Perioperative Experience Research Articles

Ketamine in perioperative analgesia for knee surgeries: Review of evidence from randomized controlled trials

Successful perioperative analgesia for knee surgeries results in improved patient satisfaction and promotes successful rehabilitation. However, effective perioperative pain control is commonly a challenging task for knee surgeries. Such surgical procedures as total knee replacement or knee arthroscopy may be accompanied by severe postoperative pain. As opioids and nonsteroidal anti-inflammatory drugs are commonly used, the side effects of these types of medicines are quite common as well, especially in patients with chronic pain, as they are commonly dissatisfied with regular analgesia. Patients with chronic pain tend to have lower tolerance to pain, and be dependent and tolerant to opioids. These patients typically require higher doses of analgesics, which further negatively affect patients’ safety and the overall perioperative experience. Multimodal perioperative analgesia helps to spare opioids and promote successful rehabilitation. Ketamine is a noncompetitive N-Methyl-d-aspartate (NMDA) receptor antagonist that has been used for multimodal perioperative analgesia as an adjunct to opioids and nonsteroidal anti-inflammatory drugs. Despite the significant number of papers evaluating the role of ketamine in perioperative analgesia, the feasibility of ketamine for perioperative pain control in knee surgeries remains a subject of debate. There are only a limited number of high-quality studies on the topic. We used a systematic approach to evaluate randomized controlled trials with perioperative ketamine used for knee surgeries. The majority of the studies confirmed that the utilization of ketamine in perioperative analgesia was associated with lower pain scores, reduced opioid use, improved knee joint mobility, and an increase in patient tolerance for physical therapy and rehabilitation. The techniques for ketamine administration and dosing varied significantly, which may explain the inconsistencies between the reports. In addition, some of the studies, even those of high quality, used nitrous oxide in both the study and control groups. Nitrous oxide has NMDA receptor antagonist properties, as does ketamine. None of the studies reported whether patients were taking methadone, dextromethorphan, memantine, or magnesium sulfate, which are NMDA receptor antagonists too. The concomitant use of NMDA receptor antagonists, other than ketamine, may have interfered with the realization of analgesic effects of ketamine. Although it is largely accepted that NMDA receptor antagonism at the spinal level explains most of the analgesic effects of ketamine, it also interacts at other multiple receptors centrally, including, cholinergic receptors, nicotinic and muscarinic, adrenergic, central NMDA, and non-NMDA glutamate receptors. These influences may potentially explain why patients treated with other NMDA receptor antagonists had improved with ketamine as well. Ketamine also interacts with opioid receptors at supraspinal sites, where it produces supraspinal antinociception. Some of the studies did not report whether the participants were opioid naïve or opioid dependent. That might be an important determinant of the analgesic effect because opioid dependent patients are shown to benefit from the ketamine significantly. None of the examined randomized controlled trials assessed the effects of ketamine on opioid dependent patients. The variability between the outcomes of ketamine utilization for perioperative analgesia for knee surgeries might be, at least partially, explained by these findings.

Use of Pain Scale for Pre-operative Pain Education

A patient knowledge deficit regarding post-operative pain and pain evaluation techniques had been recognized. In the pre-operative setting, post-operative pain and the pain scale were not routinely discussed. Education about post-operative pain and evaluation techniques could improve the overall peri-operative experience for patients.

Primary Tracheoesophageal Puncture with Supraclavicular Artery Island Flap after Total Laryngectomy or Laryngopharyngectomy

Objectives: (1) Describe our perioperative experience of primary tracheoesophageal puncture (TEP) with intraoperative placement of voice prosthesis for patients undergoing total laryngectomy (TL) or laryngectomy with partial pharyngectomy requiring supraclavicular artery island flap (SCAIF) reconstruction. (2) Assess TEP voice outcomes in this patient group. Methods: Retrospective chart review of all patients undergoing SCAIF reconstruction following TL or laryngectomy with partial pharyngectomy at a single institution between 2011 and 2013 (N = 14). There were no exclusion criteria. Results: We identified 7 patients who underwent primary TEP with intraoperative placement of voice prosthesis (mean age = 64.1, 5M:2F). Six patients had prior chemoradiation for laryngeal squamous cell carcinoma. One patient had a dysfunctional larynx from radiation treatment for tonsillar squamous cell carcinoma. Five patients underwent TL and 2 patients underwent TL with partial pharyngectomy. Indwelling 16 French Blom-Singer prosthesis was placed intraoperatively prior to SCAIF reconstruction. There were no TEP-related complications, such as prosthesis displacement or leakage, intraoperatively or in the perioperative period. One patient developed a peristomal pharyngocutaneous fistula. In terms of voice outcomes, 6 patients achieved tracheoesophageal voice production within 10 months after TEP placement, and most occurred earlier (mean time = 2.9 months, SD= 3.1). One patient remained aphonic. Of the 6 patients who achieved successful voice acquisition, 2 required cricopharyngeal segment Botox injections with good response. Conclusions: Similar to free tissue transfer reconstruction, primary TEP with intraoperative placement of the voice prosthesis at the time of SCAIF reconstruction is safe and effective. Six of 7 patients had successful voice acquisition within 10 months.

