Daphne Stannard

The Role of Intravenous Acetaminophen in Acute Pain Management: A Case-Illustrated Review

For more than a century, acetaminophen has been recognized worldwide as a safe and effective agent for relieving pain and reducing fever in a wide range of patients. However, until recently, acetaminophen was available in the United States only in oral and rectal suppository formulations. In November 2010, the United States Food and Drug Administration granted approval for the use of a new intravenous (IV) formulation of acetaminophen for: 1) the management of mild to moderate pain; 2) the management of moderate to severe pain with adjunctive opioid analgesics; and 3) the reduction of fever in adults and children (age ≥ 2 years). This case-illustrated review of IV acetaminophen begins with a discussion of the rationale for the drugs development and proceeds to analyze the clinical pharmacology, efficacy, safety, and nursing implications of its use, both as monotherapy and in combination with other agents as part of a multimodal pain therapy strategy.

Pulse Oximetry for Perioperative Monitoring

CLINICAL BOTTOM LINE Pulse oximetry is a noninvasive clinical monitoring tool that estimates the arterial oxygen saturation of the blood (SpO2). In addition to providing a numerical SpO2 value, pulse oximetry provides early detection of hypoxemia by alerting clinicians, through visual cues and auditory alarms, if the pulsatility of the waveform decreases to a critical level. This warning system enables clinicians to move rapidly to assess the patient’s status and to determine whether intervention is required. Patient movement, vibration, ambient light, and vasoconstriction, among other factors, have all been demonstrated to limit the accuracy of pulse oximetry. Limitations aside, however, pulse oximetry has revolutionized patient monitoring in both acute and critical care areas, in large part because of the early detection and prompt treatment of hypoxemia the monitoring device affords.

Support Surfaces for Pressure Ulcer Prevention

Pressure Ulcers (also referred to as pressure sores, decubitus ulcers, and bed sores) are areas of localized damage to the skin and underlying tissue, and are thought to be caused by pressure, shear, or friction. PUs are more likely to occur in patients who are critically ill, have impaired mobility or are immobile, have impaired nutrition and/or obesity, or those using equipment that does not provide appropriate pressure relief, such as beds. PUs are of importance to the perioperative setting, as preoperative patients may present with multiple risk factors that can predispose them to PU development. These patients with ‘‘skin at risk’’ are subsequently immobilized for a period of time during the operative procedure.

Intraperitoneal Local Anesthetic Instillation Versus No Intraperitoneal Local Anesthetic Instillation for Laparoscopic Cholecystectomy

Within the adult Western populations of the world, up to 25% experience gallstones every year. Only a small percentage, less than 5%, experience symptomatic pain from their gallstones and seek treatment for relief. Removal of gallstones, or cholecystectomy, is the preferred treatment for this condition, resulting in approximately half a million cholecystectomies performed annually in the United States and United Kingdom. Of those, approximately 80% to 90% are performed laparoscopically.

Evidence in perioperative care.

Perioperative care is comprised of preoperative, intraoperative, and postoperative care. Given the vulnerable status of the perioperative patient, coupled with the complex nature of these areas, evidence-based practice and clinical decision-making must be rooted in high-quality evidence for safe and effective patient and family care. Evidence-based practice is comprised of patient and family preferences, clinical expertise, and best available evidence. This article showcases systematic reviews that have focused on clinical issues within the preoperative, intraoperative, and postoperative care areas. A case study presents the importance of applying best available evidence to solve a thorny clinical problem and improve patient outcomes.

Hypertonic saline for perioperative fluid management.

Authors’ conclusions HS reduces the volume of intravenous fluid required to maintain patients undergoing surgery but transiently increases serum sodium. It is not known if HS effects patient survival and morbidity but it should be tested in randomized clinical trials that are designed and powered to test these outcomes. P L A I N L A N G U A G E S U M M A R Y Hypertonic saline for peri-operative fluid management Patients usually require intravenous fluids during surgery. Sometimes large volumes of fluid are given during operations in order to maintain adequate blood pressure, but these volumes may leave patients with an excessive fluid load in the post-operative period. Hypertonic saline has a higher sodium concentration than isotonic solutions which have concentrations similar to the blood stream. Hypertonic saline might benefit patients undergoing surgery by reducing the total volume of fluid required. This review includes 15 trials comparing hypertonic saline to isotonic saline in patients undergoing surgery. These trials suggests that less fluid is required for maintenance of arterial blood pressure and blood volume in these patients during surgery if hypertonic saline is given. Kidney function was good in both groups but the serum sodium was higher in patients given hypertonic saline. The trials were too small to see important differences in patient survival or organ failure. B A C K G R O U N D Low volume resuscitation with hypertonic crystalloid solutions has been investigated for over 20 years (Shackford 1983). More recently, alterations in cellular immune function with hypertonic saline (HS) administration have been demonstrated in experimental and clinical studies (Kolsen-Petersen 2004; Rizoli 2006). Several randomized clinical trials (RCTs) of HS resuscitation in critically ill patients have been performed. A systematic review of HS compared to isotonic solution in resuscitation following burns or trauma was unable to reach a conclusion regarding benefit or harm in the presence of wide confidence intervals (Bunn 2004). Trials of HS alone, or in combination with colloids, have also been performed in the trauma population. A meta-analysis comparing 250 ml of HS (with or without dextran) with administration of 250 ml of isotonic crystalloid for the treatment of hypotension either in the field or at admission to the emergency department in 1233 trauma patients failed to demonstrate that HS with dextran confers a survival benefit (Wade 1997). Standard perioperative care includes isotonic salt (IS) solution administration to counter conditions which may cause transient intra-operative hypovolaemia including: fluid deprivation during preoperative fasting; vasodilatation due to epidural or general anaesthesia; third space sequestration of intravascular fluid; insensible fluid loss and intraoperative fluid or blood loss. These conditions are often reversed at the end of an operation. In fact, IS solution has been shown to increase the weight of patients undergoing elective major surgery by an average of three to six kilograms (kg) (Grocott 2005). While most patients tolerate the additional fluid well, postoperative improvement or reversal of the conditions outlined above may place patients with compromised cardiovascular or renal function at increased risk for development of pulmonary oedema. Patients without cardiovascular or renal risk factors may also be adversely affected by perioperative fluid gain. A recent RCT demonstrated that perioperative fluid restriction resulted in fewer major or minor postoperative complications compared to traditional care in 172 adult patients undergoing elective colorectal surgery (Brandstrup 2003). Another study demonstrated that fluid overload delayed return of gastrointestinal function (Lobo 2002). Conversely, failure to maintain intravascular volume during surgery may place patients at risk for cardiac or cerebral ischaemia. Indeed supplemental perioperative fluid administration has been shown to improve tissue oxygenation (Arkilic 2003). HS has the potential to reduce the total volume of fluid administered during operative procedures by allowing patients to draw fluid from the interstitium (and other body compartments) to counter perioperative hypotensive effects and thereby provide Intravascular support without excess fluid administration. In situations where large volume resuscitation may be harmful, such as in brain trauma, a role for HS is emerging (Ogden 2005). Notwith2 Hypertonic saline for peri-operative fluid management (Review) Copyright