A Second Look at the NPO before Surgery Order

The order for NPO after midnight the night before a scheduled surgery is ingrained in all of us no matter when you went to nursing school. The practice began in the 1800s when chloroform was introduced as an anesthetic. The patients receiving chloroform would frequently get nauseous and vomiting was common. Vomiting of course, led to an increased risk of pulmonary aspiration so it became a standard order before surgery.

Since the 1800s and the use of chloroform, our anesthetic practices and the drugs we use have improved greatly. The guidelines of the professional organizations for anesthesiologists and anesthetists acknowledge from studies conducted, that healthy patients who consume clear liquids until 2 hours before surgery are as safe from aspiration and are more comfortable than those patients who are kept NPO.

One of the issues in eating before surgery concerns gastric emptying times. While we do not want a pre-op patient to eat a Thanksgiving dinner before surgery, clear liquids leave the stomach almost immediately. Patients who drink clear liquids a few hours before have lower gastric volume and a similar or higher pH value compared to their NPO counterparts. So, clear liquids may even stimulate gastric emptying and dilute gastric secretions which is safer for the patient in general.

Interesting evidence has also emerged stating that a carbohydrate-rich clear liquid beverage, given 2-3 hours before surgery prevents dehydration, insulin resisitance and other harmful effects of pre-op fasting.

So why the disconnect between evidence and practice? In out litigious society many physicians do not want to take the chance on aspiration, in spite of the evidence. As far as the possible harmful effects of pre-op fasting it is easy to correct with ordering IV fluids. Some think patients would be confused with what constitutes clear liquids, and it would take more time to teach the patients the correct information.

Are these valid reasons to continue an outdated practice? You decide.

What is the current practice where you work?

For more information on the subject see

Preoperative Fasting: Will the Evidence Ever Be Put into Pra… : AJN The American Journal of Nursing.

Let’s Take Another Look at Pain

The word pain is one that everyone has a definition for. Everyone has their own “pain story.” Nurses know a lot about pain. Or do they? Is this an assumption we can make? We all learned in nursing school that pain is the 5th vital sign. It should be assessed every time we assess other vital information about a patient like pulse, respirations and blood pressure. We are all familiar with the definition of McCaffrey, “pain is whatever the experiencing person says it is and exists whenever he says it does.”

Then why is it that we read statistics like:

Nine in ten Americans regularly suffer pain.

One third of Americans suffer moderate to severe pain that limits normal function.

Chronic pain affects at least 116 million American adults. This is more than the total number with heart disease, cancer and diabetes combined.

Chronic pain costs $635 billion in medical treatment and lost productivity yearly.

Pain has become a national challenge and those of us in health care need to be leaders in conquering this challenge.

It is a topic that is frequently discussed in nursing schools and is seen daily in all nursing practices.

Why is it that despite postoperative analgesics,  50% of patients undergoing surgery report inadequate pain relief?

We know a lot about pain but need to know still more.

Do you know the latest evidence-based interventions for the use of opioid analgesia in treating pain? Do you have pain protocols at your place of work? When you do a pain assessment do you use more than a numeric pain scale?

If pain is a subjective experience, we need to assess much more than a pain scale rating.

We all talk about the psychosocial factors of pain but do you take them into consideration when you assess pain in your patients? Do you explore other interventions beside pharmacologic ones?

Do you know more about your patients that just their diagnosis and MAR?

Do you take into consideration other factors that contribute to pain such as stress level, sleeping habits, effects on their ADLs? Does their culture affect how they respond to pain? Are you familiar with non pharmacologic methods of relieving pain? Are you willing to work with your patients and other members of the health care team to get creative in providing pain relief?

The Cochrane review recently published information on single oral analgesics in the treatment of acute postoperative pain. Their findings? Nothing earth-shattering really. They reviewed many meds like NSAIDS, acetaminophen, codeine and oxycodone. All frequently used to control acute pain. what they found was that many of these drugs relieved pain, some better than others. But the important finding was that not all drugs worked with all patients. A single drug that relieved pain in one individual did not relieve pain in another. So what? The importance of this information is that pain relief is not a “one size fits all” and we should not expect to take that approach with our patients. If one medication does not work, we do not throw up our hands and say, “well, we tried.” We try combinations until we find one that works. We better assess other factors contributing to that pain. We get creative to treat this problem.

Start by being more aware of your assessments of your patients in pain. What else can you do besides offer them a pill or an injection?

I will be posting on pain assessment in certain populations and other helpful information to make you safe and effective nurses.

References

Institute of Medicine. June 2011. Relieving Pain in America: A Blueprint for Transforming, Prevention, Care, Education and Research.

Moore, R.Andrew et. al. (9.7.2011) Single dose oral analgesics for acute postoperative pain in adults. Cochrane Database of Systematic Reviews. Issue 9. Article No CD008659.

