The incidence of hypoxemia during surgery: evidence from two institutions

Purpose

The incidence of hypoxemia in patients undergoing surgery is largely unknown and may have a clinical impact. The objective of this study was to determine the incidence of intraoperative hypoxemia in a large surgical population.

Methods

We performed a retrospective study of electronically recorded pulse oximetry data obtained from two large academic medical centres. All adults (age ≥ 16 yr) undergoing non-cardiac surgery during a three-year period at the two hospitals were included in the analysis. Our main outcome measure was the percentage of patients with episodes of hypoxemia (SpO₂ < 90) or severe hypoxemia (SpO₂ ≤ 85) for two minutes or longer during the intraoperative period (induction of anesthesia, surgery, and emergence).

Results

We evaluated 95,407 electronic anesthesia records at the two hospitals. During the intraoperative period, 6.8% of patients had a hypoxemic event, and 3.5% of patients had a severely hypoxemic event of two consecutive minutes or longer. Seventy percent of the hypoxemic episodes occurred during either induction or emergence— time periods that represent 21% of the total intraoperative time. From induction to emergence, one episode of hypoxemia occurred every 28.9 hr, and one episode of severe hypoxemia occurred every 55.7 hr of intraoperative time.

Conclusion

Despite advances in monitoring technology, hypoxemia continues to occur commonly in the operating room and may be a serious safety concern because of its potential impact on end organ function and long-term outcomes. Further studies are needed to improve our understanding of the clinical impact of intraoperative hypoxemia and the strategies that will be most useful in minimizing its occurrence.     

The effects of a coaching project in nursing on the coaches' training motivation, training outcomes, and job performance: an experimental study

BACKGROUND: Coaching is known to benefit both the trainees and the coaches, yet research in nursing has mainly focused on the benefits to the trainees. There is little knowledge regarding the psycho-educational effects of being a coach. OBJECTIVES: To determine the effects of participation in a coaching project in nursing, on the coaches' training motivation, skills acquisition, self-efficacy, professional attitudes, transfer of training and professional performance. It was hypothesized that participation in the project would significantly improve all these outcomes among the coaches but not in a control group. DESIGN: An experimental study. SETTINGS: An innovative educational program was instituted over the last 10 years in an academic School of Nursing in Israel. Recent graduates in nursing (i.e., coaches) assisted junior students in their studies. METHODS: All graduates of one class were randomly assigned to either the experimental (22 coaches) or control group (30 similar graduates who would not be coaches). The groups were similar in the demographic details and grade-point average. Research instruments included self-report measures and performance in a simulation test (Objective Structured Clinical Examination). RESULTS: Compared with the control group the coaches improved in training motivation, self-efficacy and behavioral transfer of several nursing skills. Participation also prevented deterioration of some skills (e.g., medication management, communication skills). This stability was in contrast with the decline in most outcomes in the control group. The coaches also obtained positive behavioral transfer and demonstrated superior professional performance (OSCE). Professional attitudes were not affected. CONCLUSIONS: Participation in the project enabled the coaches to enhance some of their professional skills, and improve their training motivation and self-efficacy in performing complex nursing skills. Coaching made an important contribution in facilitating the nurses' passage from school to the professional work field and could be a form of staff development.     

Effect of Avemar--a fermented wheat germ extract--on rheumatoid arthritis. Preliminary data

OBJECTIVE: To investigate the effect of the fermented wheat germ extract (Avemar)in patients with severe rheumatoid arthritis (RA). METHODS: Fifteen female RA (Steinbrocker II-III) patients, who had unsuccessfully tried two different DMARD treatments, were enrolled in an open-label, 1-year long, pilot clinical study. DMARD and steroid therapies were recorded and continued. All patients received Avemar as additional therapy. For measurement of efficacy the Ritchie Index, the Health Assessment Questionnaire (HAQ) and the assessment of morning stiffness were applied. Patients were evaluated at baseline, 6 and 12 months. For statistical analyses the Wilcoxon test was used.RESULTS: At both 6 and 12 months, Ritchie index, HAQ and morning stiffness showed significant improvements compared with the baseline values. Dosages of steroids could be reduced in about half of the patients. No side effects of Avemar were observed.CONCLUSION:Supplementation of standard therapies with a continuous administration of Avemar is beneficial for RA patients.     

Clinical outcome and neuropsychological deficits after right decompressive hemicraniectomy in MCA infarction

BACKGROUND AND PURPOSE: The purpose of this study was to analyse in detail the functional outcome and the neuropsychological deficits in patients with space-occupying infarction of the non-dominant hemisphere one year after surgery. METHODS: Postoperative complications and retrospective consent to surgery were assessed in a semi-structured interview in 26 patients. Functional outcome was measured with the Barthel-Index (BI) and Rankin-Scale. Neuropsychological tests in 14 patients focused on visuo-spatial and visuo-constructive abilities, attention, spatial span and self-rated mood. RESULTS: The one-year survival rate was 69 % (18 of 26). The functional outcome was good (BI >/= 90) in 3 patients, fairly good (BI 75-85) in 6, moderate (BI 30-70) in 6, and poor (BI 0-25) in 3 patients. Age was an independent predictor of outcome, patients above 52 years had a BI of 50 or below. Neuropsychological tests (14 of 18) showed profound attention deficits in all patients, and visuo-spatial and visuo-constructive deficits in patients with lower formal education. Retrospectively, 4 of 18 patients would not give consent to surgery again, mostly because of the bad quality of life postoperatively. CONCLUSION: Older patients do not seem to benefit from decompressive hemicraniectomy; more than half of the surviving younger patients have a good outcome and live independently. Attention deficits are prominent in all patients; visuo-spatial and constructive deficits are less pronounced in patients with higher formal education. Retrospective agreement to decompressive hemicraniectomy is high in patients with good functional outcome.     

