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Elevated blood pressure can be lowered safely in the vast majority of patients by selecting the single drug most likely to be efficacious in that patient. Skillful management with full knowledge of drug pharmacology should provide the patient with the maximum opportunity to benefit from normalization of blood pressure while at the same time having little or no impact on quality of life.
Epidemic Kaposi's sarcoma, a neoplasm associated with AIDS, is rapidly becoming common in the United States and Europe. The pathogenesis of this form of Kaposi's sarcoma has not yet been fully understood, but epidemiological clues point to the possibility that an infectious agent (in addition to the AIDS virus HTLV-III) or an environmental toxin may be involved. The natural history and clinical course of epidemic Kaposi's sarcoma is variable. The life expectancy of an AIDS patient with Kaposi's sarcoma is probably related to his underlying immunologic status as evidenced by propensity to develop life-threatening opportunistic infections. Patients with this neoplasm should be entered on experimental treatment programs when possible in order to improve our knowledge about rational management of this disease. Recombinant interferon alfa-2a, single agent chemotherapy, and radiation all have roles in the management of the disease.
As the number of cardiac transplantation recipients grows, more centers will be performing cardiac transplantations and more anesthesiologists will be confronted with such patients. This chapter is intended to impart to the reader the basic knowledge necessary to manage both the donor and recipient intraoperatively. It is not intended to provide a complete description of the entire field including such areas as the surgical procedure or the immunologic theories involved. Rather, it is hoped that with the information provided, the anesthesiologist may optimally care for this patient group and perhaps become stimulated to investigate this area of medical science in more detailed sources.
The effectiveness of the adolescent obesity intervention SHAPEDOWN was evaluated for 15 months through a randomized experimental design study. Test groups (no. = 37) participating in the intervention were compared with a no-treatment control group (no. = 29) at four sites in northern California. The program employs a variety of cognitive, behavioral, and affective techniques adapted to make successive small modifications in diet, exercise, communication, and affect that are sustainable. Very-low-calorie or restrictive diets are avoided in the program. Parents are instructed on strategies for supporting their adolescents' weight-loss efforts. Participation in the group application of the program was associated with significant improvement in relative weight, weight-related behavior, depression, and knowledge of weight management concepts at post-treatment and at 1-year follow-up. Self-esteem increased significantly regardless of condition. Change in relative weight for the test group was -9.9 +/- 14.9% (mean +/- standard deviation) and for the control group was -0.10 +/- 13.2%. At month 15 of the study period, weight change in the test group compared with the controls was -5.15 kg. For all subject variables examined in the test group, mean change in relative weight at 1-year follow-up was negative, suggesting that none of the characteristics examined contraindicate program participation among obese adolescents seeking care. Drop-out rate was 16%. The study suggests that the program produces significant long-term outcomes in obese adolescents and is transferable to a variety of settings.
A patient returns from the operating room with an intracranial pressure (ICP) of 25 mm Hg as measured by an intraventricular catheter. What measures will decrease his ICP, what is the most threatening risk of an intraventricular catheter, and what nursing measures will decrease those risks? The clinical nurse caring for a patient with an intraventricular catheter must understand the dynamics of intracranial anatomy and physiology as well as the methods and rationale for medical and nursing management. An adequate knowledge base of each aspect of the intraventricular catheter and drainage system, from insertion to removal, is very important in decreasing the risks that confront these patients. These risks include infection, collapse of the ventricles, rapid ventricular drainage, increased potential for subdural hematoma, and subarachnoid hemorrhage. Familiarity with this information will minimize nursing uncertainties and fears, enabling the nurse to care for such patients with the required expertise and confidence.
Rabies is an acute viral encephalomyelitis with virtually a 100% case fatality rate. Only three cases of human survival after rabies have been documented. The current epizootic of raccoon rabies in the United States centered over the South Atlantic states mandates a working knowledge of rabies management and postexposure prophylaxis by health care professionals. Recently, important advances in rapid and accurate diagnosis and improvements in homologous vaccines make rabies a preventable disease in the United States.