Proton Pump Inhibitors (PPIs) Part 1

Twenty-five to thirty-five per cent of the American population is affected by GERD. In reality the numbers are probably much higher since many cases go unreported as people self medicate with over the counter (OTC) products.  The most powerful class of drugs to treat GERD is Proton Pump Inhibitors (PPIs).

Consumer Reports (2010) states that PPIs are the third highest selling class of drugs in the United States and the retail sales of Nexium alone reached 4.8 billion dollars in 2008.

Proton pump inhibitors work by blocking acid in the stomach. Why are they so popular? Because they work!

PPIs are used for GERD that does not respond to other therapies, peptic ulcer disease (PUD), erosive esophagitis and short-term GI prophylaxis. However, they are not without side effects and long-term effects.

PPIs are overused. They should not be used for simple heartburn. In dealing with acid reflux, the population needs to be educated on the fact that there are many choices to try before PPIs become necessary. Lifestyle changes such as stress reduction, weight loss, and smoking cessation are key in controlling symptoms in a large number of people. Antacids and H2 blockers should also be tried before resorting to PPIs.

The PPIs include the “prazoles:” esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix) and rabeprazole (Aciphex). All of them are enteric coated and administered orally. Esomeprazole, lansoprazole and pantoprazole, can also be administered IV.

Common Side Effects

GI disturbances; diarrhea, constipation, gas, abdominal pain

Some PPIs can cause dizziness (lansoprazole, omeprazole and rabeprazole)

Long Term Effects 

PPIs are meant to be used on a short-term basis.

The Food and Drug Administration recommends OTC use of PPIs for 14 days, up to three times a year.

When PPIs are used for longer than 1 year the following can occur:

Hypomagnesemia

• In 25% of the cases of pts who developed hypomagnesemia magnesium supplements did not help and the PPI needed to be discontinued

An increased risk of osteoporosis and fractures

• The reason for this is unclear.

An increased risk of C Difficile infections

• Remember the acid environment in the GI tract protect against the multiplication of bacteria

Interactions

Too little effect

• PPIs can reduce the effectiveness of Clopidogrel (Plavix), which has grave implications for anyone with heart disease

My next post will continue the discussion of PPIs with nursing responsibilities and teaching implications.

Sentinel Events

The Joint Commission is a not-for-profit national organization that accredits more than 19,000 health care institutions in the United States.  Their mission is

“To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” (Joint Commission, 2011)

Joint Commission accreditation is an indication that the organization that gets accredited by The Joint Commission (TJC) is committed to high quality health care and proves it by meeting performance standards.

The Joint Commission accredits all areas where nurses practice: ambulatory care, acute and long term facilities, hospitals, homecare and behavioral health care.

Learn more about the Joint Commission  at  www.jointcommission.org

The Joint Commission establishes National Patient Safety Goals (NPSG) for each of the areas they accredit. To read more about NPSG  click here.

As part of their mission TJC reviews and follows up on an institution’s sentinel event. A sentinel event as defined by TJC is “an unexpected occurrence involving death or a serious physical or psychological injury or the risk thereof.” In other words a sentinel event is when something really bad happens that could have been avoided.

Some examples of sentinel events are; suicide of a patient within the institution. an infant abduction from the institution, a hemolytic blood transfusion reaction, wrong site surgery or some cases of aspiration pneumonia.

When a sentinel event occurs the institution is required to submit a Root Cause Analysis (RCA) and action plan to TJC within 45 days of the event or the discovery of the event.

A RCA looks at the reasons for the failure or inefficiency of the processes that contributed to the event. It DOES NOT look at individuals, but on the policies and procedures in place to see if they could be improved in order to prevent this event from happening in the future. The action plan is the strategies an organization will put into place to ensure this sentinel event is not repeated.

Many nurses who orient to a new job or as a new graduate are exposed to reams of paper work on a variety of subjects that are boring and inundating. Their thoughts are “Just let me take care of patients!” Unfortunately, the organization will make you sign a document stating you received all of the paper work and that you are responsible for all of the information contained in it. Many nurses sign this without a second thought, throw the paper work away and continue to go on with “taking care of patients.” There is no need to think about it again until something happens and you are involved in a sentinel event.  You state, “I never knew I had to do that.” And the organizations risk management department will say, “You were told that information at orientation and we have a signed document that proves it.”

I am not trying to scare you but the medical environment is also a legal environment and you ARE responsible for knowing your institution’s policies and procedures.

To this end, I will be discussing some examples of sentinel events and how you as a nurse can protect yourself from litigation from them.

In my next post I will be discussing a topic that is frequently seen in nursing practice, is not emphasized in nursing school and in which a theory to practice gap exists; how to check placement of an NG tube. Stay tuned.