Medical record versus researcher measures of height and weight

This study examined the extent of agreement between medical record and researcher measures of height and weight in adults and assessed the clinical significance of any resulting differences in body mass index (BMI) (kg/m(2)) according to the categorizations of underweight, normal weight, and overweight. Medical record and researcher measurements for height (n = 85), preoperative weight (n = 84), and postoperative weight (n = 65) in older patients undergoing elective coronary artery bypass grafting were used for analysis. Researcher measurements of height and weight were obtained by the same person and were compared to height and weight measurements extracted from the medical record. Bland and Altman's limits of agreement method was used to determine the extent of measurement error between medical record and researcher values. Cohen's kappa was used to assess for clinical significance of the differences in BMI categories based on medical record and researcher measurements. For height, 7% of the values were outside the 95% limits of agreement. For preoperative and postoperative weight, less than 5% of the values were outside the 95% limits of agreement. There were no significant differences in BMI categorization using Cohen's kappa between medical record and researcher measurements. Although there may be some measurement error for height in the medical record, weight measurements may have less error and the amount of measurement error may not be clinically relevant. Height and weight measurements extracted from the medical record are reliable and accurate in patients admitted for elective surgery, as are weight measurements obtained in stable postoperative patients.     

The effect of the small intestine on 3-methylhistidine metabolism in the human

20 male adult Sprague-Dawley rats were fed exclusively parenterally. After achieving metabolic equilibrium they received a duodenoileostomy and subtotal resection leaving only 8-10% of the small gut. On the 1st postoperative day the urinary 3-MH excretion rose to 1.5-1.7 times the preoperative level, but on the 12th-14th postoperative day it fell again and was equal to the preoperative basal level. A control group of 10 rats undergoing a small gut anastomosis without resection yielded similar results. We conclude that the small gut source does not make a significant contribution to 24h-urinary 3-MH excretion in the adult rat. The transient postoperative increase in urinary 3-MH excretion is probably due to post-injury metabolism. In contrast to these are the measurements in two male patients with a short bowel syndrome because of an occlusion of the superior mesenteric artery. Both patients have a body weight of 60 kg, are aged 44 and 45 years respectively, and have a 24h-urinary 3-MH excretion of 120.7 +/- 28 mumol. More than 1 year after operation they are being nourished parenterally in metabolic equilibrium. The 24h-urinary 3-MH excretion in a similar control group of 8 healthy male volunteers is 229.4 +/- 25 mumol (measurements for 6 days after a 1-week meat-free diet). We conclude that the small gut source makes a significant contribution to 24h-urinary 3-MH excretion in the adult human. There is no evident correlation between the rat model and measurements in human.     

Rehabilitation of flexor tendon injuries by use of a combined regimen of modified Kleinert and modified Duran techniques

OBJECTIVE: Kleinert (active extension, rubber-band passive flexion) and Duran (passive extension, passive flexion) protocols are two basic types of early motion programs for rehabilitation of flexor tendon injuries. Researchers have been working on various modifications or combinations of these two protocols to improve rehabilitation results. The purpose of this study was to analyze the quality of the functional results of flexor tendon repair after a postoperative regimen of early mobilization by use of a combined regimen of modified Kleinert and modified Duran techniques. DESIGN: Thirty-seven patients (74 digits) with repaired flexor tendon injuries were treated. Functional results of the fingers were evaluated by the Buck-Gramcko system and total active motion measurements. RESULTS: The results were excellent in 73% of the fingers, good in 24%, fair in 1.5%, and none was rated poor. CONCLUSION: Our results are comparable with the previous studies that used various postoperative rehabilitation techniques. This postoperative management provides an effective way of achieving satisfactory results. Patient-assisted passive exercises are very safe and more cost effective than therapist-assisted passive exercises.     

