Management of constipation in terminally ill patients

This small study was carried out to assess the effectiveness of lactulose syrup (Duphalac) in the management of constipation in forty-six patients with terminal illnesses. The daily dose of lactulose was titrated to meet the individual patients requirements and was found to be in the region of 20 to 30 mls twice daily, despite the almost universal administration of opiates as analgesics. The study lasted 21 days in each patient capable of completing the assessment. Constipation was relieved within a an average of 3 to 4 days, and of the 512 days observed, there were 203 days in which a bowel movement occurred. Of these motions 71% were recorded as easy to move, rather than hard (21%) of loose (8%). Faecal incontinence and nausea attributable to lactulose treatment were extremely rare. Therefore, lactulose appeared to be a useful treatment for constipation in the terminally ill patient.     

口服乳果糖溶液对蛛网膜下腔出血后便秘的预防

目的探讨口服乳果糖口服溶液对蛛网膜下腔出血后便秘的预防。方法将200例首发蛛网膜下腔出血患者随机分为实验组和对照组,实验组口服乳果糖口服液患者75例。对照组未服乳果糖口服液患者125例,给予常规护理。实验组在常规护理的基础上,于入院后即口服乳果糖口服液10ml,2次/d,连续口服10d。记录患者每天的排便情况。结果对照组蛛网膜下腔出血后便秘的发生率为40.8%,实验组蛛网膜下腔出血后便秘的发生率为25.3%,2组有显著性差异（P〈0.05）。结论口服乳果糖口服液对蛛网膜下腔出血后便秘有较好的预防作用,且口服方便,易于被患者和家属接受。     

肠道综合物理疗法对不完全性脊髓损伤患者便秘的影响

目的：通过3种方法的对比观察肠道综合物理疗法对不完全性脊髓损伤患者便秘的影响。方法：选取符合入组条件的不完全性脊髓损伤患者30例,随机分为A、B、C 3组各10例。在常规干预的基础上,A组进行生物反馈电刺激治疗,B组进行肠道运动疗法治疗,C组进行肠道综合物理疗法（生物反馈电刺激结合肠道运动疗法）的治疗,治疗前后比较神经源性肠道功能障碍（NBD）评分量表、Wexner便秘评分量表、便秘患者生活质量量表评分（PAC-QOL）、便秘患者症状自评量表评分（PAC-SYM）、乳果糖及开塞露用量、肛门直肠测压等指标,分析评估疗效。结果：治疗4周后,3组的NBD、Wexner便秘,PAC-QOL及PAC-SYM评分均较治疗前有明显减少（P<0.01）,乳果糖及开塞露用量均较治疗前有明显减少(P<0.01),肛门收缩压较治疗前有明显增加(P<0.01),直肠容量感觉阈值较治疗前有明显减少(P<0.05),肛门静息压治疗前后差异无统计学意义;治疗后,C组各项量表评分、乳果糖及开塞露用量均较A、B组有明显减少(P<0.05),A、B组间差异无统计学意义,直肠测压各项指标3组间比较差异无统计学意义。结论：3种方法均可改善不完全脊髓损伤患者的便秘症状,肠道综合物理疗法比单独生物反馈电刺激及肠道运动疗法对不完全性脊髓损伤后便秘的改善作用更显著。     

Perianesthesia care of cardiac surgery patients: a CPAN review.

Postoperative nursing management of cardiac surgery patients is considered part of perianesthesia nursing core curriculum by ASPAN. In many hospitals, however, these patients bypass the PACU and are admitted directly to the ICU. For that reason, perianesthesia nurses who do not have cardiothoracic surgical ICU experience need information related to the immediate postoperative routine and nursing care regimen of cardiac surgery patients. Bleeding, cardiac tamponade, low cardiac output syndrome, and dysrhythmias are postoperative complications that are discussed. A brief overview of postoperative nursing management and several "nursing pearls of wisdom" are also presented.     

