Results of a survey of more than 30,000 nurses across Europe show that nurses who work longer shifts and more overtime are more likely to rate the standard of care delivered on their ward as poor, give a negative rating of their hospitals safety and omit necessary patient care.
Led by researchers at the University of Southampton and the National Nursing Research Unit (NNRU) at King
A significant breakthrough could revolutionise surgical practice and regenerative medicine. A team led by Ludwik Leibler from the Laboratoire Mati
Robot-assisted surgery to remove cancerous prostate glands is effective in controlling the disease for 10 years, according to a new study led by researchers at Henry Ford Hospital.
The study also suggested that traditional methods of measuring the severity and possible spread of the cancer together with molecular techniques might, with further research, help to create personalized, cost-effective treatment regimens for prostate cancer patients who undergo the surgical procedure.
The findings apply to men whose cancer has not spread beyond the prostate, and the results are comparable to the well-established and more invasive open surgery to remove the entire diseased prostate and some surrounding tissue.
Yale researchers have found that the lactate component of a common saline solution used in hospitals may have anti-inflammatory effects that can reduce injury to major organs. The finding has clinical implications for the treatment of pancreatitis, kidney injury, strokes, and even heart attacks.
The researchers induced acute pancreatitis or hepatitis in various mouse models. They then injected a portion of the mice with sodium lactate, which is a component of fluids often given intravenously to patients in hospitals to maintain proper blood pH levels.
The sodium lactate reduced the activation of toll-like receptors, components of the innate immune system that recognize foreign pathogens and launch the immune system
Postsurgical cognitive side effects can have major implications for the level of care, length of hospital stay, and the patient’s perceived quality of care, especially in elderly and fragile patients. A nationwide survey of Swedish anaesthesiologists and nurse anaesthetists has found there is low awareness of the risks of cognitive side effects following surgery. Furthermore, only around half of the respondents used depth-of-anaesthesia monitors.
Patients generally expect to make a rapid recovery from anaesthesia with a minimum of side effects. The main focus by anaesthesia personnel centres around how to minimize cardiovascular and pulmonary risks and on the management of postoperative pain, nausea, and vomiting. According to the survey results, less attention is being paid to cognitive side effects following surgery, yet these complications can have major implications for the patient.
‘We found that Swedish anaesthesia personnel viewed risk assessment, prevention, and handling of postoperative delirium and postoperative cognitive dysfunction of rather low importance. Protocol and/or standardized routines were only rarely implemented,’ observes senior investigator Professor Jan G. Jakobsson, MD, PhD, of the Department of Anesthesia & Intensive Care, Institute for Physical Science, Karolinska Institute, Stockholm, Sweden.
Postoperative cognitive impairments may arise early on after surgery, such as the short-lasting, but still distressful postoperative emergence agitation (EA). Postoperative delirium (POD) usually makes its debut one or two days after surgery, sometimes giving rise to major concerns. The more subtle but longer lasting postoperative cognitive dysfunction (POCD) generally starts during the first week after surgery, but may last for a month. Although these side effects are of major concern for both hospitals and patients, they have received less attention from anaesthesia personnel.
To gain insight regarding routines and practice for risk assessment, diagnosis, and management of postoperative cognitive side effects, and the use of EEG-based depth-of-anaesthesia monitoring (DOA), investigators sent a web-based validated questionnaire to over 2,500 Swedish anaesthesiologists and nurse anaesthetists. The questionnaire consisted of three sections covering subjective preferences, routines, and practices related to the perioperative handling of EA, POD, POCD, and awareness. The response rate was 52%.
In general the respondents considered the risk for neurocognitive side effects to be the least important during the preoperative assessment, while the risk of awareness with recall (when patients are able to recall the surgery) as well as traditional cardiac and pulmonary risk was considered of high importance.
It has been suggested that the use of EEG-based DOA monitoring to fine-tune and tailor anaesthetic delivery can reduce the risk of postoperative cognitive side effects. Previous surveys of anaesthetic practice in Sweden showed a high degree of standardization and that structured protocols for the perioperative management are in place. However, the results of this survey were more diverse. EEG-based DOA monitors were used in half of all departments, but the frequency and indication for their use varied.
‘Respondents were overall quite skeptical about the value of EEG-based DOA monitors, however their use in patients at risk for awareness was more positive among the nurse anaesthetists than the anaesthesiologists,’ notes Professor Jakobsson. ‘This attitude to DOA monitoring may be due to the rather negative stance of the Swedish Council on Health Technology Assessment regarding these devices. This is in contrast to the national guidelines in the UK, which support the use of DOA monitoring in at-risk patients.’