三维超声评估圆锥动脉干畸形左心功能的研究

目的 探讨三维超声(3DE)评估圆锥动脉干畸形(CTD)心功能的准确性及其临床意义.方法 对52例CTD患儿进行心室容量、室壁质量等3DE测量,并与二维超声(2DE)双平面Simpson法测值、对照组3DE测值及CTD患儿术后心功能情况比较.结果 方差分析、SNK均数问两两比较和直线相关分析显示:CTD病变心脏2DE测值低估较明显,与CTD术后心功能表现的相关性(r=0.20,P=0.2086)低于3DE(r=0.39,P=0.0090),但正常心脏3DE、2DE测值差异无统计学意义.与对照组相比,CTD的左心功能有不同程度减低,表现在左室收缩末期容量升高及搏出量、射血分数降低.其中有术后低心排表现者的舒张末期容量小于对照组,其搏出量、射血分数更低,差异有统计学意义(P＜0.05),致耐受手术创伤差,易发生术后低心排.结论 准确的3DE心功能定量评估可完善CTD术前诊断,对其矫治手术有指导意义,对可能出现的术后低心排进行早期干预.     

The effects of leg/body position on transcutaneous oxygen measurements after lower-extremity arterial revascularization.

A postoperative nursing goal in a patient with peripheral artery disease requiring lower-extremity arterial reconstruction surgery is to maintain blood flow and tissue oxygenation to the revascularized extremity. This may be achieved through extremity positioning. Transcutaneous oxygen (TcPO(2)) measurements provide a noninvasive objective determination of oxygen at the skin surface and assessment of underlying circulation and tissue oxygenation. The purpose of this study was to determine which lower-extremity position afforded the highest TcPO(2) in 10 subjects with a lower-extremity arterial revascularization procedure preoperatively and 24 and 48 hours postoperatively. Hypotheses included comparing preoperative and postoperative TcPO(2) measurements, leg skin temperatures, and limb volumes. The subjects were studied in three different leg/body positions: supine with legs extended, sitting with legs extended, and supine with legs-elevated 20 degrees using the Radiometer TCM30 (Radiometer; Copenhagen) and PhysitempTH-5 Thermalert (Physitemp; Clifton, NJ) monitors. There was no change in the postoperative leg TcPO(2) measurements or limb volumes compared with preoperative measurements (P = .12-.92). A small sample size and lack of peripheral artery disease stratification were among study limitations. Significant to the nursing care of patients with vascular dsease is the finding that any of the leg/body positions in this study could be used postoperatively on the revascularized extremity without decreasing TcPO(2) measurements.     

Efficacy of physical therapy for patients who have undergone mastectomies. A prospective study

This study was undertaken to determine if differences existed between a group of 49 patients who had undergone mastectomies and who received postoperative physical therapy and a group of 41 similar patients who did not. Preoperative and postoperative data were obtained for each patient from goniometric measurements of shoulder abduction, flexion, and external rotation; upper extremity circumferential measurements; and patient self-report on 10 functional assessment items. While age was controlled, an analysis of variance was used to test the effects of physical therapy and the side of surgery in relation to the dominant hand. No clinically significant differences were found between the groups for circumferential data. Goniometric measurements demonstrated that, postoperatively, the group receiving physical therapy had better shoulder range of motion and less difficulty with all functional assessment items. The results suggest that patients receiving postmastectomy physical therapy achieve better functional outcomes than those who do not.     

Transvaginal sonography of the uterine cavity following curettage for early pregnancy failure.

In a study of 50 women presenting with sonographically confirmed early pregnancy failure, the uterine contents were measured in both sagittal and transverse planes before proceeding with evacuation of the retained products of conception. A repeat sonographic study of the empty uterine cavity was performed on the day after curettage and similar measurements were made, the subjects having been divided into four groups according to gestational age. There was no significant difference between the groups in the postoperative measurements of either uterine cavity width or area, nor was the size of the empty uterine cavity influenced by the volume of tissue within the uterus before evacuation. Whilst the measurement of width was similar both before and after evacuation of the uterus in all groups, the sagittal area was significantly smaller postoperatively. There was no evidence of retained tissue at any of the postoperative sonographic examinations, nor did any of the subjects in the study develop subsequent complications. Assuming the dimensions of the uterine cavity following curettage are representative of an empty uterus, this will form the basis of a prospective study to determine whether spontaneous abortion can be safely managed without curettage in selected cases, if the preoperative sonographic measurements fall within a specified range.     