70岁以上高龄心脏瓣膜手术患者术后发生便秘的影响因素分析及对策

目的探讨70岁以上高龄心脏瓣膜手术患者术后发生便秘的影响因素,制定护理对策。方法回顾性分析本院心胸外科2017年12月—2018年12月收治的53例70岁以上高龄心脏瓣膜病患者的临床资料,将术后发生便秘的32例患者作为病例组,未发生便秘的21例患者作为对照组,进行术后发生便秘的相关因素分析;以高龄心脏瓣膜病患者术后是否发生便秘为因变量,将单因素分析中有统计学意义的变量作为自变量,采用二分类非条件Logistic回归分析探讨发生便秘的影响因素。结果70岁以上高龄心脏瓣膜手术患者术后便秘的发生率为60.38%。二分类非条件Logistic回归分析结果显示,与对照组相比,病例组患者有便秘史(OR=10.481,P<0.05)、术后发生谵妄(OR=4.936,P<0.05)和术后早期下床活动不足(OR=7.953,P<0.05)差异有统计学意义。结论有便秘史、术后发生谵妄和术后早期下床活动不足是70岁以上高龄心脏瓣膜手术患者术后发生便秘的影响因素,应根据危险因素实施针对性护理措施。     

Postoperative pulmonary dysfunction in adults after cardiac surgery with cardiopulmonary bypass: clinical significance and implications for practice.

Postoperative pulmonary complications are the most frequent and significant contributor to morbidity, mortality, and costs associated with hospitalization. Interestingly, despite the prevalence of these complications in cardiac surgical patients, recognition, diagnosis, and management of this problem vary widely. In addition, little information is available on the continuum between routine postoperative pulmonary dysfunction and postoperative pulmonary complications. The course of events from pulmonary dysfunction associated with surgery to discharge from the hospital in cardiac patients is largely unexplored. In the absence of evidence-based practice guidelines for the care of cardiac surgical patients with postoperative pulmonary dysfunction, an understanding of the pathophysiological basis of the development of postoperative pulmonary complications is fundamental to enable clinicians to assess the value of current management interventions. Previous research on postoperative pulmonary dysfunction in adults undergoing cardiac surgery is reviewed, with an emphasis on the pathogenesis of this problem, implications for clinical nursing practice, and possibilities for future research.     

人工心脏起搏器安装术后病人足底推拿的效果评价

目的探讨足底推拿对人工心脏起搏器安装术后病人便秘、体位性低血压、伤口愈合时间、睡眠时间、伤口疼痛的作用效果。方法将60例人工心脏起搏器安装术后病人,采用分层随机抽样法分为对照组30例和实验组30例,对照组予常规护理(止血、心电监护、皮肤护理、心理疗法等),实验组在对照组的基础上应用足底推拿护理技术。结果两组病人采用不同的护理方法对病人术后伤口疼痛、睡眠时间、便秘、体位性低血压、伤口愈合时间有显著性差异(P<0.01)。结论足底推拿能有效疏通全身经络,加速血液循环,改善全身症状,减少术后病人伤口疼痛和改善失眠,防止便秘,减少下床活动时体位性低血压等并发症,有利于提高病人的生活质量,加快了术后康复。     

Perioperative Landiolol Administration reduces Atrial Fibrillation after Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

Introduction

Postoperative atrial fibrillation (POAF) is one of the most common complications after cardiac surgery. Patients who develop POAF have a prolonged stay in the intensive care unit and hospital and an increased risk of postoperative stroke. Many guidelines for the management of cardiac surgery patients, therefore, recommend perioperative administration of beta-blockers to prevent and treat POAF. Landiolol is an ultra-short acting beta-blocker, and some randomized controlled trials of landiolol administration for the prevention of POAF have been conducted in Japan. This meta-analysis evaluated the effectiveness of landiolol administration for the prevention of POAF after cardiac surgery.

Methods

The Medline/PubMed and BioMed Central databases were searched for randomized controlled trials comparing cardiac surgery patients who received perioperative landiolol with a control group (saline administration, no drug administration, or other treatment). Two independent reviewers selected the studies for inclusion. Data regarding POAF and safety outcomes were extracted. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the Mantel–Haenszel method (fixed effects model).

Results

Six trials with a total of 560 patients were included in the meta-analysis. Landiolol administration significantly reduced the incidence of POAF after cardiac surgery (OR 0.26, 95% CI 0.17–0.40). The effectiveness of landiolol administration was similar in three groups: all patients who underwent coronary artery bypass grafting (CABG) (OR 0.27, 95% CI 0.17–0.43), patients who underwent CABG compared with a control group who received saline or nothing (OR 0.28, 95% CI 0.17–0.45), and all patients who underwent cardiac surgery compared with a control group who received saline or nothing (OR 0.27, 95% CI 0.17–0.42). Only two adverse events associated with landiolol administration were observed (2/302, 0.7%): hypotension in one patient and asthma in one patient.

