thermometry on the forehead and standard core temperature measurements. MEASUREMENTS AND MAIN RESULTS: Body temperature was measured using a new thermometry system (SpotOn; 3M, St. Paul, MN) on the forehead and with conventional methods in the esophagus during vascular surgery (n = 15), and in the nasopharynx and pulmonary artery during cardiac surgery (n = 15). The agreement between SpotOn and the conventional methods was assessed using the Bland-Altman random-effects approach for repeated measures. The mean difference between SpotOn and the esophageal temperature during vascular surgery was+0.08°C (95% limit of agreement -0.25 to+0.40°C). During cardiac surgery, during off CPB, the mean difference between SpotOn and the pulmonary arterial temperature was -0.05°C (95% limits of agreement -0.56 to+0.47°C). Throughout cardiac surgery (on and off CPB), the mean difference between SpotOn and the nasopharyngeal temperature was -0.12°C (95% limits of agreement -0.94 to+0.71°C). Poor agreement between the SpotOn and nasopharyngeal temperatures was detected in hypothermia below approximately 32°C. CONCLUSIONS: According to this preliminary study, the deep body temperature measured using the zero-heat-flux system was in good agreement with standard core temperatures during lower extremity vascular and cardiac surgery. However, agreement was questionable during hypothermia below 32°C.

[Central venous catheter with a poor flow]. / Huonosti vetävä keskuslaskimokatetri.

Insertion of a central venous catheter is a quite common procedure; for instance in USA it is done for approx. five million patients per year. At the operating department of Meilahti hospital, central venous catheters have been placed as a main or side procedure for approx. 2000 patients per year. In addition, central venous catheters are placed in emergency departments and in some operational units, such as dialysis catheters in dialysis units. Although the application of ultrasound imaging has now resulted in improved patient safety, complications continue to occur. To exclude complications, a chest X-ray is often taken after the procedure. The control image may reveal even unexpected issues.

Heat stress and bulkiness of chemical protective clothing impair performance of medical personnel in basic lifesaving tasks.

The study examined the impact of chemical protective (CP) clothing on the performance of lifesaving tasks in thermoneutral and cold conditions. Eleven males performed pre-exercise followed by lifesaving tasks wearing either field combat uniform at 21 degrees C (U) or CP clothing at 21 degrees C (CPN) and -5 degrees C (CPC). The tasks were ventilating a doll (VA) and connecting an intravenous line (IV). Mean skin temperature was significantly higher for CPN compared to U and CPC during pre-exercise, VA and IV. Changes in blood pressure were significantly greater with CP clothing than without during VA and IV. The number of breaths per min (in VA) and time needed for IV increased by 19% (p < 0.05) and 18%, respectively, for CPN compared to U. Due to the cold, the additional increment was 5% and 17%, respectively, for CPC. Wearing of CP clothing in thermoneutral or in cold conditions may not prevent but, especially in the cold, significantly impede the performance of basic medical tasks. The findings of this study showed that performing medical tasks while wearing nuclear, biological and chemical protective clothing is impaired due to significant changes in physiological strain. This suggests that realistic training in local conditions as well as in cold conditions is needed to realise the restrictions due to protective clothing.

A prospective study of inflammation markers in patients at risk of indirect acute lung injury.

Systemic inflammation triggered by insults like sepsis and acute pancreatitis may play a role in development of indirect acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Because little is known about the course of systemic inflammation on the days preceding diagnosis of ARDS, we prospectively monitored immune inflammatory status in 52 patients at risk and we assessed the presence of ALI and ARDS on day 7 after admission to the intensive care unit. On admission, serum interleukin (IL) 8, IL-6, and soluble IL-2 receptor concentrations were significantly higher in patients with subsequent ALI (n = 18) than in patients without ALI (n = 30). During a 4-day follow-up, IL-8 and IL-6 levels of ALI patients remained high and those of non-ALI patients decreased. None of the markers discriminated ARDS patients (n = 9) from non-ARDS ALI patients (n = 9). Among 11 patients with acute pancreatitis, ALI patients had significantly higher IL-8, IL-6, and phagocyte CD11b expression levels than did non-ALI patients, whereas among 14 patients with massive transfusion, respective findings in ALI and non-ALI patients were comparable. Results give credence to the view that systemic inflammation plays a role in development of ALI triggered by pancreatitis, but not in that by massive transfusion. This finding, if confirmed in studies with sufficient statistical power, suggests that the patients with massive transfusion do not necessarily benefit from novel biotherapies aimed at altering the course of systemic inflammation.

Predictive value of antithrombin III and serum C-reactive protein concentration in critically ill patients with suspected sepsis.

OBJECTIVE: To evaluate at admission the performance of serum antithrombin III, serum C-reactive protein, white blood cell and platelet counts, and thromboplastin time values in prediction of hospital mortality rates in critically ill patients with suspected sepsis. DESIGN: Prospective, cohort study. SETTING: University hospital medical-surgical intensive care unit. PATIENTS: One hundred eight consecutive critically ill patients with suspected sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The outcome measure was hospital mortality rate. Hospital survivors (n = 66) and nonsurvivors (n = 42) differed statistically significantly in admission antithrombin III activity (percentage of normal): survivors' median 66% (interquartile range, 48% to 82%) vs. nonsurvivors' median 46% (37% to 65%, p =.0002 by Mann-Whitney test). Analysis revealed similarly statistically significant differences between survivors and nonsurvivors in admission platelet count, admission thromboplastin time, day 1 Logistic Organ Dysfunction score, and Acute Physiology and Chronic Health Evaluation III score, but not in serum C-reactive protein concentrations or in white blood cells. However, the areas under the receiver operating curves (AUC) showed significantly worse discriminative power for admission antithrombin III concentration (AUC, 0.71; SE, 0.05), platelet count (AUC, 0.67; SE, 0.05), thromboplastin time (AUC, 0.65; SE, 0.05), C-reactive protein concentration (AUC, 0.60; SE, 0.05), and white blood cell count (AUC, 0.53; SE, 0.06) than did the day 1 Logistic Organ Dysfunction score (AUC, 0.82; SE, 0.04) and the Acute Physiology and Chronic Health Evaluation III score (AUC, 0.84; SE, 0.04). Multivariate logistic regression analysis revealed that only the Acute Physiology and Chronic Health Evaluation III score was independently associated with hospital mortality rate. CONCLUSIONS: Admission antithrombin III concentrations, but not C-reactive protein concentrations, differ significantly between hospital survivors and nonsurvivors among critically ill patients with septic infection. However, in prediction of hospital mortality rate, the discriminative power of admission antithrombin III concentration is poor, as judged by analysis of areas under the receiver operating curves, and is not independently associated with hospital mortality rate.