Richard Henker

Perceived stress, physiologic stress arousal, and premenstrual symptoms: Group differences and intra‐individual patterns

The purpose of this study was to examine evidence for perceived stress, hypothalamic-pituitary-adrenal, and autonomic nervous system involvement in premenstrual symptoms. Women with a low severity (LS, n = 40), premenstrual syndrome (PMS, n = 22), and premenstrual magnification symptom patterns (PMM, n = 26) rated perceived stress, turmoil, and fluid retention symptoms for one entire cycle. Daily late afternoon urine samples were assayed for epinephrine, norepinephrine, and cortisol. Using multivariate analysis of variance analyses, we found significant group and cycle phase and group by phase interaction effects for perceived stress. There were no group or cycle phase differences in cortisol, epinephrine, and norepinephrine. Intraindividual analyses using cross-correlation techniques revealed a positive time lagged relationship between perceived stress and norepinephrine and cortisol levels across all groups. Only women with a PMS pattern demonstrated perceived stress leading epinephrine levels. Cortisol, epinephrine, and norepinephrine levels led symptoms for all groups with one exception: there was no cross-correlation between epinephrine and turmoil for the PMS group. Perceived stress led both types of symptoms, regardless of group, and symptoms also led stress. The results provide evidence for a unique relationship between epinephrine, perceived stress, and symptoms for women with PMS, and for a reciprocal relationship between stress and symptoms for each of the groups.

Fever Applying Research to Bedside Practice

Fever occurs frequently in critically ill patients and requires knowledgeable assessment and treatment by critical care nurses. Fever can result from infection or inflammation and should be differentiated from simple hyperthermia. Although temperature measurement and fever management are not often priorities in the management of a critically ill patient, the physiologic consequences of fever may affect patient morbidity. This article defines and describes fever and its pathophysiology. An evidence-based plan of care for the assessment, planning, intervention, and evaluation of the patient with fever is outlined, using levels of recommendation based on the strength of the available evidence. A case study is presented to illustrate application to clinical practice. Commentary about the case is provided to review the salient points of care.

The Association of CYP2D6 Genotype and Postoperative Nausea and Vomiting in Orthopedic Trauma Patients

The CYP2D6 gene encodes for an enzyme that is involved in the metabolism of more than 25% of all medications, including many opioids and antiemetics. It may contribute to the risk of postoperative nausea and vomiting (PONV), a common surgical complication. However, little research has been conducted in this area. The purpose of this study was to explore the association of CYP2D6 genotypes with PONV in adult surgical trauma patients. Data from 112 patients (28% female) with single extremity fractures, aged 18–70 years, were analyzed. PONV was defined as present if patients reported nausea, were observed vomiting, or received medication for PONV. Saliva samples collected for DNA extraction and Taqman® allele discrimination and quantitative real time polymerase chain reaction (qRT-PCR) were used to collect genotype data that were then used to assign CYP2D6 phenotype classification. The incidence of PONV was 38% in the postanesthesia care unit and increased to 50% when assessed at 48 hr. CYP2D6 classification results were 7 (6%) poor metabolizers, 34 (30%) intermediate metabolizers, and 71 (63%) extensive metabolizers. No ultrarapid metabolizers were identified. Patients who were classified as poor metabolizers had less PONV and higher pain scores. Gender and history of PONV, but not smoking, were also significant risk factors. Findings suggest variability in CYP2D6 impacts susceptibility to PONV.

The effect of administered crystalloid fluid temperature on aural temperature of moderately and severely injured children