‘The results show there is a need to improve the knowledge of anaesthesia personnel about risk factors, prevention and management of postoperative cognitive side effects,’ concludes Professor Jakobsson. EurekAlert
Many women struggling to become pregnant may suffer from some degree of tubal blockage. Traditionally, an x-ray hysterosalpingogram (HSG) that uses dye is the most common procedure to determine whether a blockage exists, but it can cause extreme discomfort to the patient. UC San Diego Health System
Poor oral health and hygiene are increasingly recognized as major risk factors for pneumonia among the elderly. To identify modifiable oral health-related risk factors, lead researcher Toshimitsu Iinuma, Nihon University School of Dentistry, Japan, and a team of researchers prospectively investigated associations between a constellation of oral health behaviours and incidences of pneumonia in the community-living of elders 85 years of age or older.
At baseline, 524 randomly selected seniors (228 males, 296 females, average age was 87.8 years old) were examined for oral health status and oral hygiene behaviors as well as medical assessment, including blood chemistry analysis, and followed up annually until first hospitalization for or death from pneumonia. Over a three-year follow-up period, 48 events associated with pneumonia were identified (20 deaths and 28 acute hospitalizations). Among 453 denture wearers, 186 (40.8%) who wore their dentures during sleep, were at higher risk for pneumonia than those who removed their dentures at night.
In a multivariate Cox model, both perceived swallowing difficulties and overnight denture wearing were independently associated with approximately 2.3-fold higher risk of the incidence of pneumonia, which was comparable with the high risk attributable to cognitive impairment, history of stroke and respiratory disease. In addition, those who wore dentures while sleeping were more likely to have tongue and denture plaque, gum inflammation, positive culture for Candida albicans, and higher levels of circulating interleukin-6 as compared to their counterparts.
This study provides empirical evidence that denture wearing during sleep is associated not only with oral inflammatory and microbial burden but also with incident pneumonia, suggesting potential implications of oral hygiene programs for pneumonia prevention in the community. The International Association for Dental Research (IADR)
After a systematic review of clinical trials based on administering antidepressants for acute and chronic postsurgical pain, researchers have concluded that more trials are needed to determine whether these drugs should be prescribed for postsurgical pain on a regular basis.
Dr. Ian Gilron, a professor and director of clinical pain research in the Department of Anesthesiology, and his team of seven researchers reviewed 15 trials to determine whether the use of antidepressants for pain relief post-surgery would work more effectively than painkillers such as opioids, local anaesthetics, or acetaminophen.
Clinical trials are often used to answer questions about the efficacy of the off-label uses of drugs. In the case of antidepressants, their effects on postsurgical pain continue to be an area of research interest.
The publication of the new joint ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management introduces a number of recommendations in the field. Among other topics, the Guidelines include updated information on the use of clinical indices and biomarkers in risk assessment, and the use of novel anticoagulants, statins, aspirin and beta-blockers in risk mitigation.
Worldwide, non-cardiac surgery is associated with an average overall complication rate of between 7% and 11% and a mortality rate between 0.8% and 1.5%, depending on safety precautions. Up to 42% of these are caused by cardiac complications. When applied to the population in the European Union member states, these figures translate into at least 167,000 cardiac complications annually, of which 19,000 are life-threatening. This highlights the need for guidelines designed to improve peri-operative cardiac risk management in non-cardiac surgery patients. The updated 112 page document with 279 references is freely downloadable from the ESC and EHJ websites(1) and published in the European Heart Journal(2). It will also be available online and in print in the European Journal of Anaesthesiology from September.
The 2014 ESC/ESA Guidelines cover the entire field including surgical risk assessment, pre-operative evaluation, and optimal peri-operative management, and will also address relevant cardiological and anaesthesiological issues in patients with specific cardiac diseases and common co-morbidities who are scheduled to undergo non-cardiac surgery.
These 2014 Guidelines have been released simultaneously with the American College of Cardiology/American Heart Association Guidelines
The American Association for Thoracic Surgery (AATS) has released new evidence-based guidelines for the prevention and treatment of perioperative and postoperative atrial fibrillation (POAF) and flutter for thoracic surgical procedures.
