In relation to PACU requirements and setup, the policies, procedures, and standards determine the environment and guide the practice in which a PACU nurse delivers care. From: Global Reconstructive Surgery, 2019
Andreas H. Taenzer, Jeana E. Havidich, in
A Practice of Anesthesia for Infants and Children (Sixth Edition), 2019 A well-designed, safe
perioperative environment is essential for the delivery of high-quality pediatric anesthetic and surgical care. This is evidenced by the fact that several prominent national organizations have provided recommendations for the perioperative care of children. The American Academy of Pediatrics (AAP) published a policy statement in 2015 delineating the critical elements of the perioperative environment.1 These recommendations focus on the patient care facility and medical
policies, including staff credentialing and necessary supportive services. This document was developed to complement the Society for Pediatric Anesthesia (SPA) statement on the provision of pediatric anesthesia care.2 Institutions that desire verification by the American College of Surgeons (ACS) Children's Surgery Verification Program must contain a designated postanesthetic care unit (PACU) with appropriately credentialed staff and supportive
resources.3 These guidelines acknowledge that the perioperative environment can be challenging, and health care facilities must understand these challenges and be prepared to manage children and family members through this difficult process. Policies and procedures based on recommendations from national organizations and developed with input from all stakeholders, including physicians, nurses, family members, and child-life specialists, comprise the foundation for a safe,
patient- and family-centered perioperative environment. The ideal perioperative environment is patient- and family-centered, combining aspects of safety, ergonomics, and comfort for patients, family members, and staff. The family and patient experience starts with the admission process and concludes with the discharge to home or the hospital ward. Familiarity with personnel and surroundings reduces stress for patients and families while fostering trust and
comfort. Ideally, a child should be under the care of the same team throughout the perioperative period. For example, the child and family benefit if the admitting nurse later cares for the child and the family in the PACU. This may be achieved by creating an integrated perioperative environment, in which children are admitted, prepared, and allowed to recover in the same space, with the same nurses and child-life specialist. Privacy and shelter from noise
are important aspects of the patient and family experience. The ability to spend time with the child without being disturbed is something that many families appreciate, and this helps the child cope with the stress of a strange environment. Most PACUs contain individual patient rooms or cubicles for preoperative and postoperative care, similar to a typical pediatric intensive care unit (PICU). Equipment (Table 47.1) and available medications
(Tables 47.2 and 47.3) should be standardized throughout the unit and be compatible with transport monitors and other devices used in the medical facility (e.g., PICU). Cognitive aids such as preprinted emergency drug cards should be available for every child.1 This important safety measure may reduce the risk of drug errors in emergency situations. These rapid reference sheets may be attached to each child's bed or chart on admission so that a
quick dose recommendation is readily available. Alternatively, the electronic record should have precalculated emergency drug doses for each child. Nurses, residents, fellows, attending physicians, and other personnel working in the perioperative area must be competent in the provision of neonatal and pediatric advanced life support. Team training in mock codes and enhanced communication have been shown to improve outcomes.4–6
Continuous medical education in the provision of pediatric care is often required by hospital credentialing committees as well as institutions requesting ACS verification.3 The PACU should be located near the operating room to decrease the amount of time spent in transport of a sedated and/or critically ill patient. If transporting a sedated patient from a
remote location, the patient's vital signs and a metric of respiration should be monitored along the route. Appropriate airway equipment and drugs should be immediately available. Transport from the operating room to the PACU should be carried out under the direct supervision of a trained expert. The security and patency of the airway, IV and arterial lines, drains, and urinary catheters should be checked before transport. Children should be covered during transport to maintain normothermia and
appear presentable (e.g., remove garments and sheets that contain blood and secretions). Unless children are awake, with protective airway reflexes intact, or unless there is a specific contraindication, it is appropriate to transport extubated children in the lateral position (i.e., tonsillectomy recovery position) so that the tongue lies away from the larynx and secretions and vomitus leave the mouth rather than enter the larynx, possibly leading to airway
obstruction or pulmonary aspiration. To assess ventilation and maintain a patent airway with the child in the decubitus position, we recommend applying the thumb to the forehead to extend the neck and holding the fingers (the finger tips are the most sensitive part of the hand) over the mouth (or nose) to feel for exhalation. A precordial stethoscope may also be used to auscultate respirations. If the child is breathing room air, a pulse oximeter can serve as a crude metric of ventilation