Conclusion

Landiolol administration reduces the incidence of POAF after cardiac surgery and is well tolerated.     

Lactulose in the management of constipation: a current review.

OBJECTIVE: To review the current published clinical studies evaluating the clinical efficacy and safety of lactulose compared with other laxatives or placebo. Adverse effects associated with lactulose are also reported. DATA SOURCES: Information was retrieved by searching the MEDLINE and EMBASE databases for clinical trials, abstracts, conference proceedings, and review articles dealing with lactulose. STUDY SELECTION: Emphasis was placed on clinical trials where lactulose was compared with other laxatives or placebo in patient populations where the diagnosis of constipation was reasonably established. DATA EXTRACTION: The methodology and results from clinical studies were evaluated. Assessment of the studies was made based on diagnosis of constipation, prior management of patients, follow-up of patients, dosage, and adverse effects. DATA SYNTHESIS: Clinical trials in geriatric patients, terminally ill patients, children, and normal and constipated subjects were reviewed. In most instances, lactulose was compared with a placebo, without incorporating the current education on dietary techniques for improving defecation. CONCLUSIONS: Generally, clinical trials have demonstrated a beneficial response compared with placebo, although sometimes that response has been only marginally better, from a clinical point of view.     

From theory to practice: preventing pain after cardiac surgery.

A pain management guideline was developed at the Royal Columbian Hospital, New Westminster, British Columbia, to prevent pain after cardiac surgery. The guideline was based on a wellness model and was predicted on the World Health Organization's analgesic ladder. Patients are given nonopioids around the clock and throughout the postoperative stay and are given an opioid to prevent procedural pain and treat breakthrough pain. In an evaluation of the guideline, records from 133 cardiac surgery patients were retrospectively reviewed. The type and dose of analgesics administered for the first 6 days after surgery, the effectiveness of the pain management plan, the occurrence of adverse effects, time to extubation, and postoperative lengths of stay were determined. Ninety-five percent of patients had effective pain relief. Almost all patients received acetaminophen around the clock. A total of 89% received indomethacin. All patients received opioids intermittently. Doses of opioids were converted to morphine oral equivalents, which peaked on day 1 after surgery (38 equivalents) and decreased sharply by day 2 (< 10 equivalents). Median postoperative length of stay was 5 days for patients who had bypass surgery and 6 days for patients who had valve surgery. This proactive, low-tech, low-risk, well-tolerated pain management approach is cost-effective, simple, and feasible to use. The findings support use of this approach in managing pain after cardiac surgery.     

咀嚼口香糖对老年胃肠手术患者胃肠功能恢复的影响

目的 探讨咀嚼口香糖对老年胃肠手术患者术后胃肠功能恢复的影响.方法 将60例年龄＞60岁且行胃肠手术的患者随机分为A组(常规组)、B组(早期康复组)、C组(口香糖咀嚼组),每组20例.A组患者接受胃肠手术术后常规护理;B组患者在此基础上给予术后早期胃肠功能恢复锻炼,如床上活动、腹部按摩、缩肛运动等;C组患者于常规护理基础上,在术后8～12 h开始咀嚼口香糖,每天3次,每次15～20 min.记录并比较3组患者术后恢复肛门排气时间,术后口干、口臭、恶心、腹胀等不适症状发生情况,术后住院时间.结果 术后恢复肛门排气时间,B、C组较A组均明显缩短,差异有统计学意义(P＜0.05);术后不适发生情况C组少于A、B组,差异有统计学意义(P＜0.05);术后住院时间比较,3组间没有明显差异(P＞0.05).结论 咀嚼口香糖可以促进老年胃肠手术患者术后肠蠕动的恢复,预防腹胀,消除术后口干、口臭等不适症状且方法简便安全,可以作为术后辅助治疗在临床上推广使用.     

