MULTIPLE CASE STUDY : PRE-ANESTHESIA ASSESSMENT IN AMBULATORY ANESTHESIA PATIENTS

The incidence of perioperative adverse events in children aged 0 to 15 years was 5.2%. Preoperative scientific and accurate anesthesia assessment is a crucial step in ensuring the safety of pediatric surgery. Perioperative risk prediction is a digital quantitative evaluation of the level of perioperative risk, which classifies the degree of danger. In order to further standardize the methods of anesthesia assessment and identify risk factors, Chinese Society of Anesthesiology organized experts in anesthesiology from children's specialty hospitals and general hospitals, along with statisticians from public health colleges, to jointly draft the "Chinese expert consensus on pediatric anesthesia assessment and perioperative risk prediction (2024 edition)".The anesthesia assessment includes history collection, physical examination, laboratory examination, American Society of Anesthesiologists physical status, difficult airway assessment, and identification and assessment of critically sick children. Perioperative risk prediction includes preoperative anxiety, perioperative respiratory adverse events, regurgitation and aspiration, emergence delirium, postoperative nausea and vomiting, postoperative ICU admission, postoperative acute kidney injury, perioperative mortality, and risk prediction for in-hospital mortality in children with congenital heart disease undergoing non-cardiac surgery.This consensus has formulated a total of 16 recommendations, aiming to promote anesthesiologists' familiarity with the content of pediatric anesthesia assessment, identify risk factors for adverse events during the perioperative period, and take targeted measures to reduce the occurrence of adverse events and improve the safety of children during the perioperative period.

Introduction: Birt-Hogg-Dubé syndrome (BHD), is a rare inherited autosomal dominant disorder characterized by skin fibrofolliculomas, pulmonary cysts, spontaneous pneumothorax, and renal tumors, caused by germline mutations in the FLCN gene, which encodes folliculin. BHD has no sex predilection and tends to manifest in the third or fourth decade of life. A family history of pneumothorax is an important clue, along with physical exam and unique imaging findings. This case discusses an individual who had multiple criteria required to diagnosis BHD but had a hindrance in treatment due to its delayed diagnosis. Case presentation: A 43-year-old female with a past medical history of obstructive sleep apnea (not on CPAP), active smoker (∼20 pack year), and recurrent spontaneous pneumothoraces (three prior since 2022, some requiring chest tube insertion) presented for dyspnea. Chest xray revealed a small right apical pneumothorax. She was alert and oriented, SpO2 96% on room air, respiratory rate 12, heart rate 80 bpm, blood pressure 147/82 mmHg, and afebrile. White blood cell count was 12,320 with lymphocyte predominant differential. Physical exam was notable for facial fibrofolliculoma. Review of CT scan exhibited diffuse cystic lung disease with a basilar predominant pattern, subpleural cysts, and renal cysts. Upon further questioning regarding family history, she eluded her sisters and aunt had Birt Hogg Dube syndrome. Due to the patient being clinically stable with a small pneumothorax, she was placed on a non-rebreather mask for nitrogen washout therapy and chest xray the following day showed resolution. She was encouraged to follow up with interventional pulmonary for possibility of pleurodesis and to obtain genetic testing for FLCN gene. Discussion: The prevalence of BHD is about two cases per million, although this may be underestimated. Menko, et al (2009) published diagnostic criteria for BHD, of which this patient met two minor criteria. While she is still pending genetic and histopathologic testing, it is important to note that negative FLCN gene testing does not exclude the diagnosis, as up to 40% of patients with negative testing still meet diagnostic criteria. Imaging includes bilateral pulmonary cysts with a basilar predominance, +/- pneumothorax, and bilateral renal cysts with a high tendency of becoming malignant. Unlike other cystic lung diseases, BHD usually does not lead to progressive loss of lung function. It is crucial to keep BHD in the differential when evaluating patients with cystic lung disease and a strong family history of pneumothoraces.

Mortality and morbidity in ambulatory surgery are rare, and thus the patient's quality of life (i.e., the ability to resume normal activities after discharge home) should be considered one of the principle end-points after ambulatory surgery and anesthesia. We conducted a systematic review of the instruments to measure the quality of recovery of ambulatory surgical patients in order to advise on the selection of appropriate measures for research and quality assurance. A systematic literature search of MEDLINE, EMBASE, CINAHL, HAPI, PsycINFO, Web of Science Search History, Biosys Previews Search, HealthStar, and ASSIA was performed to identify patient-based outcome measures to assess postoperative recovery from ambulatory anesthesia. The instruments were assessed for eight criteria: appropriateness, reliability, validity, responsiveness, precision, interpretability, acceptability, and feasibility. Seven articles met the inclusion criteria set for the review. The quality of the identified instruments was variable. Only one instrument, 40-item Quality of recovery score, fulfilled all eight criteria, however this instrument was not specifically designed for ambulatory surgery and anesthesia.