OBJECTIVE Warm intravenous fluid (W-IVF) administration is the standard of care to prevent hypothermia in injured adults. It is argued that such administration may not be helpful for treating injured children, because children often do not require as much intravenous fluid (i.v.f.) as adults. The purpose of this study was to compare the effects of W-i.v.f. to room temperature intravenous fluid (RT-i.v.f.) administration on aural temperature (Ta) in injured children during the first hour of trauma resuscitation. DESIGN A randomized, controlled repeated-measures trial. SETTING Emergency department, intensive care unit, and diagnostic areas in a level I pediatric trauma center. SAMPLE Thirty moderately or severely injured children, ranging in age from 2 to 17 years (mean age = 8.9 years; SD = 4.4). METHODS Eligible children were randomly assigned to receive either W-i.v.f. or RT-i.v.f. on ED arrival. Warmed IVF was administered with the Hotline fluid warmer (SIMS Level 1, Rockland, Mass). Aural temperatures were measured on arrival and every 10 minutes for 1 hour with a Core-Check Tympanic Thermometer (IVAC Medical Systems, San Diego, Calif). The level of significance for hypothesis testing was set at 0.05 (two-tailed). RESULTS Groups were comparable in age, gender, weight, amount of infused i.v.f., Revised Trauma Score, room temperature, and baseline Ta. On average, Ta for the W-i.v.f. group increased by 0.25 degree C from baseline to final Ta, whereas Ta for the RT-i.v.f. group decreased by 0.32 degree C from baseline to final Ta. Repeated-measures analysis of covariance, treating baseline Ta as a covariate, demonstrated that Ta response profiles were similar (p = 0.06). CONCLUSIONS When comparing the changes between baseline and final Ta for the W-i.v.f. and RT-i.v.f. groups, the standardized difference in temperature change was 0.62. Although results of the repeated measures analysis of covariance were not statistically significant, the standardized difference in temperature changes was large enough to warrant administration of W-i.v.f., even at slow flow rates, to prevent hypothermia in injured children.

Evaluation of four methods of warming intravenous fluids

OBJECTIVE The purpose of this in vitro study was to compare four methods of warming intravenous fluid (IVF) with a control of unwarmed IVF at flow rates of 200, 400, 600, 800, and 1000 ml/hr. DESIGN A 5 x 5 factorial experimental design was used to evaluate the methods of warming IVF and the control at varied flow rates. METHODS The methods of warming IVF in this study included the following: (1) the Level 1 System 250 fluid warmer with D-60HL tubing (Level 1 Technologies, Inc., Rockland, Mass.); (2) the Level 1 System 250 fluid warmer with D-50 tubing (Level 1 Technologies, Inc.); (3) the Hotline fluid warmer with L-70 tubing (Level 1 Technologies, Inc.); and (4) the Baxter DW 1000 D blood fluid warmer with blood cuff set tubing (Baxter Healthcare Corporation, Valencia, Calif.). The IVF temperatures were measured with thermocouples at three points: (1) in the intravenous solution bag, (2) in the tubing after the infusion pump, and (3) 2 cm proximal to the end of the tubing. Ambient temperature and the temperature at the three measurement points were recorded when the temperature at the point 2 cm proximal to the end of the tubing was stable for 3 minutes. RESULTS With single-lumen tubing, fluids flowing at low rates (e.g., 200 ml/hr) were barely warm at the end of the tubing. In contrast, fluid warmed with triple-lumen technology was consistently kept warm throughout the tubing.

OPRM1 and COMT Gene–Gene Interaction Is Associated With Postoperative Pain and Opioid Consumption After Orthopedic Trauma:

Background: mu-opioid receptor (OPRM1) and catechol-O-methyltransferase (COMT) contribute to the neurotransmission pathway of pain. COMT affects mu receptor expression and density in the brain. The aim of this study was to explore the OPRM1 and COMT interaction effects on postoperative pain and opioid consumption. Methods: This cross-sectional exploratory study used genotype and clinical data from 153 postoperative patients. Using multiple regression analyses, four single-nucleotide polymorphisms of COMT (rs6269, rs4633, rs4818, and rs4680), their haplotypes, and diplotypes were considered for their interactions with A118G of OPRM1 regarding postoperative pain and opioid consumption. Results: For opioid consumption, significant interactions were found between OPRM1 A118G and COMT rs4680 (p = .037) and between OPRM1 and COMT rs4633 (p = .037). Patients having Met158Met of COMT rs4680 and AG/GG of OPRM1 or TT of COMT rs4633 and AG/GG of OPRM1 consumed the largest amount of opioid compared to those having other combinations. For postoperative pain, a significant interaction was found between OPRM1 and the low pain sensitivity (LPS; GCGG) haplotype of COMT (p = .017). For patients with no copies of the LPS haplotype, AA of OPRM1 A118G was significantly associated with higher pain scores compared to the variant AG/GG. However, the opposite direction was observed for patients with at least one copy of the LPS haplotype. Conclusions: The interaction of OPRM1 with COMT may contribute to variability in postoperative pain and opioid consumption. Additional larger studies are needed to confirm findings.