The use of chewing gum for postoperative ileus prevention in patients undergoing radical cystectomy

Does the postoperative use of chewing gum in patients undergoing radical cystectomy (RC) facilitate intestinal motility recovery, reduce intestinal recanalization times and decrease length of stay? Postoperative ileus is a temporary impairment of intestinal motility and a frequent complication after RC. It is characterized by abdominal distention and absence of bowel functions, with symptoms including nausea, vomiting, pain and cramps. This results in an increase in length of stay, patient discomfort and costs. Different studies investigated the efficacy of chewing gum use, as a form of simulated feeding, in accelerating the resolution of ileus after several abdominal surgical procedures. Considering the lack of specific studies, some other conducted in similar abdominal procedures were included in this literature review. Despite the diversity of type of surgery, all considered studies show for patients who received chewing gum, a significant reduction in the time of first flatus and faeces, a reduction in the time of first bowel movements; not all included studies instead have found a significant decreasing in morbidity and length of stay. The chewing gum use seems to be a simple and inexpensive way to enhance recovery of bowel function, although it is probably still a little known procedure. It is possible recommending the administration of chewing gum in patients after cystectomy, monitoring the effectiveness, upon the recognition of possible conditions that might contraindicate its use.     

Hemodynamic management of patients in the first 24 hours after cardiac surgery

OBJECTIVE: To describe the physiologic alterations, evaluation, and hemodynamic management of patients in the first 24 hrs after cardiac surgery. DESIGN: A brief review of preoperative and intraoperative events, postoperative physiology, and a discussion of the evaluation and hemodynamic management of cardiac surgery patients postoperatively based on a review of the literature, known physiology, and clinical experience. RESULTS: After cardiac surgery, patients undergo alterations in cardiac performance related to co-morbid conditions, preoperative myocardial insults and interventions, the surgical procedure, and intraoperative management. Predictable responses evolve rapidly in the first 24 hrs after surgery. Monitoring, diagnostic regimens, and therapeutic regimens exist to address the patterns of response and occasional complications. CONCLUSION: By understanding preoperative and intraoperative events and their evolution in the intensive care unit, clinicians can effectively manage patients who experience cardiac surgery.     

Impact of prophylactic mupirocin for radical esophagectomy

The preoperative intranasal application of mupirocin significantly decreases the rate of nosocomial S. aureus infections among patients who are S. aureus carriers. However, it remains unclear whether the routine preoperative use of mupirocin would reduce postoperative S. aureus infections, especially methicillin-resistant Staphylococcus aureus (MRSA) infections, and who would benefit from the prophylactic use of mupirocin. Ninety-six consecutive patients who had undergone elective radical esophagectomy with right thoracotomy and laparotomy were evaluated. Fifty-one patients were given 2% mupirocin calcium ointment 3 times daily over 3 consecutive days before surgery. Uni- and multivariate analyses were performed to identify factors affecting the following three issues: postoperative MRSA infection, postoperative pneumonia, and the length of postoperative hospital stay. In univariate analyses, the preoperative application of mupirocin significantly reduced MRSA infection, postoperative pneumonia, and length of postoperative hospital stay. Multivariate analyses indicated significant associations between mupirocin administration and reductions in both MRSA infection and postoperative pneumonia, but not in length of postoperative hospital stay. Radical esophagectomy with right thoracotomy and laparotomy for esophageal carcinoma warranted the preoperative prophylactic administration of mupirocin in order to reduce postoperative infectious complications from MRSA. Its routine use for such a high-risk procedure is entirely reasonable.     

150例重度功能性便秘患者围术期护理

目的总结重度功能性便秘经腹腔镜辅助下结肠次全切除＋改良Duhamel术的护理经验。方法对150例重度功能性便秘经腹腔镜辅助下结肠次全切除联合改良Duhamel术患者的临床资料进行分析。结果术后7例出现肛门便血,12例出现大便次数增多,2例出现肠梗阻症状。结论耐心细致的术前准备,完善的术中、术后护理对提高手术治愈率、减少术后并发症起着关键作用。     

Imaging of abdominal complications following cardiac surgery

Ten thousand seven hundred fifty-six patients underwent cardiac bypass surgery at the Mater Hospital national cardiac unit between September 1979 and April 1993. Of this group, 49 patients were identified who had developed postoperative gastrointestinal complications leading to 16 deaths. Twenty-five patients developed gastrointestinal hemorrhage, eight patients developed gallbladder disease, five patients developed phlegmonous pancreatitis, eight patients developed bowel perforations, and three patients developed intestinal pseudoobstruction. The particular radiological features that lead to diagnosis in each case are discussed and relevant literature is briefly reviewed.     

