Alfentanil

Patient-controlled sedation for colonoscopy

Hong Kong Medical Journal April 2004

Patient-controlled sedation (PCS) is rapidly becoming accepted as an alternative sedation method for colonoscopy. In this technique, a bolus of the sedative agent is delivered from a syringe pump in response to the press of a button. The patient self-administers the sedative to the point at which he or she is satisfied with the level of sedation. The purpose of this prospective study was to assess the safety, feasibility, and acceptability of PCS in a large group of patients undergoing colonoscopy. (1)

Five hundred patients undergoing colonoscopy at a university-affiliated endoscopy center in Hong Kong were recruited for this study. Sedation was delivered by means of a patient-controlled syringe pump that contained a mixture of propofol and alfentanil. Patients were instructed on how to use the hand-held button before the procedure. Vital signs, including pulse rate, oxygen saturation, and blood pressure were monitored and recorded throughout the procedure and recovery period.

After the patient was fully conscious and oriented, a questionnaire to assess patient satisfaction was administered by the postanesthesia care unit nurse. Additionally, 24 to 48 hours after the procedure, patients were contacted by telephone to determine whether they had experienced any delayed side effects, whether they were satisfied with this method of sedation, and whether they would be willing to use PCS as their sedation method for future colonoscopy procedures. Satisfaction was scored on a 10-cm visual analog scale, with zero indicating "not satisfied" and 10 indicating "very satisfied." Summary statistics, including means, standard deviations, and Chi square tests, were used to analyze the variables.

Findings. The mean dose of propofol used was 0.93 mg/kg. Forty-three patients (8.6%) developed hypotension during the procedure, five patients required supplemental IV fluid, and two patients required cessation of PCS. The remainder had transient hypotension that did not require further treatment. Sixteen patients (3.2%) developed delayed side effects. The mean satisfaction score was high (ie, 7.2). Approximately 78% of the patients said they would be willing to use PCS as their sedation method for future colonoscopy.

Clinical implications. The results of this study indicate that the use of PCS for colonoscopy is safe, feasible, and acceptable to a majority of patients. Perioperative nurses should be prepared for PCS use to increase and should ensure that the required patient monitoring procedures are performed consistently.

Effect of increased inspired oxygen concentration on surgical site infection

JAMA January 2004

Surgical site infection (SSI), the second most frequently reported type of health care-associated infection, continues to be an important public health concern. Destruction of bacteria by oxidation (ie, oxidative killing) is a viable process to control bacteria that are involved in the development of SSIs. Oxidative killing depends on the oxygen tension in contaminated tissue. Increasing the oxygen tension can be achieved by increasing the fraction of inspired oxygen (FI[0.sub.2]) (ie, by providing supplemental oxygen to the patient). The purpose of this double blind, randomized study was to determine the effect of routine use of high FI[0.sub.2] during the perioperative period on the incidence of SSI in a general surgical population. (2)

Patients undergoing major intra-abdominal surgical procedures under general anesthesia were assigned randomly to one of two groups. Participants in group I received 80% oxygen (ie, FI[0.sub.2] of 0.8) and participants in group II received 35% oxygen (ie, FI[0.sub.2] of 0.35) during surgery and for the first two hours after surgery. The presence of an SSI in the first 14 days after surgery was noted. Standard statistical techniques, including multivariate regression analysis, were used to distinguish differences between the two groups.

Findings. Analysis was completed on data from 160 patients. Overall, 29 patients developed SSI for a rate of 18.1%. Twenty patients (25%) in group I developed SSI versus nine patients in group II (11.3%). The rate of SSI was significantly higher in group I (P = .02). The odds ratio for the two groups was 2.63 (95% confidence interval, 1.1-6.2). The results of multivariate logistic regression analysis showed that FI[0.sub.2] was a predictor of SSI.

Clinical implications. This study yielded unexpected results. Administration of FI[0.sub.2] 0.8 during the perioperative period resulted in a doubling of the SSI rate in patients undergoing a variety of major abdominal procedures. Results of this study, therefore, do not support the routine use of a high FI[0.sub.2] to reduce the incidence of SSI in patients undergoing major abdominal surgery. Perioperative nurses should be aware, however, that supplemental oxygen during the perioperative period may benefit certain patients, and they should be prepared to assist members of the surgical team in implementing the use of supplemental oxygen when necessary.

Communication styles and patient compliance

American Journal of Health Studies April-September 2003

Patient noncompliance with health care recommendations is a serious problem. A health care provider's communication style has the potential to significantly improve compliance, and consequently, patient satisfaction. The purpose of this study was to determine the best communication strategy that both male and female health care providers can use to elicit the greatest patient compliance and satisfaction. (3)

One hundred eighty undergraduate students at a large western university were each asked to read one of six different scenarios of a dialogue between a health care provider and patient. Each scenario presented the use of one type of communication style for an initial visit and use of a second communication style on a subsequent visit in response to a patient's admitted noncompliance with health care recommendations. Communication strategies included positive regard (ie, indicating approval of another's actions), negative regard (ie, indicating disapproval), and neutral regard (ie, simply providing directives for action). The combinations included in the scenarios were positive/negative, neutral/negative, and positive/neutral.