Does method of anesthesia modify postoperative ischemia incidence? A study of patients after aortocoronary bypass operations

In the postoperative period after coronary artery bypass graft surgery, the physician's enhanced attention should be focused on the incidence of myocardial ischaemia. The increased stress in the awakening patient as well as the return of autonomous reflexes can be the cause of imbalances in myocardial oxygen supply and uptake. Therefore, a probable influence of the pharmacologic profile of the intraoperatively applied anaesthetics on the incidence of postoperative myocardial ischaemia is of importance for adapting therapy on ICU to minimize any ischaemic risk. After approval by the ethics committee, a prospective randomized study was performed in 40 male patients who underwent coronary artery bypass graft surgery. The aim of the study was to compare balanced anaesthetic techniques performed with fentanyl and halothane, isoflurane and enflurane, respectively, with total intravenous anaesthesia performed with fentanyl and midazolam. An index to classify detection of ischaemia into three categories (ischaemia, probable ischaemia, no ischaemia) was established, based on measurements of myocardial lactate extraction and ST-segment analysis. Simultaneously, measurements of haemodynamic parameters and serum concentrations of catecholamines and intraoperatively applied anaesthetics were taken. In 8% of all measurements (30% of all patients) ischaemia was detected in the observation period and in 37% of all measurements (72.5% of all patients) probable ischaemia was detected. No significant difference was found concerning the incidence of myocardial ischaemia between all groups. The results of this investigation indicate that the application of inhalational anaesthetics for maintaining anaesthesia in coronary artery bypass graft surgery does not increase the risk of postoperative myocardial ischaemia.     

Leucocyte-depleted cardioplegia does not reduce reperfusion injury in hypothermic coronary artery bypass surgery.

This study investigated the effects of leucocyte-depleted cardioplegia on postreperfusion oxidative stress and myocardial injury in elective hypothermic coronary artery bypass surgery. Forty patients were randomized to receive either cardioplegia with leucocytes depleted by an in-line Pall BC1B filter, or blood cardioplegia without leucocyte depletion. Transmyocardial oxidative stress was assessed by oxidized glutathione measurements in samples taken simultaneously from the coronary sinus and aortic root, and myocardial injury by postoperative CKMB and troponin-T measurements. The BC1B filters reduced numbers of cardioplegia leucocytes by a mean of 90.7%. Both patient groups demonstrated significant increases (p < 0.001) in transcardiac oxidized glutathione gradients after crossclamp release. No significant differences were found between the groups for postreperfusion oxidized glutathione gradients, postoperative levels of CKMB or troponin-T, or in the frequency of perioperative and postoperative complications. These results suggest that leucocyte-depleted cardioplegia does not significantly improve myocardial protection in patients undergoing elective coronary artery bypass surgery.     

Rehabilitation of the mastectomy patient: a randomized, blind, prospective study

After biopsy confirmation of breast carcinoma, women who were scheduled to undergo a modified radical mastectomy had demographic data collected, goniometric measurements of shoulder flexion and abduction, and functional evaluation of the ipsilateral shoulder performed, and upper extremity circumferential measurements at five levels determined. Patients were then randomly assigned either to a group that received immediate postoperative physical therapy or to one that did not. Results represent the combination of data from a pilot study and this subsequent study following appropriate statistical analysis. Sixty-four women in the treatment group showed a statistically significant increase in shoulder range of motion in both abduction and flexion as compared to 51 women who received no physical therapy. The treated group also had fewer problems with five of the six upper extremity functional tasks that were assessed. There were no significant differences between the groups for length of hospital stay, postoperative complications, or upper extremity edema. The authors conclude that early physical therapy intervention makes a significant contribution to return to normal function without increasing the incidence of postoperative complications or prolonging hospital stay.     