Viral polypeptides associated with the RNA replication complex in poliovirus-infected cells

A poliovirus-specific protein involved in viral RNA synthesis in vitro has been previously identified and partially purified. A second viral protein which purifies with the replication complex is described in this paper. A comparison of tryptic peptide maps of noncapsid viral protein 2 with the two replication complex-associated proteins indicates that all three are related. We designate this newly identified protein as 4a and refer to the previously identified protein as 4b. The apparent molecular weights of 4a and 4b by SDS-PAGE are 65,000 and 58,000, respectively. Pulse-chase experiments suggest that 4a may be a precursor to 4b. It is degraded within about an hour after being synthesized, and its degradation is inhibited by treatment of infected cells with iodoacetamide. An unstable precursor with the properties of 4a could conceivably contain the sequence for the 5′ terminally linked protein, VPg.     

Immunogenetics of rheumatoid arthritis in Israel

In an attempt to study the variation of associations between HLA and rheumatoid disease a population of 44 Ashkenazi and 29 non-Ashkenazi patients with Rheumatoid Arthritis were tested for HLA-A, B, C and DR antigens and compared with the relevant control groups. In contrast to the results obtained in Middle European or North American Caucasians, Rheumatoid Arthritis in Israel is not associated with B15 and Cw3, indicating that it is very unlikely that B- and C-locus antigens are involved in coding for disease susceptibility for RA. The allele DR4 which is found associated with RA in almost all populations tested so far was in the total patient group (47.9%) slightly but not significantly more frequent than in the control group (38.3%). This difference was entirely due to a nonsignificant increase in the frequency of DR4 in the Ashkenazi patients (54.5%) compared to controls (40%), while the frequency of DR4 in non-Ashkenazi patients and controls was virtually identical (38.0% vs 36.7%). Another surprising finding was that the frequency of HLA-DR1, which has been reported to be increased in different populations of patients with RA was found to be completely normal in the present study on Israeli patients. The alleles of the Bf and the GLO system did not show any significant difference between patients and controls.(ABSTRACT TRUNCATED AT 250 WORDS)     

In vivo Na+- and Cl minus-independent transport across the skin of Rana esculenta.

The relationship between the trans-epithelial Na+ and Cl minus absorptions from dilute external solutions and the H+ and base excretions were studied in Rana esculenta in vivo. The following results relate to transport from Na2SO4 solutions: 1) The Na+ absorbed is exchanged against endogenous H+. 2) Diamox injection (1.10-4 M-kg-1) simultaneously inhibits both Na+ absorption and H+ excretion. 3) The addition of amiloride to the external medium (final concn: 5-10-5 M) inhibits Na+ absorption and H+ excretion. Measurements of chloride movements from choline chloride solutions give the following results: 1) The chloride absorbed is exchanged against a base, probably HCO3-. 2) Diamox injection (1-10-4 M-kg-1)inhibits the net fluxes of both ions. When transport is measured in NaCl solutions, it is impossible to measure the HCO3-excreted when H+ is also being excreted (HCO3- plus H+ in equilibrium CO2 plus H2O). In these solutions, therefore, only the action of Diamox on the sodium and chloride fluxes was followed and was found to have similar effects on these fluxes as those described for choline chloride and sodium sulphate solutions. The results are discussed in relation to other studies on the action of inhibitors on sodium and chloride transport in the in vitro skin.     

Positioning of the premaxilla in cases of bilateral cleft lip, alveolus and palate using Latham's appliance]

SUBJECT MATTER: In cases of bilateral cleft lip, alveolus and palate, preoperative positioning of the premaxilla using Latham's appliance has been described. This method is controversial, since it may cause growth defects. PATIENTS AND METHODS: From 1992 to 2000, Latham's appliance was inserted preoperatively into 20 patients with bilateral lip, alveolus and palate clefts with extreme premaxillary protrusion. Pin fixation ensued at the age of 3 months. After adjustment of the premaxilla, the soft palate was closed and bilateral lip adhesion as well as bilateral gingivoperiosteoplasty were performed directly after the removal of the appliance. Final lip closure took place 4-6 weeks later. At the age of 2 years, the hard palate was closed. Evaluation was based on combined face-maxilla models, standard photographs and, when available, lateral skull x-rays showing the relative position of the segments, the influence of Latham's appliance on the nasal septum and the relation of the upper jaw to the skull base and mandibula. RESULTS: In all cases, a satisfactory alveolar alignment was achieved; thickening and curvature of the nasal septum occurred but receded. Neither growth disturbances nor dental germ damage were seen. In two cases, complications arose from suture dehiscence of the lip adhesion: in one patient, a screw defect caused a loosening of the appliance and there was also a transmigration of the postpremaxillary pin. CONCLUSIONS: On the basis of our experience, the use of Latham's appliance, combined with consistent orthodontic supervision and, if necessary, treatment, represents a practical option for the treatment of bilateral cleft lip, alveolus and palate, especially in cases with extreme protrusion of the premaxilla.