For about twenty years, the method for prolonged artificial respiration was an imitation of spontaneous breathing pattern. New pathophysiological informations about acute respiratory failure showed that a technique which is widely different in frequency, cycle, and tidal volume is more suitable for the fast and safe restauration of spontaneous breathing. Especially the determination of pulmonary shunt flow (QS/Qt), and of the ratio of dead space to tidal volume (VD/VT) have completed our knowledge. In the management of patients with prolonged artificial ventilation, the calculation of shunt flow allows an evaluation of therapeutic procedures. This was the reason to present a nomogram, which simplifies the determination of pulmonary shunt and to discuss an easy, non-invasive method to at least estimate its amount.
Breast feeding is a management problem requiring knowledge of the physiology of lactation, maternal and infant nutritional requirements, and specifics such as drugs which enter the milk. The job of the physician is to allay anxiety; this helps establish the let-down reflex and increases milk production. "Caking," mastitis and even abscesses are not indications for weaning. Rest, warm compresses and frequent nursing are indicated. Breast-fed infants have less tendency to obesity than those who are bottle-fed. Early solid foods in the diet are not needed.
Problems resulting from cold exposure can be successfully treated when a coordinated emergency medical transport system and appropriate equipment are available, as well as medical personnel knowledgeable in the management of frostbite and hypothermia. Clinical suspicion of these disorders is essential. Profoundly hypothermic individuals with no recordable vital signs have been resuscitated after controlled, rapid rewarming measures and the use of emergency life-support systems.
Many people with spinal cord injury (SCI) need a personal assistant (PA) to help them with activities of daily living. Personal assistance services can make a critical difference in adjustment to SCI and the ability to live independently. Using the independent living model, the person with a disability (employer) directs and monitors his/her health care needs. This article focuses on two essential skills needed by the employer of a personal assistant: 1) creation of a thorough job description using checklists and 2) communication skills needed to supervise the PA. Knowledge of these management skills will enhance the nurse's practice when working with clients who are new or experienced in using personal assistance services.
The initial treatment for a depressive episode corresponds to the early period of treatment for depression--the period which precedes what is called the phase of consolidatory treatment, which itself is eventually followed by maintenance treatment. Its precise adjustment has been the object of many pharmacological studies, but nevertheless remains largely empirical. The choice of an antidepressant depends on the therapeutic response obtained during previous episodes. The choice of dosage, on the other hand, is well standardised. The essential element is to oversee the treatment, both to detect and correct undesirable effects as well as to improve the target symptoms. Certain therapeutic considerations must be put into practice according to the types of depressive swings, such as secondary depression, chronic depression, manic depression, and atypical depressions. In any event the initial treatment of all depressions remains largely empirical at the present time, and depends on knowledge of the management of antidepressant substances, particularly since the appearance of new families of MAOIs and 5HT agonists.
Although perinatal mortality is steadily decreasing with the present relatively stable rates of cesarean section, babies born in breech presentation are at a higher risk of perinatal problems and mortality. The higher risk associated with breech delivery is more marked for preterm babies. Vaginal deliveries of term breech babies, however, present only a slightly higher risk than elective cesarean deliveries. Breech presentation is also associated with several inborn diseases or malformations. There is no standard set of general criteria for selecting route of delivery for breech presentations, but when several criteria are combined, they have been shown to reduce the risk when applied in a clinical setting. This article reviews the current knowledge of the management and outcome of breech deliveries, and concludes that vaginal breech deliveries at term are relatively safe if selected on the basis of specific criteria and performed in specialized units.
IL-2 is a biotherapeutic drug and a biological response modifier. This drug has not been approved by the Food and Drug Administration for general use but continues to undergo clinical trials. Candidates for this therapy are patients with advanced carcinoma that has not responded to standard modalities of treatment. Administration of IL-2 can lead to systemic toxicity, which usually appears to be dose-related. As a result, high-dose therapy requires intensive care. The critical care nurse assesses and documents side effects that occur as a result of IL-2 therapy and must be aware of both the physical and psychological needs of the patient. Through successful assessment and intervention, the nurse can gain the knowledge required to manage, both physically and psychologically, patients who are undergoing this therapy.