Analgesic Prescription and Administration to Adolescents Admitted to an Adult Versus Pediatric Trauma Center

OBJECTIVETo compare the prescription and administration practices for narcotic and non-narcotic analgesics given to injured adolescents admitted to an adult versus pediatric trauma center. METHODSA retrospective chart review of 45 medical records for documentation of prescribed and administered analgesics in the first 48 hours of hospitalization. RESULTSAdolescents treated at the adult trauma center had significantly more narcotics ordered in the first 24 hours of admission compared to adolescents in the pediatric trauma center. However, when controlling for injury seventy, there was no difference between the narcotic administration at the two trauma centers. There were no differences in the types or numbers of doses of non-narcotic analgesics prescribed or administered. CONCLUSIONThere were no differences in the prescription or administration of narcotic and non-narcotic analgesics to injured adolescents in an adult versus a pediatric trauma center. Future research should focus on the prospective enrollment of injured adolescents at additional trauma centers and a larger sample size to validate or refute these findings.

Accuracy of Temporal Artery Thermometry as an Indicator of Core Body Temperature in Patients Receiving General Anesthesia

Purpose: To evaluate the agreement of temporal artery temperature (Tat) with esophageal temperature (Tes) and oral temperature (Tor), and explore potential factors associated with the level of agreement between the thermometry methods in different clinical settings. Design: A prospective repeated measures (induction, emergence, and postanesthesia care unit) design was used. Methods: Temperature data were collected for 54 patients receiving general anesthesia. Analyses included descriptive statistics, paired t tests for the within‐patient comparison of temperature methods, Bland‐Altman plots to examine agreement between methods, and multiple linear regression to identify factors associated with the agreement between methods. Findings: Tat was significantly higher compared with Tes and Tor (P < .05) and was poor at detecting hypothermia. The use of a muscle relaxant and surgical site were suggested to be associated with the difference between Tat and Tes at emergence. Conclusions: Tat is more convenient, but less accurate, than other thermometry methods. These inaccuracies are exacerbated by common anesthetic medications.

Perianesthesia Measurement During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Procedure: A Case Report and Review of the Literature

Purpose This purpose of this case study and review was to understand perianesthesia care of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy surgery (CRS+HIPEC). Design Case study. Methods The perianesthesiaa medical record of a patient under CRS+HIPEC was analyzed to study the characteristics of perianestheia care for CRS+HIPEC. The literature of perianestheisa care for CRS+HIPEC was reviewed. Findings The challenges that perianesthesia care for CRS+HIPEC include—but are not limited to—electrolyte abnormalities, hemodynamic instabilities, and temperature fluctuation. Optimal perianesthesia management of a patient treated with CRS+HIPEC requires control of a complex interplay of physiologic mechanisms. Conclusions Besides maintenance of clinical and laboratory parameters, and recognition and treatment of any changes, evidenced‐based guidelines are needed, not only for the optimal perianesthesia management of these patients, but also to avoid potential life threatening intraoperative and postoperative complications. The standardization of perianesthesia management for CRS+HIPEC is a necessary step in meeting these goals.

Crisis Team Management in a Scarce Resource Setting: Angkor Hospital for Children in Siem Reap, Cambodia

Introduction A crisis team management (CTM) simulation course was developed by volunteers from Health Volunteers Overseas for physicians and nurses at Angkor Hospital for Children (AHC) in Siem Reap, Cambodia. The framework for the course was adapted from crisis resource management (1, 2), crisis team training (3), and TeamSTEPPs© models (4). The CTM course focused on teaching physicians and nurses on the development of team performance knowledge, skills, and attitudes. Challenges to providing this course at AHC included availability of simulation equipment, cultural differences in learning, and language barriers. The purpose of this project was to evaluate the impact of a CTM simulation course at AHC on attitudes and perceptions of participants on concepts related to team performance. Methods Each of the CTM courses consisted of three lectures, including team performance concepts, communication, and debriefing followed by rotation through four simulation scenarios. The evaluation instrument used to evaluate the AHC CTM course was developed for Cambodian staff at AHC based on TeamSTEPPs© instruments evaluating attitude and perceptions of team performance (5). CTM team performance concepts included in lectures, debriefing sessions, and the evaluation instrument were: team structure, leadership, situation monitoring, mutual support, and communication. The Wilcoxon signed-rank test was used to analyze pre- and post-test paired data from participants in the course. Results Of the 54 participants completing the three CTM courses at AHC, 27 were nurses, 6 were anesthetists, and 21 were physicians. Attitude and perception scores were found to significantly improve (p < 0.05) for team structure, leadership, situation monitoring, and communication. Team performance areas that improved the most were: discussion of team performance, communication, and exchange of information. Conclusion Teaching of non-technical skills can be effective in a setting with scarce resources in a Southeastern Asian country.