Nurse training with simulation: an innovative approach to teach complex microsurgery patient care.

Simulation has become an integral part of education at all levels within the medical field. The ability to allow personnel to practice and learn in a safe and controlled environment makes it a valuable tool for initial training and continued competence verification. An area of specific interest to the reconstructive microsurgeon is assurance that the nursing staff has adequate training and experience to provide optimum care for microsurgery patients. Plastic surgeons in institutions where few microsurgeries are performed face challenges teaching nurses how to care for these complex patients. Because no standard exists to educate microsurgery nurses, learning often happens by chance on-the-job encounters. Outcomes, therefore, may be affected by poor handoffs between inexperienced personnel. Our objective is to create a course that augments such random clinical experience and teaches the knowledge and skills necessary for successful microsurgery through simulated patient scenarios. Quality care reviews at our institution served as the foundation to develop an accredited nursing course providing clinical training for the care of microsurgery patients. The course combined lectures on microsurgery, pharmacology, and flap monitoring as well as simulated operating room, surgical intensive care unit, postanesthesia care unit, Trauma Bay, and Floor scenarios. Evaluation of participants included precourse examination, postcourse examination, and a 6-month follow-up. Average test scores were 72% precourse and 92% postcourse. Educational value, effectiveness of lectures and simulation, and overall course quality was rated very high or high by 86% of respondents; 0% respondents rated it as low. Six-month follow-up test score average was 88%. Learning to care for microsurgery patients should not be left to chance patient encounters on the job. Simulation provides a safe, reproducible, and controlled clinical experience. Our results show that simulation is a highly rated and effective way to teach nurses microsurgery patient care. Simulated patient care training should be considered to augment the clinical experience in hospitals where microsurgery is performed.

The hysteroscopic approach to sterilization.

Permanent sterilization is the most common form of contraception in the United States today. Previously, this was accomplished via the laparoscopic method. A new less invasive method has been developed, in which the Essure microinsert is inserted through a hysteroscope into the fallopian tubes. A subsequent benign inflammatory process results in tubal occlusion within 3 months of insertion. Approved since 2002, this method offers high efficacy without incisions, general anesthesia, or a prolonged recovery period.

Lumbar discectomy: developing and implementing a day surgery protocol.

In some centres, patients who require a lumbar discectomy are successfully discharged the day of surgery. With the ongoing pressure to provide safe care for patients within certain bed limitations, this option was considered. Using a continuous quality improvement method, a prospective review of patients undergoing a single-level lumbar discectomy was monitored. Based on pre-set criteria, patients were included or excluded in the day surgery protocol and both groups were monitored. A large component of nursing education was provided for all patients, and will be highlighted. Data retrieved for both groups included demographics, length of operation, length in recovery room, length of hospital stay required, and the re-admission rate. There were 47 patients monitored over 11 months. Of the 34 patients entered in the protocol, seven required an overnight length of stay. The reasons for the extended length admission will be described. Of the 13 patients excluded from the protocol, one did not require an overnight stay. Following review of the data, the criteria for inclusion of patients into the protocol has been altered and patients can safely proceed with day surgery for lumbar discectomy.

Monitoring free flaps using the laser Doppler flowmeter: five-year experience.

Over a 5-year period, 232 microvascular composite-tissue transfers to the head and neck, trunk, and extremities were monitored using the laser Doppler flowmeter. Thirteen free flaps (5.6 percent) developed vascular complications, all within 4 days after surgery. The laser Doppler flowmeter detected vascular compromise in all cases with no false positives or negatives. Failure to monitor the flap according to protocol by nursing staff occurred in one patient, which led to a delay in detection of venous compromise and subsequent flap loss. The salvage rate was 69.2 percent, leading to an overall flap viability of 98.3 percent. Our series of free-flap monitoring using the laser Doppler flowmeter is the largest reported to date. Review of the English literature shows consistent support by numerous clinical series for the use of the laser Doppler as a valuable postoperative monitor after free-flap transfers.

Care of microvascular surgical instruments.

Reconstructive microsurgery, a specific category of surgery that uses revascularized tissue to repair functional or cosmetic defects, requires specialized training and continued competence of the surgeon, assistant and surgical team. Proper care of microsurgical instruments is paramount to the success of the surgery. Areas of importance such as microsurgical instrumentation, suture, operating microscope, and producing an atraumatic anastomoses will be explored indepth.

Microvascular reconstruction of the head and neck after tumor ablation.

Microvascular reconstruction of the head and neck in cancer patients after surgical ablation has significantly improved the quality of life of these patients from both a functional and cosmetic standpoint. Successful management and reconstruction of these patients requires a well-coordinated team approach. Operating room times and hospital stays have significantly decreased with coordination and experience of the team members.

Scalp replantation after traumatic injury.

A 30-year-old female patient lost her scalp in an industrial accident. Surgeons used a microscope to reconnect the arteries and veins in her scalp and to reattach the scalp to the patient's cranium. The patient tolerated the procedure without complications, although she developed venous congestion in her right ear while she was in the neuroscience intensive care unit. After several days of leech therapy, the patient experienced an uneventful postoperative course. One month after discharge from the hospital, the patient's hair was growing back in and her incision lines were fading.

Microsurgical transfer of vascularized tissue to close problem wounds.

Interventions to achieve optimal wound healing challenge the skills of all health care professionals. Although most wounds are best managed by appropriate nursing intervention outside the OR, some complex wounds require more expeditious closure to ensure maximum preservation of vital structures and their functions. Microsurgical transfer of vascularized tissue (ie, flaps) often is the only method of achieving immediate wound coverage. Perioperative team members who treat such wounds must be aware of the distinct attributes and potential morbidity associated with flap procedures.

Relying on past science: nursing implications of medicinal leech therapy.

The resurgence of leech therapy is due to a need to re-establish venous circulation after micro-surgical procedures such as the reattachment of amputated body parts. Using a medicinal leech, Hirudo medicinalis, this painless procedure can drain up to 20 ml of blood at feeding and an additional amount via slow but continuous flow after feeding. Nurses play a key role before, during, and after the therapy in educating and emotionally preparing patients and families. Guidelines for nursing actions during the therapy as well as implications for nursing research are discussed.

Perioperative care of the craniotomy patient: a review.

1. Knowledge of the patient and the planned positioning allows the perioperative nurse to prepare for the needs of the individual craniotomy patient in surgery. 2. Microsurgical instrumentation often required with a craniotomy requires special handling and care. 3. Methylene blue should never be used in neurosurgical procedures. 4. The sitting position for posterior fossa surgery requires special precautions.