SSI-Normothermia

I found the following information on the Opana Website and was wondering what you thought? SDS has been doing a great job capturing all the patients that require pre-op warming (laparotomy patients). Patients are warmed with the Bair Hugger blankets and we will find out in the coming months whether the SSI (surgical site infection) rate is down.
My question for the PACU nurses is the following: currently our discharge criteria from PACU is 35.5 degrees C. OPANA and Safer Healthcare Now indicates tha Best Practice is that normothermia is 36-38 degrees C. Do you think that we should change our discharge criteria to 36 degrees C to support Best Practice?

OPANA recommends the following guidelines to maintain normothermia in the perioperative area. Please remember that your institution's policies and the recommendations of your anesthesia departments may not concur with the following guidelines and must supersede these standards. All information given below is referenced and is based on evidence found in the literature written on this subject.

Background:
In 2002, researchers conducted a point prevelance survey of nosocomial infections among 6,745 patients in 29 Canadian acute care hospitals across nine provinces. Canadian surgical site infection rates were found to account for 21% of five types of infections surveyed, ranking third most common in nosocomial infections. (1)
Surgical Site Infections can increase mortality, readmission rate, length of stay and cost for patients who incur them. While rate of surgical site infection ranges between 2-3% for clean cases, an estimated 40-60% of these infections are preventable. (2)
The Canadian Patient Safety Institution was developed to look into these and other risks to patients in hospitals. Subcommittees were organized to focus on specific areas of the healthcare environment where patients may be at risk of injury or nosocomial insult. The campaign to deal with Surgical Site Infections and other potential risks to patients in hospital, was the "Safer Healthcare Now!" campaign. It focussed on 10 areas of healthcare with high rates of negative outcomes which were occurring predominantly in Intensive Care Units, Surgical Suites, geriatric and medical inpatient units. (3)
One of the topics that Safer Healthcare Now! focussed on, that is most relevant to the perianesthesia nursing group, was "Surgical Site Infection", based on the above findings from the research.

Goal of the Safer Healthcare Now! Intiative for Surgical Site Infections:
"Prevent Surgical Site Infections (SSI) and deaths by reliably implementing ideal perioperative care for all surgical patients." (3)
After investigation and searching the literature into studies in this field, the contributing factors for negative outcomes related to surgical site infections were determined and were categorized into just 4 main groupings. Interventions for consideration and implementation, based on evidence in the research that was related to these infection rates, were then recommended.
Interventions for the Prevention of Surgical Site Infections:
1. Appropriate use of prophylactic antibiotics (including appropriate selection, timing and discontinuation)
2. Appropriate hair removal at the surgical site: minimally, and if necessary, clipping of hair rather than shaving
3. Maintaining post-operative glucose control for major cardiac surgery patients cared for in an ICU
4. Perioperative normothermia for all open abdominal surgery patients
**Note: Normothermia: Medical literature suggests that patients have a decreased risk of surgical site infection if they are not allowed to become hypothermic at any time during the perioperative period. Although temperature control may benefit other surgical patients, such as intentional therapeutic hypothermia for hypothermic cardioplegia, for the SHN campaign this measure only applies to the colorectal or open abdominal surgical population for the purposes of national measurement. Open abdominal surgery includes all open urology, nephrectomies, prostatectomies, hysterectomies, excluding vaginal hysterectomies, thoracic, pneumonectomies and pulmonary thoracic surgeries.(2)

Contributing Factors for Hypothermia:
Extremes of age
Females
BMI
Length and type of surgical procedure
Cold irrigants and wet skin preparations
Fluid shifts
Room temperature
Comorbidites (the presence of large open wounds, endocrine diseases, pregnancy, burns, peripheral vascular disease)
Type of anesthesia used (general, regional)
Anxiety
Negative Outcomes from Hypothermia:
Surgical site infection (impaired wound healing)
Patient discomfort (shivering)
Increased need for blood products (impaired platelet function, reduced coagulation)
Altered drug metabolism
Unexpected, negative cardiac events
Increased need for mechanical ventilation
Reducing the Risk of Hypothermia in the Perioperative Visit:

The prevention of Surgical Site Infections from hypothermia in the open abdominal surgery, and in any surgical group, can be accomplished or reduced by maintaining a normal temperature (36º - 38º C) through all stages of the perioperative course:

a) Preoperative warming of patients: warm flannel blankets from electric blanket warming cabinets, forced-air convection "housecoats", clothing to cover patients' extremeties and heads, preoperative monitoring of patient temperature, observation of overt indicators of hypothermia (regardless of core temperature): shivering, peripheral vasoconstriction, piloerection
b) Intraoperative warming of patients: warm fluids such as intravenous and irrigants, blood warmers, continuous monitoring of patient temperature (core preferable, tympanic) throughout the procedure, humidified and warm gases, warming blanket under patient on the operative table
c) Postoperative warming of patients: warm flannel blankets from electric blanket warming cabinets, forced-air convection blankets, circulating water mattresses, warm IV fluids, immediate and frequent monitoring of patient temperature until normalized (core preferable, tympanic), observation of overt indicators of hypothermia (regardless of core temperature): shivering, peripheral vasoconstriction, piloerection

Outcome Indicator: The postoperative surgical patient will have a normal temperature between 36.0º - 38.0º C in the PostAnesthesia Care Unit. (2)

Data collection for the SSI Campaign for Normothermia, Inclusion/Exclusion Criteria:

1. Total number of patients during this month who had an inpatient surgical procedure of this type (colorectal surgery). If more than one surgical procedure was performed during a single index hospitalization, include data only from the first surgical procedure.
2. Exclude patients whose age is less than 18 yrs on admission to hospital.
3. Exclude patients whose principal diagnosis code or admission diagnosis is suggestive of a preoperative infectious disease
4. Exclude patients who were admitted for treatment of burns or for organ transplantation (3)

Goal Rate:
95% patients who have undergone open abdominal surgery, or colorectal surgery specifically, will have documented postoperative temperatures in the range of 36.0º - 38.0º C. (3)

PeriAnesthesia Nursing Interventions:

1. Preoperatively: PreAdmission Units can instruct patients to bring their own warm housecoats, slippers, pyjama bottoms and headwear to the hospital for the day of surgery.
On the day of surgery, a preoperative temperature should be taken. Monitoring patients for obvious signs of hypothermia is necessary (shivering, peripheral vasoconstriction, piloerection). Patients should wear their own housecoats, socks, pyjama bottoms and headwear until entering the Operating Room. Only after induction of anesthesia should the clothing be removed (it may be necessary to have the patient remove his own outer "housecoat" prior to general anesthesia) and only the clothing that is necessary to remove in order to access the surgical site.
Any signs of infection (fever, rigor) should be reported to a healthcare professional on the morning of surgery and prior to entering the Operating Room.
2. Postoperatively: Post Anesthetic Care Units and Day Surgery Units should monitor postoperative temperatures IMMEDIATELY upon admission from the Operating Room and document these on the postoperative document (paper or online). Temperatures outside of the range of 36º - 38º C should be treated at once (warming measures should begin at once if temperature less than 36º C; report temperatures greater than 38º C to the surgical team for immediate treatment).
Once measures for treatment have been taken, postoperative temperatures should be taken every 30 minutes until the patient's temperature is within normal range. Once normothermia has been reached, frequent postoperative temperature tracking is no longer necessary in the PACU/DSU environment until just prior to transfer or discharge, unless other signs of hypothermia appear: shivering, peripheral vasoconstriction, piloerection. Complete documentation on the patient's chart of all temperatures should be recorded.

Written by Paula Ferguson

References:
1. Brennan. N Engl J Med. 1991; 324: 370-376.
2. CIHI Healthcare Canada, 2004. Unpublished data from D. Gravel, the Point Prevelance Working Group, the Canadian Nosocomial Infection Surveillance System, the Canadian Hospital Epidemiology Committee, "Point Prevalence Survey of Nosocomial Infections Within Seleced Health Care Insitutions" (2004).
3.www.saferhealthcarenow.ca

QUICK ECG Interpretation

Steps to Interpretation
1: Rhythm Analysis
􀂄Interpret ECG rhythm at bottom of 12 lead
􀂄Measure PR, QRS, QT
􀂄Analyze rate, regularity