Families' and children's postoperative pain--literature review

The purpose of this study was to describe the findings of a literature review focusing on the viewpoint of family members in children's postoperative pain assessment and management. The study was based on empirical studies of families and children's postoperative pain published in 1991-2000. Eleven articles found in two databases (PubMed + Cinahl) were nonrandomly selected for an analysis. Qualitative deductive content analysis was used to investigate what is known about family members' views on children's postoperative pain based on empirical studies. The findings showed that families are a source of support for children in postoperative pain. However, parents have criticized pain-related instructions provided by the hospital staff. In addition, they have described difficulties in identifying and managing children's pain at home. Further research is needed to deepen our understanding on children's postoperative pain as a family experience. Family nursing theories could be used more in studies focusing on children's postoperative pain. More attention should be paid on parents' needs and on their counseling about children's pain in clinical pediatric nursing.     

The Numeric Rating Scale for Clinical Pain Measurement: A Ratio Measure?

? Abstract: The Numeric Rating Scale (NRS‐11) has been widely used clinically for the assessment of pain. Its use for clinical research is controversial. Reports differ as to whether or not the NRS‐11 should be treated as a ratio pain measurement tool. This study compared the NRS‐11 to a ratio measure for pain assessment: the visual analog scale (VAS). Simultaneous pain measurements using these 2 scales were compared in clinical situations commonly encountered in a tertiary community hospital. Whereas linear relationships were noted in laboring patients and in postoperative patients with thoracic or abdominal incisions during cough, no such correlations were noted for the same postoperative patients at rest or for postoperative orthopedic patients. The NRS‐11 should not be considered to be interchangeable with the VAS. Its use for clinical research should be limited to situations where it has specifically demonstrated linear properties. ?     

Valoración del dolor durante el postoperatorio inmediato de cirugía cardiaca mediante la Behavioural Pain Scale

IntroductionPatients in the immediate postoperative period of cardiac surgery have abolished communication skills and therefore can not express pain. Pain produces significant adverse effects that alter the patients’ course. Therefore, identifying and controlling them will lead to increased quality of care for the critical patient.ObjectiveTo measure the degree of pain in patients in the immediate postoperative period of cardiac surgery by scaling Behavioural Pain Scale.Material and methodAn observational, prospective and longitudinal. Patients over 18 years in the first 24 hours of admission with no communication problems who were under sedation and subjected to mechanical ventilation were included. Twenty patients were enrolled in the study. The Behavioural Pain Scale (BPS) was used during two procedures usually considered as a painful practice in the literature, that is, mobilization and/or postural changes and aspiration of secretions.ResultsTwenty-seven measurements were made of procedures considered as painful. The results obtained by applying the scale BPS showed that 70.4% of patients had no pain, 22.2% had mild to moderate pain and 7.4% had unacceptable pain.ConclusionThis study has identified that the patients suffer pain during the postoperative period. Within these patients, there is a small, but not insignificant number whose pain is unacceptable during this period. This finding serves as a beginning for a line of research to improve the handling of the postoperative pain during immediate post-operative cardiac surgery.     

Improving the quality of postoperative pain relief

A review of the literature shows a constant need to improve the quality of postoperative pain management. The objective of this study was to decrease the intensity and variation of postoperative pain by developing a nurse-based pain service on the ward. An acute pain nurse was appointed and an educational programme with detailed algorithms was started. Regular pain intensity measurements were implemented. Postoperative pain intensity, treatments and side-effects were assessed both before and after the introduction of the new system in 400 patients divided into two consecutive groups of equal size. The number of patients with inadequately treated pain (actual pain > 3/10) dropped by 64% after major gynaecological surgery (25 vs 9%, 95% CI for differences 7-24%; p<0.001 for pain scores). On an average, inadequate pain relief (retrospective average pain > 3/10) on the first postoperative day was more frequent on the ward before than after the reform (47 vs. 21%; 95% CI for differences 15-35%; p<0.001 for pain scores). The incidence of side-effects was similar in both groups (p> 0.05). The intensity and variation of postoperative pain on the ward decreased by developing a nurse-based pain service with an acute pain nurse, an educational programme and regular pain intensity measurements.     