because desaturation will occur quickly if hypopnea develops. However, if oxygen is provided to the child, desaturation may not occur for a considerable time in the setting of apnea, and ventilation should be monitored by close observation, a precordial stethoscope, capnography, or ideally, by a combination of these. We recommend that children in a potentially unstable condition be transported with a pulse oximeter, capnogram, an electrocardiographic (ECG) monitor, and a blood pressure cuff or a
transduced arterial line. The monitoring lines, IV drips, infusion pumps, and other equipment should be clearly labeled and simplified before transport. A tackle box containing airway equipment and emergency medications is useful, especially when children are transported to or from remote locations. A child often appears awake after the stimulation of tracheal extubation and transfer to the stretcher but may subsequently become obtunded and obstruct the
airway during transit to the PACU or PICU. Just as frequently, a child may become restless during transit. Although restless behavior has many causes, hypoxia should be ruled out first. The guard rails on the stretcher should always be raised when the child is in it and padding with pillows may prevent injury to the child. Most importantly, the anesthesiologist should remain at the head of the stretcher during transport maintaining vigilance of the child and the monitors throughout the
transfer. The transfer of care from the operating room personnel to the PACU or PICU is a crucial element of quality patient care that deserves considerable focus and the importance of this process cannot be overemphasized. Ideally, it is a stepwise process following an institutional protocol that begins in the operating room with communication to the receiving unit before
the end of the procedure that provides pertinent patient information as well as required nonstandard equipment and medication to the receiving care team. On arrival in the PACU, a rapid assessment of the child should be undertaken to ensure that the child has a patent airway and that the vital signs are stable. Once the child has been properly assessed, an admission heart rate, oxygen saturation, respiratory rate, blood pressure, and temperature should be recorded. Supplemental oxygen is
administered as indicated, recognizing the limitations of the monitors to detect hypoventilation in such cases. Many children object to having an oxygen mask fixed to their faces; a funnel-type mask or open hose with large flow rates may be less objectionable (although less optimal). In the healthy child, if the child is awake enough to object to a mask with oxygen, the child does not require supplemental oxygen (although the combative, hypoxic child will require not only oxygen but
establishment of a patent airway as well). Numerous patient safety organizations and health care institutions have devoted considerable time and resources to improve patient transfer processes with the primary objective to improve safety, increase the quality of care, and decrease health care costs. Education of health care personnel about the importance of this endeavor is the first step to implementing effective transfers of care; several methods have been
suggested.4,7–12 Standardized handoffs containing validated checklists and protocols are considered essential components of this process. Institutions with effective and organized handoff systems have reported a decrease in the number of medical errors and improved patient outcomes.6,13–16 Surgeons, anesthesia providers, and intensive care physicians involved in the care of the child should be present and
actively participate during the transfer of care from the operating room to the PACU or PICU. Specific circumstances such as language barriers, developmental delay, or family concerns should be conveyed to members of the team accepting care of the child. Since cultures vary within and among different institutions, we recommend developing a formalized transfer of care process that focuses of critical aspects of patient care, including pertinent patient information and history, surgical
procedures, type of anesthesia administered, airway management, medications (especially antibiotics and analgesics), fluids administered, hemodynamics, estimated blood loss, unexpected events, anticipated patient progress, and information that needs to be relayed to parents or hospital staff in the event the patient is being admitted. Any unanticipated or serious events, such as unanticipated difficult airway, hemodynamic instability, or surgical complications, should be clearly communicated. If
continuous infusions of local anesthetics are administered (e.g., epidural catheter infusion), the dose, concentration, rate, and maximum infusion rate should be conveyed. Tasks that need to be completed in the near future should be discussed with the team accepting the care of the patient. All stakeholders should have the opportunity to ask questions and confirm the transfer information at the conclusion of the handoff. The anesthesia team must remain with
the child until he or she has stable vital signs and the PACU or PICU team is comfortable and ready to assume responsibility for the child. Physicians who will be in charge of taking care of the child in the PACU or PICU after the anesthesia team leaves must be clearly identified by name, and methods to contact them (e.g., pager number) must be given to surgeons, anesthesiologists, and regional block and pain services. It is important to understand that barriers may exist at several levels and
preclude the effective transfer of care. Such circumstances frequently implicated include external distractions, noisy environments, shift changes, and differences in culture and priorities between individuals providing and accepting care of the child.12,17–20 Ideally, the nurses taking care of the child postoperatively are already familiar with the child and family from the preoperative setting. The nurse/patient ratio should be 1 :