2: Lead Grouping
􀂄Group the leads that reflect each wall of the left ventricle
Inferior Wall ––II, III, aVF (sometimes V4)(RCA AFFECTED)
Lateral Wall ––aVL, I, V5, V6 (CIRCUMFLEX AFFECTED)
Septal Wall ––V1 (RCA AFFECTED)
Anterior Wall ––V2, V3, V4 (sometimes Lead I)(LAD AFFFECTED)

3: Assess Each Grouping
Ischemia--ST Depression
Injury--ST elevation
Infarction--possible Q wave
Damage as cardiac tissue depleted of oxygen escalates with time from ischemia, injury to infarction.
Damage will be displayed in only leads facing the injured myocardium

Another reminder that the OPANA conference is next weekend.

New Staff Members

I have been late welcoming Stacey to PACU on this Blog. Stacey is a New Grad who recently graduated from the University of Windsor, and passed her RN's with flying colours in June. Stacey (and her sister!) Shelley have been working together through her Preceptorship in PACU and from what I've heard, it has been a wonderful opportunity for both of them.

Care of the Pre-Operative Opthalmic Surgical Patient

Care of the Pre-Operative Opthalmic Surgical Patient

•Advances in opthalmic surgical techniques and improved anesthetics have lessened the duration of the Peri-op and Post-op period.
•Most surgeries are completed within an hour.
•The goal of management is to maximize patient’s level of comfort using the least amount of sedation.

Discharge planning is coordinated in the Surgeon’s office pre-operatively. Patients must have a responsible adult drive them home and stay with them for the first 24 hours.

•Communication between the Circulating RN, the Block RN and Anesthesia is essential due to the quick turnover of cases.
•Efficient and effective time management while maintaining patient focused care is vital

Common Opthalmic Surgeries
Cataract Surgery
Normal Eye: A healthy, clear lens allows a sharp image to fall on every part of the retina allowing a crisp, clear image to be seen.
Cataract Eye: A cloudy lens scatters light, causing a hazy image to be seen.

•Usually less than 45 minutes
•Outpatient procedure
•Almost painless
•Usually only topical anesthetics (eye gtts) and lidocaine gel

VITRECTOMY
•a surgical procedure in which instruments are introduced into the eye to treat or repair various diseases and conditions of the retina and vitreous.
•performed under local anesthesia and in an ambulatory or outpatient operating room.
•30 minutes to 2 hours depending on the nature of the condition and the complexity of the operation.
•Some of the diseases that can be treated with a vitrectomy include retinal detachment, diabetic retinopathy, macular hole.

TRABECULECTOMY
•Patients with dangerously high IOP (glaucoma) that can not be treated with eye gtts, may require a trabeculectomy.
•a "flap valve" is made on the top of the eye, the white part of the eye hidden under the upper eyelid. This becomes a bypass for the blocked natural drain relieving the eye pressure



PRE-OP EYE DROPS
•Orders checked by Surgeon on the Department of Opthalmology Surgical Record
•Started 1 hour pre-op in SDS, continued in Block area
•Located on the SDS drug cart and pre-bagged.

MYDRIATICS AND CYCLOPLEGICS
Mydriatics dilate the pupil - tropicamide
- phenylephrine
Cylcoplegics dilate the pupil and cause paralysis of accommodation (inability to focus) -tropicamide
-cyclopentolate
-homatropine
NSAID
•Flubiprofen gtts
- Inhibition of intra-operative miosis (constriction) and inflammation of the eye.
TOPICAL AGENTS
•Tetracaine 0.5% gtts routinely used and given as prescribed by Anesthesia.
–Currently no standing order, but anesthesia will give a verbal
–Onset of action 5-10 seconds
–Gtts go in both eyes
–Located in blue bin on shelf in Block area
–Lidocaine gel is sometimes instilled by anesthesia to complete block
BLOCK MEDS
•Rovicaine/ Lidocaine
•Hyaluronidase: an enzyme that inactivates the Collagen Tissue
1. Less quantity of the anaesthetic solution required when the enzyme is used.2. Greater diffusion of the anaesthetic solution 3. Prolonged effect of the injected solution.

