From emergency services to neurosurgical intensive care, the role of the nurse in neurosurgery

Treating a patient with a head injury requires a full general assessment, a rigorous evaluation of the severity of the trauma and the prevention of brain insults of systemic origin. Monitoring by the nurse is essential and determines the carrying out of additional tests. She must look out for neurological deterioration and prepare the patient and his or her family for potential sequelae.     

A diagnostic score to predict the difficulty of a laparoscopic cholecystectomy from preoperative variables

Background: Modified logistic regression analysis of 24 variables in 300 patients undergoing laparoscopic cholecystectomy found the following parameters independently predictive for a difficult operation: right upper quadrant pain (p < 0.01), rigidity in right upper abdomen (p < 0.01), previous upper abdominal surgery (p < 0.01), biliary colic within the last 3 weeks (p < 0.05), white blood cell count >10 × 10⁹/l (p < 0.05), thickening of the gallbladder wall (p < 0.05), hydroptic gallbladder (p < 0.05), pericholecystic fluid (p < 0.01), shrunken gallbladder (p < 0.01), and no filling of the gallbladder in preoperative intravenous cholangiography (p < 0.05). Methods: Based on these variables a diagnostic model was developed to predict the difficulty of a laparoscopic cholecystectomy, with scores ranging from 0 (ideal case) to IV (conversion to open cholecystectomy expected) prior to surgery. Results: When the reliability of our model was examined in a second study in 340 consecutive patients undergoing laparoscopic cholecystectomy 80% of the patients were predicted correctly. Conclusions: Our model should help to select patients for either laparoscopic or open cholecystectomy based on the expected difficulties and the experience of the surgeon.     

陈琳：再见十二种颜色

那天，天寒地冻，行人都穿了厚厚的棉衣，我在高波工作室门口遇见她们。一辆笨重的吉普车，从里面依次跳出一个个鲜亮五彩的人，那是陈琳、中国辣妹和助手们。她们好似迎面的蝴蝶，带着十二种颜色的缭乱，一时间让人有些失措——我想说，无论谁在这个沉闷的冬天看见这幅风景，都会以为是春天破茧而来了。     

The effect of a toothguard on the difficulty of intubation

Dental damage is the most common reason for complaints against anaesthetists. The purpose of this study was to investigate the common belief that the use of a toothguard at the time of intubation causes intubation to be more difficult. We studied 80 patients, half of whom were intubated with a toothguard in situ and the other half intubated without a toothguard. The time taken from mouth opening to successful passage of the tracheal tube through the vocal cords was measured. In the toothguard group, the recorded time also included the time taken to insert the toothguard. The median time to intubation in the group with a toothguard was 24 s and the median time to intubation in the group without a toothguard was 17 s. The difference of 7 s in the time to intubation was statistically significant (p =0.0003). As the recorded times also included the time taken to insert the toothguard, we do not regard this result to be clinically significant and believe that anaesthetists should think carefully before disregarding this simple protective device.     

Simple preoperative parameters to assess technical difficulty during a radical perineal prostatectomy

Purpose

We aimed to propose a practical selection method predicting the easier radical perineal prostatectomy (RPP) cases before the operation.

Methods

Fifty sequential RPP cases were divided into two groups according to the estimated difficulty of the operation (Group I: Easier, Group II: Difficult) which was assessed by using a RPP difficulty scale, constituted by three parameters (operation time, blood loss, and the judgment of the surgeon) each ranging between 1 and 3 points. As the localization parameters, skin-to-prostatic apex (SPAD) and skin-to-prostatic base (SPBD) distances and distance between bilateral ischial tuberosities (ITD) were measured. During suprapubic ultrasonography, a probe-divergence angle (PDA) and prostate volumes (PV) were recorded. These parameters were compared between the groups.

Results

In Group I (n = 29) and Group II (n = 21), the difficulty scores were 4.37 (3–5) and 6.80 (6–9), respectively. Data of age, clinical stages, and findings of digital rectal examination were not different between groups. While SPBD, SPAD, and ITD values were found similar (p > 0.05), PDA and PV were significantly different. PDA was > 45 degree in 21 cases in Group I (72.4 %) and in 7 cases in Group II (33.3 %) (p = 0.011). The mean of PV was 37.4 (20–60) cc and 49.9 (30–75) cc in Group I and Group II, respectively (p = 0.001).

Conclusions

While planning RPP operations, by selecting the prostate cancer cases with a prostate of low volume and localized deeper in the pelvis during suprapubic ultrasonography, urologists may have a chance to perform this technique more easily during the learning period.     

From Hesitation to Appreciation: the transformation of a single,local donation‐nurse project into an established organ‐donation service

This study evaluates the transition from a local project to promote organ donation to a permanent county‐based donation service inspired by the Spanish model. To address the problem of declining donation rates, a project with one donation‐specialized nurse (DOSS) was initiated at a single neuro‐intensive care unit. This project was later expanded into a permanent on‐call service consisting of seven DOSSes, covering a large urban county. During the different periods (before, during project and during permanent service), the DOSS function's effect on donation rates was significant, and the number of eligible donors that became actual donors increased from 37% to 73% and 74%, respectively. The effect on family vetoes was as prominent with a decrease from 34% to 8% and 14%. The staff appreciation of the DOSS function was also evident during the periods; all areas included in the questionnaire (family care, donor care and staff support) have improved greatly owing to the DOSS. The transition from a single, local donation‐nurse project, to an on‐call service with several DOSSes covering a large urban county was a success considering the donation rates as well as the staff's appreciation. Hence, organizational models from abroad can be adjusted and successfully adopted.     

Development of a difficulty score for spinal anaesthesia

Background. Multiple attempts at spinal puncture may be hazardous.Accurate preoperative prediction of difficulty adds to the deliveryof high quality care. This clinical trial was designed to: (i)determine the predictive performance of difficulty variables;(ii) compare senior and junior anaesthetists; (iii) developa score to predict difficulty during the performance of spinalanaesthesia. Methods. A total of 300 patients subjected to urological proceduresand scheduled for spinal anaesthesia were independently assessedand stratified according to the categories of the difficultypredictors of spinal anaesthesia into one of nine grades (0–8)and randomized according to the experience of the anaesthetistinto two groups (group A, staff with more than 15 yrs’experience; group B, resident with more than 6 months but lessthan 1 yr in training). The number of attempts and levels, andsuccess rate of the technique were the outcome variables. Datawere analysed by multivariate analysis and receiver operatingcharacteristic (ROC) curves. Results. The bony landmarks of the back and the radiologicalcharacteristics of the lumbar vertebrae were two independentpredictors of difficulty. Multivariate analysis indicated differencesbetween junior and senior staff but ROC curves indicated nodifference. Grade 4 was the difficulty score at or above whichdifficulty was expected whether or not radiological characteristicsof the vertebrae were included. Conclusions. Spinal bony landmarks and radiological characteristicsof the lumbar vertebrae are independent predictors of difficultyduring spinal anaesthesia. There is no difference between seniorand junior anaesthetists. Grade 4 is the difficulty score ator above which difficulty is expected. Br J Anaesth 2004; 92: 354–60