In three scenarios, the health care provider was female, and in the other three scenarios, the health care provider was male. The researchers hypothesized that participants would react differently to communication style depending on whether the provider was male or female because gender stereotypes lead participants to expect more positive communication styles from women and more negative or neutral communication styles from men.

The participants were told to imagine themselves as the patient and were asked to complete a questionnaire eliciting their level of compliance and satisfaction. Analysis of variance statistical techniques were used to analyze the variables.

Findings. There was no difference in the observers' perception of the likelihood of patient compliance based on the gender of the provider when positive regard followed by negative regard or positive regard followed by neutral regard was used. Multivariate analysis revealed that patient satisfaction was significantly higher for the use of a positive/negative regard strategy combination over all other combinations when used by both male and female providers (P < .001).

Clinical implications. This study indicates that patients were most satisfied when. either a male or female health care provider used a combination of positive regard on an initial visit and negative regard after the patient admitted noncompliance. This suggests that patients may expect to be reprimanded for noncompliance and may be more satisfied with care when providers react to noncompliance with negative regard. The change from positive to negative regard may indicate to a patient that the provider is concerned and takes the patient's health seriously. Perioperative nurses should consider incorporating these communication strategies into their interactions with patients.

Surgical site infection with Pseudomonas aeruginosa

Injection Control and Hospital Epidemiology October 2003

Contamination from exogenous flora, particularly from the hands of caregivers, is one of the mechanisms involved in the development of SSI. Surgical site infection at the chest site after cardiac surgery most often involves grampositive bacteria, such as staphylococci, and less frequently involves gramnegative bacteria, such as pseudomonas. The purpose of this study was to determine the cause of an outbreak of SSI with Pseudomonas aeruginosa after cardiac surgery. (4)

Surveillance data were reviewed for patients who underwent a cardiac surgical procedure at a tertiary care, university teaching hospital from 1999 to 2001. Health care workers who were present during cardiac surgery procedures were examined, and their fingernails were cultured. Environmental surface cultures were obtained from the OR and equipment used in the cardiac procedures, and heating, ventilation, and air conditioning records were reviewed. Pulse-field gel electrophoresis was performed to compare isolates recovered from patients with those recovered from staff members. A case of SSI was defined as any patient who developed an SSI with Pseudomonas aeruginosa after cardiac surgery.

Findings. There were no cases of SSI with Pseudomonas aeruginosa from 1999 to 2000. Between January and August 2001, there were five cases of SSI with Pseudomonas aeruginosa. Thirty-three environmental cultures from numerous sites, including a thermogenesis machine, a slush solution, a brush used to clean cardiac instruments, a rubber instrument tray liner, an ice machine, hand lotion in the substerile room, and perfusion machine fluid, all were negative for pseudomonas.

Two cardiac surgeons, one physician assistant, one surgical technologist, and one perioperative nurse were involved with two or more of the five patients who developed SSIs. A cardiac surgeon who was involved in each of the five cases was found to have advanced onychomycosis of the thumbnail. Cultures of the thumbnail grew Pseudomonas aeruginosa. Molecular subtyping with pulse-field gel electrophoresis revealed that isolates recovered from two of the patients with SSI who were available for testing were identical to isolates from the surgeon.

Clinical implications. The results of this study suggest that colonized onychomycotic nails may serve as an infection reservoir and lead to transmission of infection. Perioperative nurses and all members of the perioperative team must be mindful of their primary responsibility--patient safety. They should adequately cover any hand lesions and seek medical evaluation for any lesion that persists longer than three weeks. Double gloving also is appropriate to help prevent infection transmission.

GEORGE ALLEN

RN, PHD, CNOR, CIC

DIRECTOR OF INFECTION CONTROL

DOWNSTATE MEDICAL CENTER

BROOKLYN, NY

NOTES

(1.) D W Lee et al, "The safety, feasibility, and acceptability of patient-controlled sedation for colonoscopy: Prospective study," Hong Kong Medical Journal 10 (April 2004) 84-88.

(2.) K O Pryor et al, "Surgical site infection and the routine use of perioperative hyperoxia in a general surgical population," JAMA 291 (Jan 7, 2004) 79-87.

(3.) C J Cropley, "The effect of health care provider persuasive strategy on patient compliance and satisfaction, American Journal of Health Studies 18 no 2/3 (2003) 117-125.

(4.) L A Mermel et al, "Pseudomonas surgical-site infections linked to a healthcare worker with onychomycosis," Infection Control and Hospital Epidemiology 24 (October 2003) 749-752.

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