Challenges and Opportunities: Improving the Perioperative Experience for Patients Receiving Palliative Care (FR415)

1. Identify your ED/PC ‘‘Champions.’’ Specific case examples highlighting unmet palliative care needs in the ED are described, as well as the identification of clinical and administrative staff best suited to foster lasting changes. 2. Review the existing literature. By incorporating important emergency medicine policy statements, major review articles, and consensus reports, we provide essential information to support the initiation of collaborative work with the ED. 3. Identify ED resources. Recommendations are offered to actively engage the interdisciplinary ED team (physicians, nurses, social workers, chaplaincy, aides, and administrators) in the use of key PC resources. 4. Develop a plan to complete a needs assessment. We provide a sample self-assessment tool to catalog strengths and limitations of the existing ED services and their interface with outpatient, pre-hospital, and hospital-based services. The session will conclude with specific quality improvement recommendations to engage stakeholders and to measure outcomes.

Considerations for the use of short-acting opioids in general anesthesia

Anesthesiologists play a critical role in facilitating a positive perioperative experience and early recovery for patients. Depending on the kind of procedure or surgery, a wide variety of agents and techniques are currently available to anesthesiologists to administer safe and efficacious anesthesia. Notably, the fast-track or ambulatory surgery environment requires the use of agents that enable rapid induction, maintenance, and emergence combined with minimal adverse effects. Short-acting opioids demonstrate a safe and rapid onset/offset of effect; that short effect is both predictable and precise. It also ensures easier titration and reduced or rapidly reversed side effects. Due to their distinct pharmacokinetic and pharmacodynamic properties, and, in one case, rapid extra-hepatic clearance of remifentanil, these agents have several applications in general anesthesia.

Anesthesia in patients with arthrogryposis multiplex congenita: a report of 10 patients.

Anesthesia in patients with arthrogryposis multiplex congenita: a report of 10 patients.

Partnerships and New Learning Models to Create the Future Perioperative Nursing Workforce

To create new and sustainable approaches for development of the perioperative nursing workforce, perioperative nursing leaders at a hospital collaborated with administrators and faculty at a school of nursing to create an innovative learning model that reintroduces perioperative experiences to students in a nursing baccalaureate program. Key components of the initial approaches included an externship for nursing students and a revised internship for experienced nurses who wished to work in perioperative nursing. Project leaders then expanded the nursing student learning opportunity by adding two additional elective perioperative courses to the curriculum. Formation of perioperative clinical placement sites within the senior-level adult acute care course was an additional positive outcome of these initial initiatives. These initiatives resulted in decreased use of agency nurses at the clinical site where the externships take place and increased numbers of younger nurses working in the perioperative areas where they externed, with high levels of satisfaction reported by nurses involved in the program. Through this innovative collaboration, the perioperative nurse shortage at the hospital has abated, and the opportunity to continually recruit new colleagues into the practice of perioperative nursing has been established.

Being altered by the unexpected: Understanding the perioperative patient's experience: A case study

The present paper focuses on the process of understanding the patient in the context of perioperative caring and reports a story narrated by a perioperative nurse as well as her emerging understanding of the patient prior to surgery at an operating department. This qualitative case study had a dual purpose; firstly, to describe how the perioperative nurse's understanding of the patient emerged and, secondly, to establish how the researcher interpreted the situation. As a perioperative nurse and researcher, the author is both the narrator and interpreter. To date we have rarely discussed the fact that, in a perioperative context, the patient might feel ashamed of his/her body, even before arriving at the operating department. This new understanding emerged from the hermeneutical dialogue in the present study.

