Paula R. Graling

Descending cervical mediastinitis

Descending cervical mediastinitis is an uncommonly reported presentation of infection originating in the head or neck and descending into the mediastinum, which is fraught with impressive morbidity and mortality rates of 30% to 40% or more. We present the INOVA-Fairfax-Alexandria Hospital experience with descending cervical mediastinitis, January 1, 1986, to April 1, 1997; in addition we review the English-language medical and surgical literature with regard to this entity. Computed tomography and magnetic resonance imaging serve to aid both diagnosis and management. The application of broad-spectrum antibiotics should initially be empiric, with an eye to coverage of mixed aerobic and anaerobic infections. Definitive treatment mandates early and aggressive surgical intervention. All affected tissue planes, cervical and mediastinal, must be widely debrided, often leaving them open for frequent packing and irrigation. The treating physician must remain always alert to the further extension of infection, which, if it occurs, must be further debrided and drained. Tracheostomy serves a dual role of further opening cervical fascial planes and securing an often compromised airway.

Thoracic esophageal perforations.

Background Recognition of the importance of early diagnosis and aggressive, definitive surgical intervention has brought about a dramatic decline in mortality related to distal esophageal perforation. Methods We retrospectively analyzed all cases of thoracic esophageal perforation diagnosed at our hospital from September 1, 1979, through April 1, 2001. The study group consisted of 62 patients (43 men) with a mean age of 58.8 years (range, 20–92 yr). Results In the group of 39 patients with early diagnosis (≤24 h), hospital survival was 87%, which increased to 93% when early diagnosis was combined with aggressive surgical treatment. Among the 23 patients with late diagnosis (>24 h), survival approached 70%. Yet, in patients who were treated aggressively with surgery, survival was almost 90% despite delayed diagnosis. Conclusion We recommend aggressive, definitive surgery for thoracic esophageal perforations, whether diagnosed early or late. A variety of options are discussed with regard to complicated presentations.

Effectiveness of 2% CHG cloth bathing for reducing surgical site infections.

We conducted a prospective cohort study on the effectiveness of preoperative bathing with chlorhexidine gluconate (CHG) cloths for reducing surgical site infections. We hypothesized that use of CHG cloths as an adjunct to surgical prep would significantly reduce the endogenous flora of surgical patients and therefore reduce surgical site infections. Data from a control group of patients who had undergone general, vascular, and orthopedic surgery were used for comparison. Results indicated an overall reduction of infection in the group that received a 2% CHG bath before surgery. There also was a possible reduction in postoperative organ space infection, although the sample numbers were extremely small. To reduce surgical site infections, we suggest a nursing protocol of preoperative bathing with a 2% CHG cloth for patients undergoing general and vascular surgery, and an additional trial to investigate the use of preoperative CHG cloth baths in all surgical patient populations.

Priority Patient Safety Issues Identified by Perioperative Nurses

Much of the work done by perioperative nurses focuses on patient safety. Perioperative nurses are aware that unreported near misses occur every day, and they use that knowledge to prioritize activities to protect the patient. The purpose of this study was to identify the highest priority patient safety issues reported by perioperative RNs. We sent a link to an anonymous electronic survey to all AORN members who had e-mail addresses in AORNs member database. The survey asked respondents to identify top perioperative patient safety issues. We received 3,137 usable responses and identified the 10 highest priority safety issues, including wrong site/procedure/patient surgery, retained surgical items, medication errors, failures in instrument reprocessing, pressure injuries, specimen management errors, surgical fires, perioperative hypothermia, burns from energy devices, and difficult intubation/airway emergencies. Differences were found among practice settings. The information from this study can be used to inform the development of educational programs and the allocation of resources to enhance safe perioperative patient care.