NURSING CONSIDERATIONS
•Instillation of gtts improve with tilting pts head upward
•place first gtt inside the lower lid
•Other drops may be instilled from above with pt looking downward.
•Avoid placing gtts on cornea
•The natural blinking of the eye distributes the drug
•Avoid touching the tip of the applicators to any part of the eye

ROLE OF THE BLOCK NURSE
•Admit pt to block area, receive report from SDS RN – when is next gtt due?
–TIP: at bottom of SDS nursing record the schedule will be noted ie:
•#1 0900 KL #2 0915 #3 0930 #4 on call

•Identify correct pt: check armband, check allergies
•Confirm laterality of operative site. SDS RN usually marks operative side with surgical marker, if it is not done, Block RN can do it.

•In order to increase efficiency, the Block RN will do the check on the OR side of the pre-operative checklist. This is necessary also, because as the Block Nurse, you also want to ensure that everything is complete and accurate before the anesthetist gives the block
–Anesthetic record
–H&P
–Consent
–Etc.
–NOTE: pt’s on anticoagulant therapy need a recent InR

•Ensure pt has voided
•Ask pt to move up on stretcher so head fits comfortably in the head support. TIP: place a rolled blanket under pt’s neck
•Place a blanket under pt’s knees
•Apply ECG lead and BP cuff. These will remain on for the entire surgical procedure (the leads will be returned with the next patient)

•NP can be applied and O2 turned on once versed is given by anesthesia
•Continue with the application of gtts. Communicate with anesthesia when you have given the 3rd dose
•Tetracaine gtts: 3 gtts OU intervals of 1 gtt per eye
•Topical Betadine solution to operative eyelid
•Anesthesia then ready to inject local anesthetic and the BLOCK
•After block, eye is taped shut to prevent corneal abrasions
•Monitor VS q5min until transfer to OR 18

HONAN BALLOON
•A Honan Balloon is sometimes used, especially with Dr. Dixon’s patients.






GUIDELINES FOR USING THE HONAN BALLOON
•All patients should be monitored for signs of bradycardia (Oculocardiac reflex) while pressure is being applied to the eye.
•The optimum pressure to be used should be well below pressure in the central retinal artery. Using the 20 to 30 mm Hg of monitored pressure for 30 to 60 minutes before surgery, clinically results in very soft, safe, surgical eyes. With a soft eye excess vitreous pressure is typically absent.
•Also encourages the block anesthetic agent to be absorbed posteriorly
•Some surgeons believe that when using the balloon, Intraocular lens implantation is much easier and safer. From the surgeon’s viewpoint, there is much less stress and strain.


RETROBULBAR BLOCKS
•Most anesthetists prefer to do Peri-bulbar Blocks, however some (Dr. O) likes the Retrobulbar as that is what he was trained to do. It used to be the ‘Gold Standard’
•Retro-bulbar is a longer needle, but uses less anesthetic. Drug is placed intraconally (between the rectus muscles and the optic nerve)
•slightly higher chance of Brainstem anesthesia

PERIBULBAR BLOCKS
•Local anesthetic agents are placed within the orbit, but do not enter the area of the cone of the rectus muscles.
•It was introduced as a safer method, but complications have also been reported.

Medial Canthus Peribulbar Block

Infero-temporal Peribulbar Block

•The signs of a succesful block are:
•Ptosis (drooping of the upper lid with inability to open the eyes)
•Either no eye movement or minimal movement in any direction (akinesia)
•Inability to fully close the eye once opened.
•Since the local anaesthetic is placed outside the muscle cone the concentration around the optic nerve may not be sufficient to abolish vision completely. Some light perception will therefore remain; however the patient is not able to see the operation.

COMPLICATIONS OF BLOCKS
Potential for:
•Seizures: treat like any other seizure: ABCD’s
•Vasovagal: from muscle tugging—vagal stimulant—bradycardia: treat with atropine
•Brain stem paralysis: observe change in LOC, RR, HR—will need critical care support: EMERGENCY!
•Hemorrhage: arterial/venous
•Perforation of the globe: Treatment is Vitrectomy
Notice how anesthetist asks pt to try to keep eye open during block. They are looking for tugging and twitching. If suspected will withdraw needle and reinsert