Thromboelastography as an indicator of post-cardiopulmonary bypass coagulopathies

Postoperative hemorrhage in patients undergoing open-heart surgery is a major cause of morbidity and mortality. Monitoring of coagulation in these patients has routinely involved the activated clotting time. Thromboelastography is currently used as a monitor of coagulation during liver transplantation. The thromboelastogram, by providing information on the interaction of all the coagulation precursors, gives more clinically useful information on coagulation than that available from the coagulation profile or the activated clotting time alone. This study was done to assess the usefulness of thromboelastography in open-heart surgery. Thirty-eight patients (29 undergoing coronary artery bypass grafting and 9 undergoing valve replacement) were studied with activated clotting time, thromboelastography, and coagulation profiles during three periods: before bypass, during bypass, and after protamine administration. Thromboelastography was a significantly better predictor (87% accuracy) of postoperative hemorrhage and need for reoperation than was the activated clotting time (30%) or coagulation profile (51%). Thromboelastography is easy to use and provides diagnostic data within 30 minutes of blood sampling.     

Coining and Defining Novel Nursing Terminology. Part 1: Critical Incident Nursing Diagnosis

PURPOSE.  In the first of a three-part series, a novel nursing terminology is introduced and proposed for inclusion in the North American Nursing Diagnosis Association (NANDA) International Classification—Critical incident nursing diagnosis (CIND)—defined as the recognition of an acute life-threatening event that occurs as a result of disease, surgery, treatment, or medication.
DATA SOURCES.  The literature, research studies, and meta-analyses from a variety of disciplines, and personal clinical experience serve as the data sources for this article.
DATA SYNTHESIS.  The current nursing diagnoses in the NANDA International Classification are inaccurate or inadequate for describing nursing care during life-threatening situations. The lack of standardized nursing terminology creates a barrier that may impede critical communication and patient care during life-threatening situations.
CONCLUSIONS.  Coining and defining a novel nursing terminology, CIND, for patient care during life-threatening situations are important and fill the gap in the current standardized nursing terminology.
IMPLICATIONS FOR NURSING PRACTICE.  Refining the NANDA International Classification will permit nursing researchers, among others, to conduct studies on nursing diagnoses in conjunction with the proposed novel nursing terminology: CIND. Parts 2 and 3 of this series will propose additional nursing terminology: critical incident nursing intervention and critical incident control, respectively.     

The Costs and Benefits of Nurse-Midwifery Education: Model and Application

To promote nurse‐midwifery education, it is important for educators to know the value students bring to clinical training sites and academic institutions, the value nurse‐midwifery graduates bring to taxpayers who help support nurse‐midwifery education, and the value an education in nurse‐midwifery brings to the graduate. The first purpose of this study was to develop a model to include all costs and benefits of nurse‐midwifery education to: 1) students; 2) clinical sites where nurse‐midwifery students obtain clinical experience; 3) academic institutions that house nurse‐midwifery education programs; and 4) others (most often taxpayers) who may contribute to nurse‐midwifery education. The second purpose of the study was to develop a prototype nurse‐midwifery education program to illustrate the use of the model. Considering the four entities together, the costs, benefits, and net benefits to society were estimated. Data were collected to estimate all costs and benefits to the four entities as they function within this prototypical program. For the prototype, all entities realize a net benefit from the investment in nurse‐midwifery education. For society, the benefit‐cost ratio is 1.57. Nurse‐midwifery students show the highest benefit‐cost ratio (2.05) of the four entities, followed by the clinical sites, others (primarily taxpayers), and academic institutions.     

The Combined Use of Propofol and Fentanyl for Outpatient Intravenous Conscious Sedation

BACKGROUND: Intravenous conscious sedation is currently being widely utilized for outpatient surgery including dermatologic surgery. Even though this type of anesthesia is typically administered by a trained, licensed anesthetist, it is important for dermatologists who either intend to or are currently utilizing this type of anesthesia to be familiar with some of the methods and agents that are commonly employed. OBJECTIVE: Propofol and fentanyl are two anesthetic agents that are in prevalent use for skin and soft tissue surgery of brief or limited duration. With the goal of familiarizing dermatologic surgeons with this form of anesthesia, a study was conducted to evaluate the safety and effectiveness of the combination of propofol and fentanyl when used for conscious sedation in an outpatient dermatology center. METHODS: Twenty patients, ages 25-65 years, who required conscious sedation were enrolled. Each patient received a standard dosage of fentanyl and propofol, as determined on a kilogram basis. Sedation time, total procedure time, recovery time, and total propofol dose, along with side effects, were determined. RESULTS: The mean onset to sedation was 52.5 seconds, the mean procedure time was 40 minutes 37 seconds, and the mean interval to recovery was 3 minutes 43 seconds, with a mean total dose of propofol of 5.83 mg/kg. Minimal side effects occurred. CONCLUSION: Propofol when used in conjunction with fentanyl appears to be a safe, quick, and effective method of providing conscious sedation.     

More hypotension in patients taking antihypertensives preoperatively during shoulder surgery in the beach chair position

Purpose

Hypotension is common in patients undergoing surgery in the sitting position under general anesthesia, and the risk may be exacerbated by the use of antihypertensive drugs taken preoperatively. The purpose of this study was to compare hypotensive episodes in patients taking antihypertensive medications with normotensive patients during shoulder surgery in the beach chair position.

Methods

Medical records of all patients undergoing shoulder arthroscopy during a 44-month period were reviewed retrospectively. The primary endpoint was the number of moderate hypotensive episodes (systolic blood pressure ≤ 85 mmHg) during the intraoperative period. Secondary endpoints included the frequency of vasopressor administration, total dose of vasopressors, and fluid administered. Values are expressed as mean (standard deviation).

Results

Of 384 patients who underwent shoulder surgery, 185 patients were taking no antihypertensive medication, and 199 were on at least one antihypertensive drug. The antihypertensive medication group had more intraoperative hypotensive episodes [1.7 (2.2) vs 1.2 (1.8); P = 0.01] and vasopressor administrations. Total dose of vasopressors and volume of fluids administered were similar between groups. The timing of the administration of angiotensin-converting enzyme inhibitors and of angiotensin receptor antagonists (≤ 10 hr vs > 10 hr before surgery) had no impact on intraoperative hypotension.

Conclusions

Preoperative use of antihypertensive medication was associated with an increased incidence of intraoperative hypotension. Compared with normotensive patients, patients taking antihypertensive drugs preoperatively are expected to require vasopressors more often to maintain normal blood pressure.