Cardiovascular collapse during anesthesia in a patient with preoperatively discontinued chronic MAO inhibitor therapy

We describe a patient in whom long-term monoamine oxidase (MAO) inhibitor therapy was discontinued 20 days before surgery with general anesthesia. This patient developed severe perioperative hypotension after administration of 10 mg of bupivacaine through an epidural catheter, which was corrected only after potent vasopressor therapy. We attribute this hemodynamic instability to attenuation of this patient's sympathetic tone based on several mechanisms: (1) residual effect of long-term administration of MAO inhibitor that caused a decrease in the number of β-adrenergic receptors (adrenergic subsensitivity due to receptor down-regulation), (2) recovered MAO activity causing effective degradation of sympathetic amines, and (3) combined attenuating effects of general and epidural anesthesia on sympathetic tone.     

Closed suction wound drainage and lower-segment caesarean section

Summary. In a randomized controlled study of wound suction drainage after transverse suprapubic incision for lower-segment caesarean section no significant advantages could be demonstrated for routine drainage in terms of wound infection, haematoma formation, duration of hospital stay or analgesic requirements.     

Complete hepatic venous isolation and extracorporeal chemofiltration as treatment for human hepatocellular carcinoma: A phase I study

Background: We performed a phase I study of a novel system of complete hepatic venous isolation and extracorporeal chemofiltration in patients with unresectable hepatocellular carcinoma (HCC) to determine (a) whether systemic exposure to doxorubicin could be limited after high-dose hepatic arterial infusion (HAI), and (b) the hepatic maximum tolerated dose (MTD) of doxorubicin. Methods: Ten patients with biopsy-proven HCC were treated with 20-min HAI of doxorubicin (17 total treatments). Two patients were treated with doxorubicin 60 mg/m², three patients were treated at 90 mg/m², and five patients received 120 mg/m². A newly developed dual-balloon vena cava catheter was advanced from the femoral vein, and the balloons were inflated to isolate and capture total hepatic venous outflow. The hepatic venous blood was pumped through extracorporeal carbon chemofilters before return of the blood to the systemic circulation. Results: Peak systemic doxorubicin levels were an average 85.6% lower than were peak prefilter levels (p<0.01). Because all catheters were placed percutaneously and because the chemofiltration markedly limited systemic chemotherapy exposure, patients were discharged 1 day after 16 of the 17 treatments. The hepatic and systemic MTD of doxorubicin in this treatment protocol was 120 mg/m². Conclusions: This novel system of complete hepatic venous isolation and chemofiltration limits systemic chemotherapy toxicity and will allow use of higher doses of chemotherapeutic agents to treat HCC. The results of this study were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Prevention and Management of Postoperative Nausea and Vomiting: A Look at Complementary Techniques

Complementary modalities, used alone or in combination with pharmacologic therapies, play an important role in the prevention and management of postoperative nausea and vomiting (PONV) and post discharge nausea and vomiting (PDNV). This article will review the evidence for the effective use of complementary modalities: acupuncture and related techniques, aromatherapy, and music therapy that may be integrated in the perianesthesia nurse's plan of care to prevent or manage PONV.     

Electromyographic monitoring of profound surgical muscle relaxation during cardiac anesthesia

Quantitative assessment of neuromuscular block produced by large doses of nondepolarizing neuromuscular blocking agents during cardiac surgery is not possible with conventional methods of monitoring. Various posttetanic responses can, however, be elicited, even when no twitch response is present. Posttetanic responses measured by electromyography were used in this study. Twenty-four male patients undergoing coronary bypass surgery were anesthetized with sufentanil plus diazepam. Neuromuscular block was provided either with pancuronium 0.1 mg/kg or with vecuronium 0.07 mg/kg initially and supplemented with small increments when indicated. Neuromuscular block was monitored from the hypothenar muscle. The ulnar nerve was stimulated by train-of-four, with supermposed periodic tetanic stimuli to evoke posttetanic responses, once every 7 to 15 minutes. The tetanically potentiated responses were detectable during 96% ± 3.6 (vecuronium) and during 97% ± 3.7 (pancuronium) of the entire intraoperative period, while the nonpotentiated electromyographic responses were present for less than 50% of the time. The sum (of the amplitudes) of 6 posttetanic responses is significantly (p<0.05) greater than the sum of 6 nonpotentiated responses and than the size of a single-peak posttetanic response when compared with the normal, nonpotentiated responses. Higher-frequency tetanic stimuli (100 or 200 Hz) produced greater posttetanic responses (p<0.05) than did the 50-Hz tetanic stimulus. There were only slight or no significant differences in the degree of posttetanic potentiation between pancuronium and vecuronium either before, during, or after cardiopulmonary bypass. With posttetanic responses, we could detect changes in the level of neuromuscular block that occur during cardiac surgery and that are related to cardiopulmonary bypass, cooling, rewarming, and large doses of corticosteroids and antibiotics. Furthermore, it was not necessary to extend the arm or to use an arm board (on which the hand is immobilized when using mechanical monitoring methods) during cardiac surgery.     