1 for sick children and 1 : 2 or 1 : 3 for routine cases. It has been reported that staffing ratios, nursing surveillance techniques, and vigilant monitoring of patients in the PACU by pediatric-trained nursing staff improve patient outcomes.21–23 Available staffing and resources in the PACU or PICU should be in place before transporting the child from the operating room. All children should be monitored continuously in the PACU. At
the very least, this should include continuous pulse oximetry and intermittent noninvasive blood pressure and temperature monitoring. Most PACUs also monitor the electrocardiogram continuously, although some limit this to children with cardiac disease or complex multiple-organ disease. During emergence, many children are so active that it is impossible to maintain the monitoring devices in place. If the child is not hypoxic and is sufficiently awake to remove the monitors, he or she probably
does not require the monitors any longer. If the child falls back to sleep, then a pulse oximeter probe should be reapplied, particularly for at-risk children such as those with obstructive sleep apnea (OSA). For a child who is physically or mentally challenged, it may be necessary to apply light restraints until he or she is oriented and awake.The Postanesthesia Care Unit and Beyond
Perioperative Environment
Transport to the Care Unit
Arrival in the Care Unit
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PACU Setup and Requirements
Susan R. Fossum, ... Maria A. Pedersen, in Global Reconstructive Surgery, 2019
Optimization of Patient Flow
Upon the patient's arrival at the PACU, the anesthesiologist and the operating room nurse provide the PACU nurse with a full report concerning intraoperative care. This report should include performed surgery, type of anesthesia, any complications that may have occurred, drugs given, allergies, history, blood loss, pertinent laboratory results, and intravenous fluid status. Both the anesthesiologist and the surgeon are responsible for writing post-operative orders. These orders should include parameters for oxygen delivery, intravenous fluid administration, NPO status, medications for pain control and nausea, and infection prophylaxis. Surgery-specific orders may also be written. These orders must be acknowledged by the PACU nurse, and if there are any questions in regard to the orders, they must be clarified.
Before the anesthesiologist leaves the PACU, the nurse should be comfortable with the report, the patient status, and his or her ability to take care of the patient. If a patient's condition deteriorates, the PACU nurse must report this to the anesthesiologist and get assistance as needed.
The initial assessment of the patient was done in the preoperative area, where any changes in the patient's health status were observed and noted before surgery. This information is part of the report the PACU nurse receives when the patient arrives in the PACU.
Upon arrival to the PACU, the initial assessment and evaluation of the patient takes place. Cardiac monitoring and pulse oximetry equipment is placed on the patient, along with an oxygen mask; a temperature is taken as well. Initial patient assessment includes a visual inspection, including evaluation of the airway, breathing, cardiac function, surgical site, level of consciousness, and skin color. Nursing responsibility includes staying at the patient bedside until protective reflexes return, any oral adjuncts are removed, and patient has safely emerged from anesthesia (Fig. 1.7.2).
For safety, it is important for the patient to be on a gurney or bed that has working brakes and side rails. If the side rails are not functioning, it is necessary for the PACU nurse to remain at the bedside. If a family member is available, they can sit at the bedside until the patient is awake, responsive, and following commands.
The goal in the PACU is to have a calm, responsive, and comfortable patient. Having a family member at the bedside, especially if the patient is a child, can bring great comfort to the patient. One can involve the family member in the care of the patient by having him or her talk to the patient, hold a hand, or rock the child while holding. These comfort measures often will decrease the need for pain medication. It also gives the nurse an opportunity to show family members how to take care of their loved ones.
The patient's condition is evaluated throughout the PACU stay. Ongoing assessment and evaluation includes adequacy of the airway/respiration, vital signs, peripheral perfusion (capillary refill, skin temperature), pulses of extremities, level of consciousness, and pain level. It is recommended that the vital signs be recorded every 5 minutes for the first 15 minutes, then every 15 minutes for 1 hour, then every 30 minutes for 2 hours, and then every hour or until the patient is discharged from the PACU. Unstable patients will require more frequent vital signs and longer observation.
In general, patients are ready to be discharged to their hospital room when they are awake, can move all extremities, are able to maintain an oxygen saturation level of 92 or higher, and have stable vital signs and good pain control. The surgical site needs to be dry with minimal bleeding present. The modified Aldrete Score is a discharge tool frequently used to determine whether a patient is ready to be discharged (Table 1.7.1).
Before discharge, post-operative instructions are given to family members and/or nursing staff caring for the patient. These instructions should include information about pain control and patient diet as well as surgery-specific instructions such as dressing care, bathing, and daily activities (Fig. 1.7.3).
After the report is given, the patient needs to be transferred safely either on a bed or gurney with side rails, or by wheelchair to their hospital room, or discharged home with a family member. If lifting is required for patient transfer, adequate assistance to do so safely for both the patient and the nurse must be ensured. For infection control purposes, the PACU space and monitor equipment must be cleaned and disinfected before the next patient is received.