Selection of a Method to Rate the Strength of Scientific Evidence for AORN Recommendations

The use of scientific evidence to support national recommendations about clinical decisions has become an expectation of multidisciplinary health care organizations. The objectives of this project were to identify the most applicable evidence-rating method for perioperative nursing practice, evaluate the reliability of this method for perioperative nursing recommendations, and identify barriers and facilitators to adoption of this method for AORN recommendations. A panel of perioperative nurse experts evaluated 46 evidence-rating systems for quality, quantity, and consistency. We rated the methods that fully covered all three domains on five aspects of applicability to perioperative nursing practice recommendations. The Oncology Nursing Societys method was rated highest for all five aspects of applicability, and interrater reliability of this method for perioperative recommendations was 100%. Potential barriers to implementation of the rating method include knowledge deficit, staff resources, resistance to change, and fear of showing that lower levels of evidence support some recommendations. Facilitators included education, resource allocation, and starting small. Barriers and facilitators will be considered by the implementation team that will develop a plan to achieve integration of evidence rating into AORN documents. The AORN Board of Directors approved adoption of this method in June 2010.

Perioperative care of the patient with morbid obesity.

Obesity recently has been called an epidemic. In the United States, more than 60% of adults are overweight. Although obesity and morbid obesity share numerous etiological factors (eg, genetic, environmental, psychosocial, economic), accepted treatment options differ. Morbid obesity requires urgent and definitive correction to treat both current and possible future complications and to help prevent a probable shortened lifespan. Generally, it is accepted that nonsurgical approaches to weight loss for a person who is morbidly obese are unsuccessful. This Home Study describes the major surgical procedures currently available to treat morbid obesity and discusses the information that nurses need to know about perioperative care of patients who are morbidly obese.

The Lithotomy Position in Colon Surgery

: The modified lithotomy position frequently is used in general surgery because it gives excellent simultaneous access to the abdomen and perineum. There are a variety of complications that may occur including lumbosacral plexus stretch, sciatic and peroneal nerve injury, and compartment syndrome of the legs. Through preoperative nursing assessment of a patients age, nutritional status, skin condition, pre-existing disease state, and anticipated type and length of surgical procedure, patients at risk for developing postoperative complications may be identified. The perioperative nurses role is to use this knowledge to assist the surgical team in safe patient positioning and optimal intraoperative care.

Kicking It Up a Notch—Successful Teaching Techniques

Leaders in todays ORs face the challenge of preparing nurses to work in highly technical and demanding environments. Various programs have evolved to prepare nurses to successfully and safely care for perioperative patients. This article reviews teaching techniques used in the Inova Learning Network, Falls Church, VA, perioperative nurse fellowship program and examines why they are successful.

Implementing a Perioperative Nursing Fellowship Program

The population of nurses in the United States is aging. After suffering high OR nurse vacancy rates for several years, leaders at the Inova Health System Implemented a nurse fellowship program. This six-month didactic and precepted learning program is aimed at experienced RNs who do not have OR experience but would like to work in the OR. Two years after implementation, the OR nurse vacancy rate in the health system has decreased from 27% to 15.5%.

Late stage (III and IV) non-small cell cancer of the lung: results of surgical resection at Inova Fairfax Hospital.

One hundred forty-two patients underwent surgery and related treatment for advanced stage (III, IV) non-small cell cancer of the lung. One hundred seventeen patients underwent up-front surgery, with a hospital mortality rate of 1.7% (2/117). Kaplan-Meier 5-year survival in this group was 31% (± 5). Twenty-five patients underwent neoadjuvant therapy followed by surgical resection, with respective rates of hospital mortality, complete pathologic response, and major pathologic response of 0%, 16%, and 64%. Kaplan-Meier 5-year survival in this latter group was 34% (± 11). Of the 16 patients undergoing neoadjuvant therapy who had complete pathologic response or significant downstaging from stage III disease, Kaplan-Meier 5-year survival was 61% (± 15).Three clinical observations of interest emerged regarding survival. First, in those patients with postresection FEV1 < 1.0 L, hospital mortality rate was 20%, and there were no 5-year survivors (P < 0.0001). Second, where neoadjuvant therapy was associated with complete pathologic response or significant downstaging of disease, there was a trend for improved survival in the downstaged group, but it did not reach statistical significance (P = 0.14). Third, adjuvant therapy was associated with improved 5-year survival (P = 0.03), particularly for combination chemotherapy and radiotherapy (P = 0.02).