规范化护理质量管理在心外ICU术后患者中的应用及效果

目的:探讨规范化护理质量管理对心外ICU术后患者的影响。方法:将176例心外ICU术后患者按入院时间分为对照组78例和实验组98例。对照组给予常规护理,实验组使用心外ICU规范化护理质量管理模式。观察、比较两组护理效果。结果:实验组医源性损伤、ICU谵妄、非计划拔管发生率低于对照组(P<0.05);实验组气管插管留置时间、留住ICU时间少于对照组(P<0.05);患者满意度评分实验组高于对照组(P<0.05);两组护理并发症发生率比较差异无统计学意义(P>0.05)。结论:规范化护理质量管理可有效提高心外ICU术后患者护理安全和护理质量,节约医疗护理资源,具有良好社会效益。     

术前清洁灌肠对选择性胸腰椎手术患者术后便秘的影响

目的探讨术前清洁灌肠对选择性脊柱手术患者术后发生便秘的影响。方法选择择期进行胸腰椎手术的非瘫痪患者205例,排除其他引起便秘的因素,随机分成两组:术前灌肠组103例;非灌肠组102例;统计术后便秘的发生率。结果灌肠组仅12例发生便秘,未灌肠组30例发生便秘,两组差异显著(P<0.01),并且灌肠组术后便秘再处理较非灌肠组简便。结论术前常规清洁灌肠可明显减少脊柱手术患者术后便秘的发生。     

Cardiac troponin I concentrations, but not electrocardiographic results, predict an extended hospital stay after coronary artery bypass graft surgery

BACKGROUND: Cardiac damage in coronary artery graft (CABG) surgery is an important contributor to postoperative cardiac dysfunction and delayed hospital discharge. Currently, no simple method exists for its quantification. METHODS: In a prospective study of 300 patients having routine CABG surgery, we compared cardiac troponin I (cTnI) concentrations at 6 and 24 h after surgery with electrocardiographic (ECG) results as predictors of an extended postoperative stay in the intensive care unit (ICU) and in the hospital. We stratified outcome variables by tertiles of cTnI concentration and studied the significance of differences between outcome variables across tertiles. RESULTS: Multivariate analysis showed that 24-h cTnI is a significant predictor of increased postoperative ICU stay (P = 0.012) and postoperative hospital stay (P = 0.024). For 6-h cTnI, corresponding significance values were P = 0.29 and 0.9. ECG was of no value (P = 0.39 and 0.47). Differences in 24-h cTnI were highly significant, particularly for lowest vs highest tertiles, and allowed stratification of risk into "low" (<10 microg/L), "equivocal" (10-20 microg/L), and "high" (>20 microg/L). CONCLUSIONS: Use of a single 24-h cTnI value to quantify perioperative myocardial damage identifies patients who are at greater risk of extended ICU and hospital stays. This strategy could assist in allocation of patients to different management streams after CABG surgery.     

Perioperative surveillance for adverse myocardial events

Perioperative myocardial infarctions occur in 1 to 4% of unselected noncardiac surgical patients, and are associated with high mortality. Detection of these events can be challenging, because 'typical' symptoms of myocardial ischemia may not be present or may be masked in the perioperative period. Therefore, surveillance by means of intraoperative cardiac monitoring and postoperative serial electrocardiograms (ECGs) and troponins may be needed. Cardiac monitoring not infrequently detects ST-segment changes suggestive of ischemia during or shortly after surgery. To respond to these changes, the risk for coronary artery disease should be assessed before recommending additional interventions. For all vascular surgery patients, and for patients who have or are felt to be at risk for coronary artery disease, serial postoperative 12-lead ECGs and troponins should be considered. Among surgical patients not meeting these criteria, obtaining routine ECGs in the absence of signs or symptoms that suggest a cardiac event may be falsely reassuring and is not felt to be useful. The presence of elevated postoperative troponins predicts worsened prognosis, and argues for intensified risk factor modification. The need for noninvasive cardiac testing or cardiac catheterization should be made on an individual basis.