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Post-Operative Anesthetic Complications
Robin Gray Cox, in Global Reconstructive Surgery, 2019
Cardiovascular Complications
The most common cardiovascular complication seen in the PACU is hypotension. Hypotension in this setting is generally caused by hypovolemia and/or the effect of anesthetic drugs, including spinal/epidural blockade. More rarely, hypotension is caused by a primary cardiac event, sepsis, pneumothorax, fat/air embolism, or anaphylaxis. These rare events will often have presented in the OR, but may become obvious only in the immediate post-operative period. The important message is that patients with hypotension require close evaluation and appropriate treatment. It is important to know the normal blood pressure and heart rate at different ages (Table 1.9.1) as well as the patient's preoperative blood pressure, particularly in adults who may have underlying hypertension.
The clinical signs of hypovolemia vary with age. Hypotension may be a late sign of hypovolemia in children. Typically, the heart rate will increase, but this may be attenuated in the presence of anesthetic drugs, or in patients taking beta-blockers. In children, the degree of peripheral perfusion is a very helpful clinical sign—specifically, the color and warmth of the extremities and the speed of capillary refill. These peripheral signs may be less helpful in the elderly with poorer peripheral circulation. Urinary output is a useful sign in major cases that require a urinary catheter. Ideally, patients should produce at least 1 mL/kg/hr of urine. Suspected hypovolemia should be treated with 10 mL/kg boluses of crystalloid (normal saline or lactated Ringer's). Colloid solutions such as 5% albumin offer little added benefit, are expensive, and may be difficult to obtain in some countries. If anemia is significant (<80 g/L), blood transfusion may be required.
Hypotension from anesthetic drugs will usually resolve spontaneously as the effects wear off and the patient awakens. It is not generally necessary to administer inotropic drugs or vasopressors to correct the problem in the PACU. PACU staff should be aware, however, of other possible causes for hypotension, including the possibility of occult bleeding after major surgery.
Some patients may be hypertensive in the PACU. This may be related to poorly controlled preoperative hypertension; therefore it is important for adults (and arguably children) to have their blood pressure measured during their preoperative visit. Other causes for post-operative hypertension include pain and anxiety, bladder distension, ED, and respiratory distress, as well as rare causes such as hyperthyroidism (thyroid storm). Typically, the cause is underlying hypertension and/or post-operative discomfort. Treatment initially is to ensure that the patient has good pain and anxiety control. Occasionally it is necessary to reduce very high blood pressure with specific agents, such as labetalol.
Cardiac arrhythmias are rare in the post-operative period if there is no underlying heart disease. The presence of moderate to severe underlying heart disease might well be a good reason to postpone surgery unless there is a compelling medical reason to proceed. Anesthesia may lead to benign perioperative rhythm disturbances, such as supraventricular or ventricular ectopy, or nodal rhythm. If there is hemodynamic stability, these typically resolve with time and do not require specific treatment. If the cardiac arrhythmias are more severe, treatment is along the lines recommended by the Advanced Cardiac Life Support and Pediatric Advanced Life Support courses.
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Muscle-Sparing and Free TRAM Flap Breast Reconstruction
Joseph J. Disa, ... Toni Zhong, in Aesthetic and Reconstructive Surgery of the Breast, 2010
Postoperative Care
Postoperatively, all free TRAM flap patients are kept in the Post-Anesthesia Care Unit overnight to allow frequent flap monitoring. They receive IV antibiotics and deep vein thrombosis prophylaxis with low molecular weight heparin through the duration of their hospitalization. Flap checks include capillary refill, color, and warmth and Doppler checks to the TRAM skin-island. Patients are usually transferred to the floor the following morning at which time they may be up to a chair and advanced to diet as tolerated. Intermittent compression devices are kept on until they demonstrate adequate ambulation.
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Assessment, Methodology, Training, and Policies of Sleep
D.R. Hillman, ... P.R. Eastwood, in Encyclopedia of Sleep, 2013
Sleep in the Postoperative Period
Return of ready rousability is an important criterion to be met before discharge from the post-anesthesia care unit following anesthesia, apart from those patients with non-anesthetic causes for prolonged unconsciousness, such as neurological injury. The similarities between the behavioral appearances of anesthesia and sleep and, to some extent, those between the sleep and post-anesthesia electroencephalogram (EEG) signatures cloud analysis of post-anesthetic sleep. It appears quite likely that anesthesia can transpose into natural sleep, providing there is no disturbing postoperative pain, particularly late at night when the propensity to sleep is high.