The mode of action of treatment by IgG of haemolytic anaemia induced by an anti-erythrocyte monoclonal antibody

Tolerization of pathogenic antigens is one of the experimental strategies that has been proposed to prevent autoimmune disease. We have investigated here whether neonatal intraperitoneal infection of Lewis rats with Mycobacterium bovis-BCG has any effect on the expression of adjuvant arthritis (AA), an autoimmune disease that is produced by immunization of the rats with dead mycobacteria in mineral oil (i.e. Freund's complete adjuvant (FCA)). We found that neonatal infection with 10⁸ viable BCG bacilli rendered all Lewis rats resistant to the expression of AA after FCA immunization. This BCG-induced protection from reactive arthritis was not seen in Lewis rats infected with smaller inocula (10⁶ BCG bacilli) or if the infection was performed after the neonatal period (e.g. at 3 weeks of age). Neonatal administration of 65-kD mycobacterial heat shock protein (hsp65, a key antigen in the etiopathogenesis of AA) failed to protect Lewis rats from AA; injection of lactoferrin (an autoantigen that may be involved in the physiopathology of autoimmune arthritis) to newborn Lewis rats decreased the severity of AA observed after FCA immunization of the animals. Western blotting revealed that Lewis rats that had acquired resistance to AA also showed changes in their repertoire of antibody specificities; among these alterations was decreased anti-hsp65 reactivity. We conclude that neonatal infection with BCG, but not hsp65 injection, renders Lewis rats resistant to AA and that the phenomenon is associated with change in the repertoire of specificities of circulating antibodies.     

Effect of Flumazenil on Ventilatory Drive during Sedation with Midazolam and Alfentanil

Background: Patients who receive a combination of a benzodiazepine and an opioid for conscious sedation are at risk for developing respiratory depression. While flumazenil effectively antagonizes the respiratory depression associated with a benzodiazepine alone, its efficacy in the presence of both a benzodiazepine and an opioid has not been established. This study was designed to determine whether flumazenil can reverse benzodiazepine-induced depression of ventilatory drive in the presence of an opioid.

Methods: Twelve healthy volunteers completed this randomized, double-blind, crossover study. Ventilatory responses to carbon dioxide and to isocapnic hypoxia were determined during four treatment phases: (1) baseline, (2) alfentanil infusion; (3) combined midazolam and alfentanil infusions, and (4) combined alfentanil, midazolam, and "study drug" (consisting of either flumazenil or flumazenil vehicle) infusions. Subjects returned 2-6 weeks later to receive the alternate study drug.

Results: Alfentanil decreased the slope of the carbon dioxide response curve from 2.14 +/- 0.40 to 1.43 +/- 0.19 l [dot] min sup -1 [dot] mmHg sup -1 (x +/- SE, P < 0.05), and decreased the minute ventilation at PET CO2 = 50 mmHg (V with dotE 50) from 19.7 +/- 1.2 to 14.8 +/- 0.9 l [dot] min sup -1 (P < 0.05). Midazolam further reduced these variables to 0.87 +/- 0.17 l [dot] min sup -1 [dot] mmHg sup -1 (P < 0.05) and 11.7 +/- 0.8 l [dot] min sup -1 (P <0.05), respectively. With addition of flumazenil, slope and V with dot sub E 50 increased to 1.47 +/- 0.37 l [dot] min sup -1 [dot] mmHg sup -1 (P < 0.05) and 16.4 +/- 2.0 l [dot] min sup -1 (P < 0.05); after placebo, the respective values of 1.02 +/- 0.19 l [dot] min sup -1 [dot] mmHg sup -1 and 12.5 +/- 1.2 l [dot] min sup -1 did not differ significantly from their values during combined alfentanil and midazolam administration. The effect of flumazenil differed significantly from that of placebo (P < 0.05). Both the slope and the displacement of the hypoxic ventilatory response, measured at PET CO2 = 46 +/- 1 mmHg, were affected similarly, with flumazenil showing a significant improvement compared to placebo.     

A study of the provision of health checks and health-promotion clinics in 18 general practices

Summary

• ? The objective of this study was to describe the variation in provision of health checks and health-promotion clinics operating under the regulations of the 1990 Contract for general practice in the UK.
• ? Eighteen group practices in three Family Health Service Authority (FHSA) areas of England (two in the South West Thames region and one in the Yorkshire region) were selected for the study. The nurses, largely responsible for the implementation of the health checks at these practices, were interviewed using semi-structured interview schedules. They were asked about age-groups targeted, means of recruiting patients for clinics, duration of clinic appointments, and procedures carried out in clinics.
• ? All practices offered health checks, and 55% had started doing so before introduction of the 1990 Contract. Recruitment for health checks took place in a number of ways: self-referral (83% of practices); opportunistically in those with coronary heart disease risk factors (78%); opportunistically during attendance for cervical smears (62%); screening in at least one patient group (78%). Blood pressure, height, weight, urinalysis and life-style advice were included by all practices. Stress management and quit smoking strategies were offered only by a minority of practices. Duration of first health-check appointment ranged between 15 and 30 minutes.
• ? The basic content of health checks, and life-style advice given appeared consistent between the widely varying practices. However, the resources available for intervention and follow up showed more variation.

     

Undergraduate nursing education reform in France: from vocational to academic programmes

DEBOUT C., CHEVALLIER‐DARCHEN F., PETIT DIT DARIEL O. & ROTHAN‐TONDEUR M. (2012) Undergraduate nursing education reform in France: from vocational to academic programmes. International Nursing Review Background: France is currently implementing a number of reforms to the healthcare and education systems. Within this context, a comprehensive reform of undergraduate nurse education was launched in 2009, bringing nurse education closer to the higher education environment. It is likely in future to move from being vocational towards becoming an academic educational programme. Aim: In this paper, the 2009 reform of the French pre‐registration nursing curriculum will be analysed in light of the European framework. Process: The pedagogical approach, methods and content of nursing education in France are undergoing an in‐depth reorganization. The main innovation that the reforms introduce is a competency‐based approach. France is joining the group of countries that require first degree‐level entry to the nursing profession. Conclusion: There are still many unanswered questions regarding the competencies and qualifications required by both the academic and clinical educators many of whom have not been previously involved in research or publications. The future status of nursing science is unclear, as is the way in which the nursing profession will be able to retain control over its educational mechanisms.