Patients With Parkinson's Disease in the Perioperative Setting

NURSES AND NURSING STUDENTS are often drawn to qualitative research. Opinions vary on the explanation for this, but one possibility is the ease of understanding the patient's story when told in narrative terms. Nursing values the unique individual and his or her experiences. Qualitative research delves into those rich events to discover new knowledge. Another plausible idea is the common resistance to statistics, which is inherent in quantitative research! The science of nursing is advanced by the appropriate use of qualitative methods, quantitative methods, and blends of both. Mary W. Stewart, PhD, RN, is a Professor and Director of the PhD program, Special Assistant to the Dean, School of Nursing, University of Mississippi Medical Center, Jackson, MS ErratumJournal of PeriAnesthesia NursingVol. 29Issue 6PreviewIn the Research News column, ‘‘Patients With Parkinson’s Disease in the Perioperative Setting,” by Mary W. Stewart (28;5:321-323), the wrong journal was listed for the article in review. The original article was published in the American Journal of Nursing, not the Journal of Advanced Nursing, as originally cited. The correct reference is: The Perioperative Experience of Patients with Parkinson’s Disease: A Qualitative Study. An Exploration of the Patient Perspective by Anderson LC, Fagerlund K. Full-Text PDF

Pain management for pediatric tonsillectomy: An integrative review through the perioperative and home experience

This integrative review aims to increase our understanding of current pain management care practices for children undergoing tonsillectomy. Synthesis of the literature resulted in four main opportunities for care providers to manage pain: preoperative education and preparation, intraoperative surgical interventions, and postoperative pharmacologic and nonpharmacologic interventions in the post anesthesia care unit and home settings. Nurses have many opportunities to understand pain management practices and intervene to minimize pain experienced in pediatric outpatients undergoing tonsillectomy.

Huddle for Improved Staff Productivity

A rapid improvement event (RIE) targeted to improve turnover times in the operating rooms directly impacted the practice of PACU nurses. The RIE showed inefficiencies and redundancies among team members and throughout the surgical process. Patients were connected and disconnected to blood pressure cuffs three different times during the perioperative experience. Multiple reports were given to PACU nurses from the OR nurse and anesthesia. Theobjectivesof theprojectwere todecreaseOR turnover times, find and maximize efficiencies throughout the surgical patient’s journey and eliminate redundancies in process and improve staff satisfaction. Several experimentswere implemented after reviewing the process and identifying areas to improve. Vital sign equipment was standardized and adaptors acquired so the blood pressure cuff could be placed once and remain in place for entire perioperative experience. Standardworkwas developed for team members that defined roles and reduced redundancies increasing efficiencies during patient hand offs. The handoff between the OR and PACU nurse was eliminated and anesthesia reported all pertinent information in their hand off. This enabled the PACU nurse to expedite pain management and assessment of post surgical needs 5-7 minutes sooner. Having the blood pressure cuff already in place saved 1-2 minutes leading to faster assessment of vital signs and increased quality of patient care management and increased staff satisfaction.

Small Changes Equal Big Payoff

A rapid improvement event (RIE) targeted to improve turnover times in the operating rooms directly impacted the practice of PACU nurses. The RIE showed inefficiencies and redundancies among team members and throughout the surgical process. Patients were connected and disconnected to blood pressure cuffs three different times during the perioperative experience. Multiple reports were given to PACU nurses from the OR nurse and anesthesia.

The Impact of Congenital Cardiovascular Malformations on the Assessment and Surgical Management of Infants with Cleft Lip and/or Palate