With minimally invasive surgery, discharge from the post-anesthesia care unit may be followed by discharge home in a few hours and it is likely, although not well studied, that natural sleep cycles remain relatively undisturbed. Relevant to this, it is interesting to note similarities in behavioral effects between anesthesia and sleep, with anesthesia (undisturbed by surgery and pain) sharing some of the restorative properties of sleep, and its potency being subject to circadian and sleep deprivation influences.
However, the disturbance of sleep and the potential danger for patients increase with more invasive surgery, as surgery-associated physiological derangement is greater and pain and its management intrude. While the effects of anesthetic drugs dissipate in the early postoperative period, the heavy postoperative analgesia/sedation required in these circumstances means that upper airway obstruction remains a potential problem for the vulnerable patient requiring ongoing use of these drugs. Regional anesthetic techniques provide a method of circumventing some of these potential difficulties.
The degree of postoperative sleep disturbance varies with the type and extent of surgery, magnitude of pain and adequacy of its treatment, patient personality, and the environment in which the patient is nursed. Environmental disturbances include noise, light, activity in adjoining spaces, and frequency and intrusiveness of observations. The disturbances in sleep pattern include sleep deprivation, fragmentation, and disturbed sleep architecture with particular loss of REM sleep. They may persist for many days postoperatively. Not surprisingly, these disturbances can lead to serious cognitive and psychomotor disturbance. While drug-induced sedation can offset these problems to some extent by enhancing the propensity to sleep, this is at the cost of increased susceptibility to upper airway disturbances and ventilatory depression in susceptible individuals, such as those with OSA. In such patients, postoperative sleep disturbance may compound the effects of sleep disturbance induced by the condition itself, amplifying the degree of hypersomnia. A prolonged period of postoperative sleep disturbance can lead to a state of ‘REM sleep rebound’ once the external factors disturbing sleep settle. With REM sleep rebound, the proportion of REM relative to non-REM sleep increases substantially above the usual adult proportion of 20–25% of total sleep time. It is during this stage of sleep that ventilatory drive, rousability and muscle activation are most depressed and, hence, the patient is most vulnerable to upper airway obstruction or other ventilatory disturbance. Hence ‘REM rebound’ can increase the vulnerability to breathing disturbances of such patients.
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Sleep and anesthesia
David R. Hillman, Peter R. Eastwood, in Reference Module in Neuroscience and Biobehavioral Psychology, 2021
Sleep in the postoperative period
Return of ready rousability is an important criterion to be met before discharge from the post-anesthesia care unit following anesthesia, apart from those patients with non-anesthetic causes for prolonged unconsciousness, such as neurological injury. The similarities between the behavioral appearances of anesthesia and sleep and, to some extent, those between the sleep and post-anesthesia EEG signatures present a challenge in accurately determining the presence of post-anesthetic sleep (Tung and Mendelson, 2004). It appears quite likely that anesthesia can transpose into natural sleep providing there is no disturbing postoperative pain, particularly late at night where the propensity to sleep is high.
With minimally invasive surgery, discharge from the post-anesthesia care unit may be followed by discharge home in a few hours and it is likely, although not well studied, that natural sleep cycles remain relatively undisturbed. Relevant to this it is interesting to note similarities in behavioral effects between anesthesia and sleep, with anesthesia (undisturbed by surgery and pain) thought to share some of the restorative properties of sleep, and its potency being subject to circadian and sleep deprivation influences.
However, the disturbance of sleep and the potential danger for patients increases with more invasive surgery, as surgery-associated physiological derangement is greater, and pain and its management intrude. While the effects of anesthetic drugs dissipate in the early postoperative period, the possible heavy postoperative analgesia/sedation required in these circumstances means that upper airway obstruction remains a potential problem for the vulnerable patient requiring ongoing use of these drugs. Regional anesthetic techniques provide a method of circumventing some of these potential difficulties.