Influence of cross-education training in postoperative hand therapy

Early studies have shown an effect of cross-education training in normal volunteers and in patients with neuromuscular disorders. In this prospective study, I evaluated application of this principle after upper extremity surgery and immobilization. A detailed therapy program to the contralateral unoperated extremity was initiated in one half of the patients. The other half of the patients had only routine postoperative instructions for rest, elevation, and protective splinting. Range of motion and strength measurements were done preoperatively and at intervals up to three months after operation. Analysis of results shows little difference in range of motion measurements in either group. However, return of strength in the extremity operated on was significantly augmented, up to 150% of the control group, in the patients who received cross-education training. Application of this principle to rehabilitation after injury to specific functional units may increase recovery.     

Gastric hypercarbia and adverse outcome after cardiac surgery

OBJECTIVE: It has been postulated that splanchnic ischemia, as manifested by gastric hypercarbia, helps to trigger excessive systemic inflammation, which has been linked to the development of adverse postoperative outcome. This study examined whether gastric PCO(2) values are associated with adverse outcome in cardiac surgical patients. DESIGN AND SETTING: Prospective cohort study in a tertiary-care hospital. PATIENTS: 43 patients undergoing elective cardiac surgery. INTERVENTIONS: Simultaneous measurements of gastric PCO(2) (using automated air tonometry) and arterial PCO(2) were obtained at the beginning and end of surgery. The difference (gap) between regional PCO(2) and arterial PCO(2) (corrected for temperature) was calculated. Adverse outcome was defined as in-hospital death or prolonged (>10 days) postoperative hospitalization. MEASUREMENTS AND RESULTS: Fourteen patients fulfilled the predefined definition for adverse outcome. Postoperative ICU stay and postoperative hospital length of stay were significantly longer in these patients. At the end of surgery gastric minus arterial PCO(2) gap was significantly larger in patients with adverse outcome. Global hemodynamic and perfusion related variables were not associated with adverse outcome (cardiac index, mean arterial pressure, mixed venous oxygen saturation, arterial lactate, arterial base excess). CONCLUSIONS: Gastric minus arterial PCO(2) gap after surgery is larger in patients with adverse postoperative outcome, which supports the theory that gastrointestinal reduced perfusion is relevant to the pathogenesis of postoperative morbidity.     

Semi-continuous versus injectate cardiac output measurement in intensive care patients after cardiac surgery

Objective Commercially available semi-continuous cardiac output (SCCO) monitoring systems are based on the pulsed warm thermodilution technique. There is evidence that SCCO fails to correlate with standard intermittent bolus cardiac output (ICO) in clinical situations with thermal instability in the pulmonary artery. Furthermore, ventilation may potentially influence thermodilution measurements by enhanced respiratory variations in pulmonary artery blood temperature and by cyclic changes in venous return. Therefore, we evaluated the correlation, accuracy and precision of SCCO versus ICO measurements before and after extubation.Design Prospective cohort study.Setting Intensive care unit (ICU) of a university hospital.Patients and participants 22 cardiac surgical ICU patients.Interventions None.Measurements and results SCCO and ICO data were obtained at nine postoperative time points while the patients were on controlled mechanical ventilation. Further sets of measurements were taken during the weaning phase 20 min before extubation, and 5 min, 20 min and 1 h after extubation. SCCO and ICO measurements yielded 286 data pairs with a range of 1.8–9.9 l/min for SCCO and 1.9–9.8 l/min for ICO. The correlation between SCCO and ICO was highly significant (r=0.92;p<0.01), accompanied by a bias of –0.052 l/min and a precision of 0.56 l/min. Correlation, accuracy and precision were not influenced by the mode of respiration.Conclusions Our results demonstrate excellent correlation, accuracy and precision between SCCO and ICO measurements in postoperative cardiac surgical ICU patients. We conclude that SCCO monitoring offers a reliable clinical method of cardiac ouput monitoring in ICU patients following cardiac surgery.     

