John P. McDonough

Discovery, development, and clinical application of sugammadex sodium, a selective relaxant binding agent

Neuromuscular blockade, induced by neuromuscular blocking agents, has allowed prescribed immobility, improved surgical exposure, optimal airway management conditions, and facilitated mechanical ventilation. However, termination of the effects of neuromuscular blocking agents has, until now, remained limited. A novel cyclodextrin encapsulation process offers improved termination of the paralytic effects of aminosteroidal non-depolarizing neuromuscular blocking agents. Sugammadex sodium is the first in a new class of drug called selective relaxant binding agents. Currently, in clinical trials, sugammadex, a modified gamma cyclodextrin, has shown consistent and rapid termination of neuromuscular blockade with few side effects. The pharmacology of cyclodextrins in general and sugammadex in particular, together with the results of current clinical research are reviewed. The ability of sugammadex to terminate the action of neuromuscular blocking agents by direct encapsulation is compared to the indirect competitive antagonism of their effects by cholinesterase inhibitors. Also discussed are the clinical implications that extend beyond fast, effective reversal, including numerous potential perioperative benefits.

Anesthetic Related Advances with Cyclodextrins

Cyclodextrins encapsulate and electrostatically bind to lipophilic molecules. The exterior of cyclodextrins are water-soluble and maintain aqueous solubility despite encapsulation of non-aqueous soluble molecules. This unique ability to encapsulate lipophilic molecules and maintain water solubility confers numerous pharmacologic advantages for both drug delivery and removal. Cyclodextrins, a component part of supramolecular chemistry, may be in its infancy of anesthetic application but recent advances have been described as novel and revolutionary. A review of current research coupled with an understanding of cyclodextrin properties is necessary to fully appreciate the current uses and future potentials of these unique molecules.

The Occurrence of Acute Postoperative Confusion in Patients after Cardiac Surgery

This study quantified the occurrence of acute confusion in cardiac surgery patients at three German hospitals. A total of 867 patients, 22–91 years old, were examined each nursing shift postoperatively for 5 days for the presence of acute confusion using a modified version of the Glasgow Coma Scale and Confusion Rating Scale. The night shifts and the third postoperative day showed the most frequent periods of occurrence. Confusional state was noted in patients ranging from 10.5% for patients aged <70, to 40.7% for patients >80 years of age. Those found at increased risk were patients of increasing age and coexisting disease. Targeted nursing interventions for patients at increased risk of acute confusion may decrease this complication.

Incidence and prevalence of postoperative acute confusion in heart surgery patients after coronary artery bypass and heart valve replacement surgeries

Im Gegensatz zum Ausland liegen fur Deutschland keine Daten uber die Verbreitung von akuter Verwirrtheit nach herzchirurgischen Eingriffen vor. Durch das Auftreten akuter Verwirrtheit verlangert sich die Krankenhausverweildauer aber um bis zu 13 Tagen. Damit hat dieses Phanomen hohe pflegerische Relevanz. Die vorliegende Pravalenz-/Inzidenzstudie wurde mit dem Ziel durchgefuhrt, mit Hilfe einer multizentrischen Erhebung genaue Informationen uber die Inzidenzrate der akuten postoperativen Verwirrtheit nach herzchirurgischen Bypass- und Herzklappenoperationen zu erhalten. Die Datenerhebung erfolgte als Gelegenheitsstichprobe in drei verschiedenen deutschen Herzkliniken. Der Beobachtungszeitraum erstreckte sich vom Operationstag bis einschlieslich zum funften postoperativen Tag. Im Rahmen dieser prospektiven Kohorten-Studie kamen alle Patienten uber 18 Jahre, die sich im Zeitraum vom 1. Februar bis 30. April 2000 einer Bypass- und/oder Herzklappenoperation unterzogen, als Studienteilnehmer in Frage. 860 Pati...Compared to foreign countries, Germany does not have data about the occurrence of acute confusion following heart-surgery. However, the occurrence of acute confusion does extend the hospital length of stay for up to 13 days. Thus, this phenomenon is of high relevance to nursing. This prevalence/incidence study was implemented with the goal of obtaining exact information on the incidence rate of acute postoperative confusion after a heart surgery through a multicenter evaluation. The data evaluation took place in the form of a convenience sample survey in three different German clinics specializing on heart surgeries. The observation period lasted from the day of the surgery up to the fifth postoperative day. In the context of this prospective Cohort-study all patients aged 18 and older who had heart surgery between February 1st and April 30th, 2000, were considered suitable as participants in the study. In the end, 860 patients were included in this study. 152 patients (17.4%) showed symptoms of acute confusion (confidence interval 14-20%). Certain circumstances seemed to predispose patients to acute confusion. A widespread occurrence could be observed particularly at night. Patients aged 81-91 were mainly affected. A confusion rate of 43.5% could be determined for this group. These results confirm the clinical importance and suggest interdisciplinary approaches for solution.

Tips for using video teleconferencing for distance education.

V ideo teleconferencing (VTC) is challenging the historically perceived notion of academia with students and faculty together in 1 classroom. The real-time capability for 2-way, multisensory interactions is bringing students and instructors together without geographical limitation. Video teleconferencing allows students to obtain instruction from a distance and has been successfully employed in multiple disciplines including nursing education. Video teleconferencing can enable optimization of resources and will likely continue to expand its role in educational programs. With the early introduction of VTC technology, the initial focus was on its limited technical capabilities and methods to overcome those limitations. Today, with refinements in VTC technology that allow for a near-television broadcast quality transmission, the focus needs to shift to refinements in the instructional delivery. A solid underlying curriculum plan and appropriate learning goals and objectives for all course content must be considered a prerequisite to any VTC distance education program. Kerns et al and Woodruff et al (unpublished data, 2005) have documented equivalence in academic achievements between distance and onsite learners. Although academically successful, distance learners do not participate in the exact same educational experience as on-site students. The use of VTC necessitates identifying and addressing the unique needs of distance learners. Video teleconferencing lends itself to varied distance learning arrangements. The instructional considerations and guidelines presented here were derived from the experience at 1 university-based nurse anesthesia program, which consisted of a near-end classroom (actual) and a far-end (virtual) classroom of distance learners. Real-time, 2-way interactive VTC was used, with both instructor and presentation material broadcast simultaneously. The near-end classroom, located on campus, transmitted more than 90% of the didactic instruction. The far-end classroom was located more than 300 miles away in a hospital clinical site. Our experience in establishing, conducting, and evaluating this distance learning program for nurse anesthesia education has unveiled factors that should be considered for a successful VTC program. Lecture Presentation