The degree of postoperative sleep disturbance varies with the type and extent of surgery, magnitude of pain and adequacy of its treatment, patient personality and the environment in which the patient is nursed. Environmental disturbances include noise, light, activity in adjoining spaces and frequency and intrusiveness of observations. The disturbances in sleep pattern include sleep deprivation, fragmentation, and disturbed sleep architecture with particular loss of REM sleep (Chung et al., 2014). They may persist for many days postoperatively. Not surprisingly, these disturbances can lead to serious cognitive and psychomotor disturbance (Hillman, 2021). While drug-induced sedation can offset these problems to some extent by enhancing the propensity to sleep, this is at the cost of increased susceptibility to upper airway disturbances and ventilatory depression in susceptible individuals, such as those with OSA. In such patients postoperative sleep disturbance may compound the effects of sleep disturbance induced by the condition itself, amplifying the degree of hypersomnia. A prolonged period of postoperative sleep disturbance can lead to continuing loss of REM sleep, with its return occurring once the external factors disturbing sleep settle. Given that this is the stage of sleep where ventilatory drive, rousability and muscle activation are most depressed its return can increase vulnerability to upper airway obstruction or other ventilatory disturbance, a factor that needs to be recognized in planning care (including monitoring) beyond the first days of the postoperative recovery period (Chung et al., 2014).
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Opioid analgesics and narcotic antagonists
A.H. Ghodse, S. Galea, in Side Effects of Drugs Annual, 2009
Drug administration route
Transdermal administration of fentanyl has been evaluated in a placebo-controlled study in 484 adults admitted to the post-anesthesia care unit after major surgery (88C). They were given supplementary intravenous fentanyl as required. Pain was better controlled by transdermal fentanyl and fewer of these patients withdrew because of dissatisfaction. There were no differences in treatment-related adverse effects.
Cervical epidural and intravenous patient-controlled analgesia with fentanyl have been compared in 42 patients undergoing pharyngolaryngeal surgery (89c). The cervical epidural route provided better analgesia at rest in the first 6 hours postoperatively, but this was not accompanied by a reduction in fentanyl dosage requirements. There were no differences in adverse effects and there were no episodes of clinical respiratory depression or severe sedation. Although the results were favorable, there were no clinical benefits from the cervical epidural technique.
Epidural anesthesia in 43 patients undergoing lumbar microdiscectomy has been compared with general anesthesia (90c). Fentanyl 5 μg/kg+propofol+vecuronium was used for induction of general anesthesia, followed by 1.2 μg/kg/hour+N2O/O2+isoflurane as maintenance anesthesia. The epidural group received fentanyl 100 μg+lidocaine+adrenaline. Nausea, vomiting, and headaches were more common in those who received general anesthesia.
Patient-controlled analgesia with intravenous fentanyl was as effective as subacromial ropivacaine with minimal adverse effects and high patient satisfaction in 48 patients undergoing open acromioplasty surgery (91c). In contrast, those who received subacromial fentanyl did not have adequate analgesia and required rescue doses of tramadol. In all cases, nausea and vomiting were the most common adverse effects.
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Side Effects of Drugs Annual 32
J.K. Aronson, in Side Effects of Drugs Annual, 2010
Sources of Medication Errors
Although discomfort experienced by physicians on duty has historically been endured and accepted as part of the profession (6R, 7C), research has suggested a link between physician fatigue and medical errors (8Cr, 9Cr). Methods to alleviate fatigue during night shifts are desirable, although the potential long-term risks should not be overlooked.
In a study of 6 years worth of records from the MEDMARX database, 19 different causes of error in a post-anesthesia care unit were identified (10cR). They were grouped into three categories – problems with policies and procedures, dosing errors, and communication. The five leading causes of pediatric medication errors were poor performance, failure to follow a procedure or protocol, lack of knowledge, calculation errors, and lack of communication. The authors gave numerous recommendations for actions to prevent errors, including the following:
•use of a pediatric formulary;
•use of a uniform system of weight-related dosing (e.g. mg/kg);
•inclusion in the prescription of the child’s weight, the dose, and the volume to be given;
•provision of checks and balances;
•avoidance of abbreviations;
•use of leading zeros to the left of the decimal point (e.g. 0.1 mg rather than .1 mg);
•avoidance of terminal zeros to the right of the decimal point (e.g. 5 mg rather than 5.0 mg);
•watching for look-alike and sound-alike medications and storing such medicines apart;
•knowing the antidote to each medication and ensuring that it is immediately available in the right dose;
•improved communication between physicians, pharmacists and nurses;
•acknowledgement and reporting of medication errors in a blame-free environment.
Abbreviations
In one study nearly 5% of 643 151 errors were attributable to the use of abbreviations (11c). Many of the problem abbreviations were on the Joint Commission’s ‘do not use’ list (Table 2).