The purpose of this study was to assess the cardiac evaluation of cleft lip and/or palate patients, characterize their cardiovascular malformations, and determine the impact of cardiovascular malformations on surgical management. A single-institution retrospective study of 329 consecutive cleft patients was performed. Cardiovascular malformations were categorized according to involvement of cardiac septa, vasculature, and valves. Their impact on the need for cardiac surgery, timing of cleft repair, need for subacute bacterial endocarditis (SBE) prophylaxis, and the perioperative experience was evaluated. Ten percent (33/329) of cleft patients had a cardiovascular malformation, and 3% underwent cardiac surgery prior to cleft repair. Malformations of the septa, vasculature, and valves were present in 9%, 6%, and 2% of cleft infants, respectively. Murmur as a sign of structural cardiovascular disease was 79% sensitive and 97% specific. Cleft palate repair was delayed by 2 months in patients with a cardiovascular malformation (P = .001). Subacute bacterial endocarditis prophylaxis was recommended, not recommended, or not specified by cardiology in 18%, 33%, and 48% of cleft patients with a cardiovascular malformation, respectively. Postoperative stay and surgical complications were not associated with cardiovascular malformation. Even in the absence of a murmur, echocardiographic screening should be considered in infants with nonspecific signs of cardiovascular disease. Greater awareness of the guidelines for SBE prophylaxis is needed. Most cleft patients with a cardiovascular malformation do not require cardiac surgery and do not experience an increased rate of complications associated with cleft surgery.

Systemic treatment of liver metastases from colorectal cancer.

Patients presenting with synchronous or metachronous colorectal cancer liver metastases (CLM) should be evaluated for multimodal management with curative intent. Preoperative systemic chemotherapy shows beneficial impact on adjuvant progression-free survival and also borderline on overall survival, without significantly increasing initially R0 resectable patients postoperative complication rates. Postoperative chemotherapy recommended based on the perioperative trial experience for those patients achieving at least stable disease during preoperative chemotherapy, or based on the adjuvant trials for patients receiving upfront resection. 'Borderline' resectable CLM, preoperative chemotherapy plays an important role in both in achievement of a resectable status and improvement of prognosis. Recent 4 drug combinations demonstrated response rates up to 80% even for advanced disease and are thus promising regimens for further evaluation in patients with resectable or unresectable liver-limited (+/- lung) disease.

Anesthetic considerations in pediatric mastocytosis: a review

Mastocytosis is an orphan disease rarely encountered by practicing anesthesiologists. Children with mastocytosis often present for procedures or surgery requiring anesthesia. Because many of the medications commonly used in pediatric anesthesia have been reported to initiate mast cell activation, parents are often very anxious about their child's perioperative experience. Laboratory investigations of serum histamine assays associated with different anesthetic drugs have not been shown to predict mast cell degranulation in these patients. However, the pediatric literature suggests that children with disease limited to the skin rarely suffer serious side effects from anesthesia, and there are no reported fatalities. Preoperative prophylaxis is usually based on expert opinion and case reports. Detailed tables summarizing reports of anesthetic medications used for children with mastocytosis undergoing anesthesia, reported side effects, and suggested prophylaxis regimens are included in this review.

Original Research

The goals of this study were to hear from patients with Parkinson's disease about their perioperative experiences and to describe those experiences using the patients' own words, particularly with regard to antiparkinson medication withholding and symptom exacerbation.We conducted a descriptive, qualitative study of patients' perioperative experiences with Parkinson's disease symptom management, performing 14 semistructured interviews with 13 participants who had Parkinson's disease and had undergone any type of surgery excepting Parkinson's disease surgeries.Patients' responses indicated concerns that hospital routines aren't flexible enough for their complex medication regimens; that hospital staff may not recognize a patient's own expertise in Parkinson's disease; and that hospital staff need more education about Parkinson's disease, especially regarding the interactions between the disease and surgery or anesthesia (or both).Participants' comments made it clear that the actions of nurses could affect the perioperative experience for better or for worse. Our findings further highlight the need for clinical care guidelines for hospitalized patients with Parkinson's disease. Nurses should take the lead in the development of guidelines for Parkinson's disease symptom management.

Ambulatory Perianesthesia Electronic Documentation—A Two-Part Series. Part II: Archiving Your Actions

Perianesthesia nurses are on the cutting edge of clinical information systems. Caring for patients throughout their perioperative experience gives the perianesthesia nurse a unique opportunity to provide care at multiple levels—from preparatory evaluation to critical care. These phases of care expose the perianesthesia nurses to documentation systems congruent to the workflow within that phase. As our practice develops, these systems adapt to meet our needs and establish an archive of the care our patients receive. Documentation provides the ability to permanently record the provision of care without our practice settings and the patient's response to that care. It depicts for others the actions and activities, but it does not always provide a depiction of the critical thinking or intuition of the care providers. It is for this reason that we, as professional perianesthesia nurses, must learn from our colleagues and from the potential role of electronic medical records in civil actions, such as malpractice suits. Sarah M. I. Cartwright, BA, RN, CAPA, is a Nurse Manager, Perioperative Services Clinical Informatics, Special Projects and OR Scheduling, and Leslie A. Edney, BSN, RN, CAPA, is a Charge Nurse, Post Anesthesia Care Unit in Perioperative Services, Georgia Health Sciences Medical Center, Augusta, GA.

