International anesthesiology clinics
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Int Anesthesiol Clin · Jan 1999
ReviewThe role of the gut in major surgical postoperative morbidity.
Gut mucosal hypoperfusion has been termed the motor of multiple organ failure. While a large proportion of high-risk surgery proceeds unremarkably, the insult to the inflammatory system during perioperative periods of regional hypoperfusion may manifest themselves over the subsequent few days, leading to microvascular thrombi, organ dysfunction, and failure. Several approaches have been made to prevent this, including systemic optimization of the cardiovascular system and specific targeting of the splanchnic circulation with monitoring techniques such as tonometry or metabolic markers of hepatic function to guide fluid and drug therapies. ⋯ Techniques that may help us identify at-risk patients may include in-depth cardiovascular assessment, possibly with echocardiography or a noninvasive cardiac output monitor such as the suprasternal adaptation of the ODM esophageal Doppler. The measurement of baseline endotoxin immune status (EndoCAb) may select those patients in advance who are most at-risk from gut mucosal hypoperfusion, thus allowing a more rational use of tonometry. Conventional risk scoring systems used in conjunction with knowledge of the type of surgery to be undertaken and whether large fluid shifts are likely along with the less conventional techniques discussed above may enable perioperative therapy to be closer to optimal.
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When performing IVCS, one must never forget the primary goal of providing patient comfort without compromising cardiopulmonary function or the patient's ability to react purposely to verbal commands and physical stimuli. When it is anticipated that required sedation will lead to loss of protective airway reflexes, such patients require a greater level of care than exists with IVCS. Deep sedation is a complication of IVCS and must be avoided. ⋯ The use of the narcotic antagonist naloxone and the benzodiazepine antagonist flumazenil should be scrutinized because they should be reserved for the unusual situation in which excessive cardiopulmonary depression occurs. Maintenance of a patent airway and stable cardiovascular function in a patient who can respond to verbal commands and physical stimuli is the primary goal of IVCS. With the agents discussed in this chapter, this goal is easily obtained, keeping the principles just mentioned in mind with all the appropriate monitoring guidelines discussed elsewhere in this text.
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In this review, traditional weaning parameters, integrative indexes, and experimental methods of predicting weaning outcomes have been reviewed. All have limitations; however, judicious application of these parameters may guide clinical decisions regarding timing of weaning trials. Of the parameters reviewed, the RSBI has several advantages and may identify patients who are candidates for weaning. ⋯ Most patients will be successfully extubated after a single SBT, and weaning methods that focus on sequential decrements in ventilator support appear to needlessly prolong ventilation. However, for patients who fail, identification of potential causes of continued ventilator dependence should focus on the various pathophysiological causes outlined. Although a number of patients will require prolonged ventilator support beyond the critical care setting, the growing experience with this population demonstrates that a large percentage have favorable outcomes.
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Int Anesthesiol Clin · Jan 1999
Nursing education, competency, and role in intravenous conscious sedation.
The advent of new hospital policies addressing analgesia and sedation motivates the nursing education department to implement an education plan for training RNs in the safe administration of medications that produce analgesia and sedation according to hospital policies. Learning materials must be procured or written, classroom content delineated, and a plan to precept all RNs who may be involved in IVCS procedures arranged. ⋯ The RN's role in collecting quality monitoring data is crucial. The development of forms that include all required aspects of patient assessment, care, and monitoring promotes compliance with hospital policy.