Table 2. Abbreviations that should not be used in prescriptions
| U (unit) | Mistaken for ‘0’ (zero), the number ‘4’ (four), or ‘cc’ | Write ‘units’ |
| IU (International Unit) | Mistaken for IV (intravenous) or the number 10 (ten) | Write ‘International Units’ |
| QD, Q.D., qd, q.d. (every day) | Unfamiliar abbreviations in some places. Period after the Q mistaken for ‘I’ (i.e. ‘qid’) | Write ‘once a day’ |
| QOD, Q.O.D., qod, q.o.d. (every other day) | Unfamiliar abbreviations in some places.‘O’ mistaken for ‘I’ (i.e. ‘qid’) | Write ‘every other day’ |
| Trailing zero (e.g. 5.0 mg) | Decimal point is missed (50 mg given) | Write (e.g.) 5 mg |
| Lack of leading zero (.5 mg) | Decimal point is missed (5 mg given) | Write (e.g.) 0.5 mg |
| > (greater than) < (less than) | Misinterpreted as the number ‘7’ (seven) or the letter ‘L’ or confused with one another | Write ‘greater than’ or ‘less than’ |
| Abbreviations for drug names | Misinterpreted because of similarities | Write drug names in full |
| Apothecary units | Unfamiliar to many practitioners; confused with metric units | Use metric units |
| @ | Mistaken for the number ‘2’ (two) | Write ‘at’ |
| Cc | Mistaken for U (units) when poorly written | Write ‘mL’ or ‘ml’ or ‘millilitres’ (‘mL’ is preferred) |
| μg or ug or mcg (micrograms) | Mistaken for mg (milligrams), resulting in dosage error | Write ‘micrograms’ in full |
| ng (nanograms) | Mistaken for mg (milligrams) or μg (micrograms), resulting in dosage error | Write ‘nanograms’ in full |
Adapted from the Joint Commission’s ‘do not use’ list (12S).
Automated dispensing cabinets
Automated dispensing systems, such as the McLaughlin dispensing system, the Baxter ATC-212 dispensing system, and the Pyxis Medstation Rx, are intended to aid pharmacy inventory, streamline distribution, and improve the security of dangerous drugs. However, their use does not reduce the overall frequency of medication errors and can sometimes even increase the risks (13R). For example, errors can occur when the system is refilled with new medicines. The sources of errors in such systems have been reviewed, with recommendations for maximizing their usefulness (14R).
Complex dosage regimens
Complexity of dosage regimens contributes to medication errors. In 101 patients with lung transplants who took a median of 15 (13–17) different drugs and 31 (26–38) dosage forms daily, 2253 doses were analysed (15c). There were 152 errors, which resulted in 303 incorrect doses (13%). Failure to keep a diary card was the only factor that was significantly associated with a higher rate of incorrect doses, and there was a significant correlation between medication errors and clinical adverse events.
Drug formulations
The pharmaceutical form of a drug can contribute to adverse effects. In one case a 63-year-old woman with Crohn’s disease swallowed azathioprine in its original blister pack and developed abdominal pain and diarrhea due to obstruction between two proximal stenoses (16A).
Working conditions
In a questionnaire study of the working conditions that could lead to near-miss errors relating to intravenous medication by 88 nurses working for 525 person-days in four wards of a Japanese hospital in 2001, workload and lack of experience in the current ward were associated with errors (17c). The number of near-miss errors was 94 (18%). There was no significant difference in the occurrence of near-miss errors among the three shifts (day shift 19%; evening shift 19%; night shift 13%). During the day shift, there was a significantly higher frequency of errors when the nursing services were delayed because of workload. During the evening shift, errors were more common when the services were delayed because of workload and when years of experience in the current ward were shorter. Nurses whose perceived level of fatigue before work was lower during the day shift and nurses whose years of experience as a nurse were longer and who had more sleep during the evening shift made significantly fewer near-miss errors than other nurses.
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Patellar Tendon Allograft for Anterior Cruciate Ligament Reconstruction
Justin W. Chandler MD, R. Alexander Creighton MD, in Surgical Techniques of the Shoulder, Elbow, and Knee in Sports Medicine, 2008
Postoperative Considerations
Follow-up
•
The first postoperative visit is scheduled within 5 days for an incision check and suture removal.
The patient is again encouraged and instructed (as done preoperatively and in the post-anesthesia care unit) in patellar mobilization, isometric quadriceps exercises, and knee flexion exercises.
Rehabilitation
•
Immediate weight bearing is permitted as tolerated with the knee in full extension for 2 weeks in a hinged knee brace.
•The patient should be weaned off crutches within the first postoperative week.
•Physical therapy is initiated 5 to 7 days postoperatively with emphasis on achieving full extension and beginning flexion exercises.