Blood pressure measurement: an evaluation of direct and indirect methods

In order to evaluate the differences between the blood pressure values obtained by direct intraarterial (DM) and indirect sphygmomanometer (IM) measurements, both systems were employed in 30 patients during their immediate postoperative period (24 hours) at our Intensive Care Unite after open heart surgery. The total number of determinations was 355. The statistical study of data lead us to the following conclusions:

• 1.1. There are significant differences between arterial pressure values obtained by DM and IM falling within an acceptable range of error for clinical purposes
• 2.2. Both methods of measurement, direct and indirect, are highly influenced by technical details that have to be carefully standardised if suitable research values are to be obtained.

     

Energy expenditure and gas exchange measurements in postoperative patients: thermodilution versus indirect calorimetry.

OBJECTIVE: To compare a method of measuring energy expenditure and gas exchange using the Fick principle with the standard indirect calorimetry technique. DESIGN: Prospective study of a consecutive sample of postoperative patients. Oxygen consumption (VO2), CO2 production (VCO2), respiratory quotient, and energy expenditure were derived from measurements of variables, including oxygen content and cardiac output. Energy expenditure and gas exchange were measured simultaneously by continuous indirect calorimetry over a 60-min period. SETTING: Surgical ICU in a university hospital. PATIENTS: Twenty-six consecutive patients (45 to 80 yrs) who underwent sustained surgical trauma. Excluded from the study entry were patients with time-related fluctuations of hemodynamic variables, poor cooperation, patients who required supplemental oxygen, or mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: While the measurements of VO2 and VCO2 by calorimetry and thermodilution were significantly correlated with one another (for VO2, r2 = .93, p less than .001; for VCO2, r2 = .26, p less than .01), VO2 and VCO2 values by indirect calorimetry were consistently greater than VO2 and VCO2 values by the Fick method (p less than .01). The respiratory quotient calorimetric measurements ranged between 0.69 and 0.99, whereas the corresponding thermodilution measurements spread to impossible values, from 0.24 to 1.30 (0.821 +/- 0.07 vs. 0.740 +/- 0.24, p less than .05). There was an insignificant relationship (r2 = .06, p = .21) between the values of respiratory quotient by the two methods. A strong, positive correlation between energy expenditure measured by indirect calorimetry and energy expenditure measured by the Fick method was observed (r2 = .92, p less than .001). The limit of agreement between the two methods was -0.24 +/- 73 kcal/day/m2 (-1.00 +/- 305 kJ/day/m2). CONCLUSIONS: In postoperative patients, while VO2 and energy expenditure measurements by thermodilution are easy to perform and accurate for clinical purposes, VCO2, and respiratory quotient measurements are too imprecise and inaccurate to serve any useful function. Therefore, in those clinical situations in which an evaluation of respiratory quotient and substrate utilization may be useful for purposes of metabolic care of the surgical patient, precise measurements of gas exchange with indirect calorimetry are mandatory.     

神经外科术后应用中分子羟乙基淀粉对凝血功能的影响

目的 神经外科患者术后会出现凝血功能亢进,本研究拟使用6％中分子羟乙基淀粉（200/0.5）来进行干预,观察其对凝血的影响.方法 选择全麻下行神经外科开颅手术患者40例,分为实验组（n=20）、对照组（n=20）.对照组术后输注晶体液,实验组术后输注6％中分子羟乙基淀粉10 ml/kg,余输液同对照组.观察病人的血常规、常规凝血功能、Sonoclot凝血功能、无创胸阻抗心功能监测.结果 两组病人术后均未出现严重并发症,对照组PT术后2、3日与术后1日比较明显缩短,Sonoclot凝血斜率和血小板功能较术前都有升高,实验组变化不显著;两组患者血小板计数,心功能状态,尿量均无明显变化.结论 神经外科术后患者凝血机能亢进,有生成血栓的倾向;术后输注羟乙基淀粉可以改善患者术后的凝血功能亢进状态,不加重患者的心功能负担.