A 1991 study of 115 internal medicine and 28 family practice residents at a large inner-city public hospital finds that both groups would perform poorly in providing preconception counseling to women of reproductive age. More than 40% of residents failed to indicate that they would provide a healthy woman with information on rubella immunization and family planning or counseling on sexually transmitted diseases and safer sex. When counseling a diabetic woman seeking pregnancy, 74% would not have discussed congenital anomalies with her and 45% would not have considered discontinuing oral hypoglycemics if she became pregnant. Furthermore, 58% would have neglected to review or change hypertension medications in a newly diagnosed pregnant woman. Although both internal medicine and family practice residents had positive attitudes toward offering preconception care, family practice residents had significantly higher attitude scores. No clear improvement was found in patient management, attitude or knowledge scores as residents progressed from their first to their third year of training.
Despite considerable documentation for retinoid-induced hyperostosis, sufficient knowledge regarding its management and histologic features is not available. In a 26-year-old man with etretinate-induced heterotopic bone formation about the hip joint, the use of etidronate disodium was unsuccessful. Surgical excision of the heterotopic bone dramatically improved restricted motion of the hip joint without initiating significant postoperative heterotopic ossification. Ultrastructural study showed abundant myofibroblasts in the fibrous tissue close to the heterotopic bone. Their role in local biologic events should be determined.
The patient with a caval filter poses a challenge to the emergency physician. Key considerations in management are a knowledge of underlying disease processes in this patient population, indications for filter placement, potential early or delayed complications associated with these devices, and appropriate diagnostics and consultation. Diagnostic evaluation should include plain radiographs to evaluate gross structural problems, filter migration, significant filter tilting or angulation, and filter leg span splaying or retraction as well as evidence of visceral perforation or obstruction. Comparison films should be obtained, if possible. Screening laboratory tests to assess coagulation, hematologic, and renal function are indicated. The possibility of recurrent PE and a reassessment of filter protection and anticoagulation status should be considered. Advanced diagnostic imaging tools such as abdominal CT, duplex sonography, and cavography may be needed to elucidate suspected caval filter complications, or suspected new DVT or IVC occlusion. Early consultation is indicated. With new and expanded indications as well as technical improvements in caval filters, increased use of these devices can be anticipated, as can associated complications first seen and evaluated by the emergency medicine physician.
Pain management is an integral part of the daily practice of PACU nurses. Despite increased understanding of pain and advanced pain-management methods, the experience of moderate to severe pain continues for many patients. This article reviews factors that influence nurses' pain management. These factors include the difficulty involved with measuring pain and the characteristics and educational preparation of the nurse. Common misconceptions and corrections to these misconceptions are summarized, and implications for practice are given. Suggestions for continuing education, including resensitizing nurses to pain management, increasing nurses' knowledge base, and examining personal factors and inherent beliefs, are given.
To investigate clinically important hypotension and bradycardia after induction of anesthesia with propofol, we analyzed data from a Phase IV stepwise study involving 25,981 patients, 1722 institutions, and 1819 anesthesiologists. In Step 1, propofol was used for induction only. In Step 2, propofol was used for induction and then maintenance by intermittent injection. In Step 3, an induction dose was followed by a maintenance infusion. Participants were to be 18-80 yr of age and ASA physical status I-III; they could not have a continuing pregnancy or prior adverse anesthetic experience. Detailed data on demographic, perioperative, and outcome variables were recorded on data collection forms. The overall incidence of hypotension (systolic blood pressure < 90 mm Hg) was 15.7%; 77% of the episodes were recorded within 10 min of induction of anesthesia with propofol. Bradycardia (heart rate < 50 beats/min) occurred in 4.8% of patients, with 42% of the episodes in the first 10 min. Only 1.3% of patients had both hypotension and bradycardia. The incidence of hypotension was significantly higher for the elderly, females, Caucasians, those undergoing abdominal and integumentary procedures, and those given propofol with opioids, benzodiazepines, or propranolol. Bradycardia was significantly more common when propofol was combined with opioids or chronically taken beta-adrenergic receptor-blocking drugs. Bradycardia and hypotension were not commonly associated. Giving this new drug by protocol, even inexperienced anesthesiologists incurred few adverse hemodynamic changes. Hemodynamic changes were transient and rarely (< 0.2%) required drug therapy. Cardiovascular changes and drug interactions were predictable and manageable based on knowledge of the pharmacology of propofol.