•The patient may begin bicycling at 3 to 4 weeks, stair-climbing machines at 8 weeks, light jogging at 12 weeks, and a gradual return to sports at 9 months (longer for allograft because of graft incorporation).
Complications
•
Graft failure at fixation or intrasubstance tear
•Infection (case reports of infection with Clostridium septicum3)
•Arthrofibrosis
•Neurovascular injury
•Disease transmission (risk estimated to be 1:1,600,000,2 no documented cases with current screening standards)
PEARLS AND PITFALLS
•Have informed consent from the patient to use an allograft.
•Know your allograft supplier's track record and tissue-processing techniques.
•Double-check the allograft label before bringing the patient to the operating room.
•Have a second allograft available in case something is wrong with the first specimen (labeling error, tissue quality, technical error) or discuss use of the patient's own tissue if something is wrong with the allograft.
•Estimate the length of the patellar tendon allograft on the basis of the patient's height (see Table 61-1).
•Treat all associated intraarticular pathologic changes.
•Tunnel placement is the key; whether you use autograft or allograft, be vigilant.
•Be sure to have stable aperture femoral fixation without compromise of the bone-tendon junction.
•If graft mismatch is encountered, be sure to obtain stable fixation at the tibia. Options include trough and staple, graft rotation to shorten it, soft tissue bioabsorbable fixation, and a combination.
•The ultimate return to sports with allograft reconstruction may be delayed because of longer graft incorporation compared with an autograft.
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A Worldwide Yearly Survey of New Data in Adverse Drug Reactions
Henry L. Nguyen, in Side Effects of Drugs Annual, 2018
Lidocaine
A case report described a 52-year-old man who suffered from cervical radiculopathy had a C6-C7 Isovue contrast agent assisted (10 mg of dexamethasone and 2 mL of preservative-free 1% lidocaine) injection [13A]. Within 5 min of entering the post-anesthesia care unit (PACU), the man was unable to swallow, had dizziness, and horizontal nystagmus and it was suggested that the local anesthesia may have affected the glossopharyngeal, abducen, and vestibulocochlear cranial nerves, respectively. After 30 min of recovery within the PACU, the symptoms resolved.
A 33-year-old woman with no significant past medical history checked into the surgical unit for an elective nasal septoplasty due to a deviated nasal septum [14A]. She was intubated with propofol and succinylcholine and then injected with 60 mL of 2% lidocaine/1% epinephrine subcutaneously in the nasal mucosa. Afterward, bradycardia occurred followed by a pulseless electrical activity. Cardiopulmonary resuscitation was performed for 20 min until LAST was suspected. She was then given 100 mL of 20% ILE and her sinus rhythm returned to normal within 3 min of the ILE infusion.
A 66-year-old man with metastatic melanoma and no knowledge of lidocaine allergy underwent further diagnostic evaluation for a thyroid nodule with fine needle aspiration [15A]. A dose of 1% lidocaine was injected into the anterior neck. Soon afterward, tachycardia and hypotension developed that were attributed to LAST. The biopsy procedure was promptly aborted and the patient was transferred to the intensive care unit for monitoring where he received intravenous fluid to stable his tachycardia and hypotension; no ILE was given. The patient fully recovered and was discharged home the next day.
A 30-year-old woman presented to the hospital in a spontaneous labor for delivery [16A]. She was given a test dose of 3 mL of lidocaine 1.5% with epinephrine for a lumbar epidural which was uneventful. The patient was then given bupivacaine 0.0625% with fentanyl 2 μg/mL for epidural analgesia. After 10 h of labor, deep variable deceleration was encountered and the patient was switched to an urgent non-emergent cesarean delivery for arrest of dilation. A dose of 15 mL lidocaine 2% with epinephrine was administered for continued epidural analgesia, but this was not sufficient so 15 mL of 3% chloroprocaine was administered epidurally. The patient was then put under general anesthesia for the cesarean section with propofol, succinylcholine, and cricoid pressure. After the procedure, angioedema was noted in the lip and tongue area, but the tryptase level was within normal limits. An allergy consult for hereditary angioedema was considered but all tests were within normal limits. The patient returned to the hospital for allergy testing 6 weeks post-delivery for allergy testing consisting of a simultaneous subcutaneous challenge with chloroprocaine and preservative-free lidocaine. This testing resulted in nasal congestion, a hoarse voice, relative hypotension (90 s/60 s), and angioedema of the lips and oropharynx consistent with an IgE-mediated anaphylactic reaction. A subcutaneous challenge with bupivacaine resulted in no symptoms. This case demonstrated a potential for anaphylaxis reaction due to local anesthetics used.
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