Arts-informed research dissemination: Patients' perioperative experiences of open-heart surgery

BackgroundThe integration of humanistic approaches, in which patients' personal experiences are acknowledged and inform practice, is integral to optimal healthcare. ObjectivesIn this study, we used an arts-informed narrative approach to understand and highlight the experiential and subjective qualities of illness and recovery from heart surgery. MethodsAn arts-informed analysis was conducted and we represented participants' stories of open-heart surgery through the media of poetry and photographic images. ResultsBy using the arts as a method for analysis and dissemination, patients' unique and deeply personal experiences of heart surgery were illuminated. ConclusionsThe arts can be particularly beneficial in healthcare and cardiovascular research, because they can inspire practitioners to become refamiliarized with the emotional, embodied, and psychosocial perioperative experiences of heart surgery from patients' perspectives.

The effect of continuing professional education on perioperative nurses’ relationships with medical staff: findings from a qualitative study

To report perceived changes to UK perioperative nurses' relationships with medical staff following periods of formal, university-based study. Continuing professional development is considered important for nursing internationally; however, practice changes may not result following formal study. The literature did not describe perioperative nurses' experiences of formal study, and it was believed differences may exist due to hierarchical interprofessional relationships in the operating theatre. Descriptive, qualitative. Unstructured interviews (N=23) were conducted between 2006-2007 with a purposive sample of perioperative nurses who had recent experience of continuing professional education. All participants were employed by one National Health Service Trust in the North of England, UK. Audio-taped interviews were transcribed fully into the ethnograph computer-assisted qualitative data analysis programme and data coded and analysed to identify themes. Findings. The findings indicated that whilst continuing professional education did not have a direct impact on practice, development of increased knowledge and confidence facilitated participants' collaboration with and questioning of medical colleagues. Such increased interprofessional collaboration was attributed to indirectly enhancing patient care. Continuing professional education appeared to lead to intrinsic changes to practitioners rather than direct behavioural change. Nurses' increased knowledge and confidence affected the balance of power in the doctor-nurse relationship in British perioperative environments. This paper is of significance to perioperative nursing and may be transferable to other areas of care.

Perioperative experience of pelvic organ prolapse repair with the Prolift® and Elevate® vaginal mesh procedures

We compared the operative and immediate postoperative experience of the trocar-based Prolift and non-trocar-based Elevate techniques used to repair vaginal prolapse. A retrospective review of Prolift and Elevate repairs was performed. Baseline characteristics and operative and postoperative variables evaluated included compartment(s) repaired, adjacent organ injury, operative time (OT), change in hemoglobin (ΔH), pain score, narcotic use, length of stay (LOS), and short-term complications. Categorical variables were assessed as counts and percent frequency. Data were compared using chi-squared analysis and paired t test. Prolift (n = 143) and Elevate (n = 77) patients were similar in age (p = 0.19). Concurrent hysterectomy was done in 22 (15.4 %) and 24 (31.2 %), respectively, and concurrent midurethral sling placed in 100 (70 %) and 50 (65 %), respectively. LOS (median, 25th,75th) after anterior/apical compartment repairs was shorter with Elevate, whether with (1.0; 1.0,1.5 vs. 2.0 days;1.0, 2.0; p = 0.003) or without (2.0; 1.0, 2.0 vs. 2.0 days; 2.0, 3.0; p = 0.024) hysterectomy, but no differences in OT, ΔH, pain score, or narcotic use occurred. Posterior compartment mean pain scores were lower with Prolift (3.6 ± 2.2 vs. 1.7 ± 1.5, p = 0.035), and three-compartment-repair pain scores were lower with Elevate (0.6 ± 1.3 vs 2.5 ± 1.9; p = 0.013). Three bladder injuries occurred with Prolift but none with Elevate. Operative and postoperative experiences were similar between groups; however, Elevate anterior/apical repairs had shorter LOS, which might reflect more aggressive discharge planning. There were no bowel or major vascular injuries, and the Prolift trocar bladder injuries did not alter the surgical procedure.