‘These guidelines have the potential to prevent the occurrence of atrial fibrillation in thousands of patients who undergo lung surgery each year. The AATS is committed to its goal of improving the care of patients around the globe who undergo cardiothoracic surgery each year. These guidelines will have a very positive impact on the outcomes of these patients,’ commented David J. Sugarbaker, MD, Director of The Lung Institute and Professor of Surgery, Baylor College of Medicine in Houston, TX, and Past President of the AATS.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, occurring in one to two percent of the general population. Many studies show an increase in mortality in patients with POAF, although it is not clear to what extent the arrhythmia itself contributes to mortality. POAF is also associated with longer intensive care unit and hospital stays, increased morbidity, including strokes and new central neurologic events, as well as use of more resources. Patients who develop POAF tend to stay two to four days longer in the hospital.
A task force of sixteen experts, including cardiologists, electrophysiology specialists, anaesthesiologists, intensive care specialists, thoracic and cardiac surgeons, and a clinical pharmacist, was invited by the AATS to develop evidence-based guidelines for the prevention and treatment of perioperative/postoperative atrial fibrillation and flutter (POAF) for thoracic surgical procedures.
‘Patients with pre-existing AF represent a high-risk population for stroke, heart failure, and other POAF-related complications,’ says Gyorgy Frendl, MD, PhD, of the Department of Anesthesiology, Perioperative Critical Care and Pain Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, who co-chaired the task force. ‘Some may present with valvular heart disease. The management of their antiarrhythmic medications and their perioperative anticoagulation may pose a challenge.’
The task force examined evidence and adapted a standard definition for POAF. The task force also developed a set of recommendations for how to:
Define and diagnose POAF
Use physiologic (ECG) monitoring of patients at risk for POAF
Best manage and treat POAF
Use rate control and antiarrhythmic drugs, considering their mechanism of action, side effects, and limitations
Best manage the patient with preexisting AF
Manage anticoagulation for new-onset POAF
Manage (long-term) and how to follow patients with persistent new-onset POAF
Among the task force’s main recommendations are:
Both electrophysiologically-documented AF and clinically diagnosed AF should be included in the clinical documentation and reported in clinical trials/studies.
Patients at risk for POAF should be monitored with continuous ECG telemetry postoperatively for 48 to 72 hours (or less if their hospitalization is shorter) if they are undergoing procedures that pose intermediate or high risk for the development of postoperative AF or have significant additional risk factors for stroke, or if they have a history of preexisting or periodic recurrent AF before their surgery.
In patients without a history of AF, who show clinical signs of possible AF while not monitored with telemetry, ECG recordings to diagnose POAF and ongoing telemetry to monitor the period of AF should be immediately implemented.
Recent evidence suggests that some prevention strategies, such as avoiding beta-blockade withdrawal for those chronically on those medications and correction of serum magnesium when abnormal, may be effective in all patients for reducing the incidence of POAF, but that some of these strategies are underused. The task force recommends that:
Patients taking beta-blockers before thoracic surgery should continue them (even if at reduced doses) during the postoperative period to avoid beta-blockade withdrawal.
Intravenous magnesium supplementation may be considered to prevent postoperative AF when serum magnesium level is low or it is suspected that total body magnesium is depleted.
Digoxin should not be used for prophylaxis against AF.
Catheter or surgical pulmonary vein isolation (at the time of surgery) is not recommended for prevention of POAF for patients who have no previous history of AF.
Complete or partial pulmonary vein isolation at the time of (even bilateral) lung surgery should not be considered for prevention of POAF, as it is unlikely to be effective.
For those patients at increased risk for the development of POAF, preventive administration of medications (diltiazem or amiodarone) may be reasonable. However, these strategies may not be useful for all thoracic surgical patients.
Guidelines for the management of patients with preexisting AF include: criteria for obtaining cardiology consults for preoperative AF; perioperative management of anticoagulation for patients on long-term anticoagulation (warfarin or new oral anticoagulants); postoperative resumption of anticoagulation; and postoperative follow-up. Specifically, catheter or surgical ablation of AF is not recommended for management of patients with postoperative AF after thoracic surgery.
‘These guidelines are best used as a guide for practice and teaching. The applicability of these recommendations to the individual patient should be evaluated on a case-by-case basis, and only applied when clinically appropriate,’ comments Dr. Frendl and the task force. ‘In addition, these guidelines can serve as a tool for uniform practices, to guide preoperative evaluations, and form the basis of large, multicenter cohort studies for the thoracic surgical community.’ EurekAlert
Beukenlaan 137
5616 VD Eindhoven
The Netherlands
+31 85064 55 82
info@interhospi.com
PanGlobal Media IS not responsible for any error or omission that might occur in the electronic display of product or company data.