Introduction: Most bacterial brain abscesses are a result of direct spread of bacteria, only a third are through hematogenous dissemination. A less common cause of hematogenous spread is via paradoxical embolism in the presence of a pulmonary arteriovenous malformation (PAVM). Currently PAVMs are not routinely screened for. Description: A 51-year-old male with past medical history of obstructive sleep apnea, and transient ischemic attack presented with left sided weakness. Initial CT head was concerning for subacute stroke. Patient’s physical exam was significant for 2/5 strength in left upper extremity, oral mucosa and skin findings were negative for telangiectasias. No significant family history reported. Initial white count negative. Worsening left sided numbness led to a repeat CT head which showed a 1.5 cm right posterior frontal/anterior mass lesion with surrounding edema. Patient underwent biopsy and drainage of brain abscess on hospital day 4, intraoperative pus was encountered. Patient was treated with ceftriaxone, metronidazole, and vancomycin. Cultures grew Actinomyces meyeri. On hospital day 8 a CT angiogram showed a PAVM in the medial middle lobe. Patient underwent right pulmonary artery angiogram on hospital day 12 which showed that the PAVM was fed by a branch of the right middle lobe pulmonary artery. After embolization follow-up angiogram showed cessation of flow through the PAVM. An MRI showed significantly less brain swelling around the cavity, based off the patient’s clinical and laboratory improvements patient was deemed stable for discharge to rehab facility on IV antibiotics. Discussion: A PAVM typically consists of afferent flow from a branch of the pulmonary artery to a branch of the pulmonary vein. Serious outcomes including strokes, seizures, and brain abscesses can arise from the right-to-left shunting of blood and paradoxical emboli. Most PAVMs are congenital associated with hereditary hemorrhagic telangiectasia, however, sporadic ones occur. Infections caused by Actinomyces are thought to induce hyperplastic changes in bronchial arteries which might lead to PAVMs. A PAVM should be considered in patients with a bacterial brain abscess and no identifiable site of infection. Treatment for PAVM include endovascular embolization vs thoracic surgery for removal.

GASTRIC ADENOCARCINOMA MASQUERADING AS CHRONIC COUGH

The objective of this study was to evaluate prognostic models for quality assurance purposes in predicting automatically detected intraoperative cardiovascular events (CVE) in 58458 patients undergoing noncardiac surgery. To this end, we assessed the performance of two established models for risk assessment in anesthesia, the Revised Cardiac Risk Index (RCRI) and the ASA physical status classification. We then developed two new models. CVEs were detected from the database of an electronic anesthesia record-keeping system. Logistic regression was used to build a complex and a simple predictive model. Performance of the prognostic models was assessed using analysis of discrimination and calibration. In 5249 patients (17.8%) of the evaluation (n = 29437) and 5031 patients (17.3%) of the validation cohorts (n = 29021), a minimum of one CVE was detected. CVEs were associated with significantly more frequent hospital mortality (2.1% versus 1.0%; P < 0.01). The new models demonstrated good discriminative power, with an area under the receiver operating characteristic curve (AUC) of 0.709 and 0.707 respectively. Discrimination of the ASA classification (AUC 0.647) and the RCRI (AUC 0.620) were less. Neither the two new models nor ASA classification nor the RCRI showed acceptable calibration. ASA classification and the RCRI alone both proved unsuitable for the prediction of intraoperative CVEs. The objective of this study was to evaluate prognostic models for quality assurance purposes to predict the occurrence of automatically detected intraoperative cardiovascular events in 58,458 patients undergoing noncardiac surgery. Two newly developed models showed good discrimination but, because of reduced calibration, their clinical use is limited. The ASA physical status classification and the Revised Cardiac Risk Index are unsuitable for the prediction of intraoperative cardiovascular events.

Spinal anesthesia is an old, simple, and popular anesthetic technique, yet much remains unknown regarding pertinent anatomy, physiology, and pharmacology. Investigations into physiologic effects of spinal anesthesia reveal complex actions on multiple organ systems. New local anesthetics, analgesic additives, and techniques are being investigated for different applications as the practice of medicine focuses on outpatient care. Safety of spinal agents and complications from spinal anesthesia continue to be examined and re-examined to improve safety. Further study will be needed to fully resolve these issues and to further understand and improve the clinical use of spinal anesthesia.

Anesthesia services are part of perioperative services that have a major influence in determining the success of adequate surgical procedures and avoiding the risk of anesthetic injury to patients. Anesthesia providers in carrying out their professional practices are authorized to provide anesthesia care services in pre-anesthetic assessments. To determine the implementation of pre-anesthetic assessments in patients with general anesthesia in the Central Surgery Installation Room of Buleleng District Hospital. This study used a qualitative research design, and a Multiple Case Study research method with a Descriptive approach. The number of participants in this study was 2 participants who met the inclusion criteria. Data collection tools used interview checklists, Observation sheets, and Pre-Anesthesia Assessment Implementation Documentation sheets. The results of this study on the examination of the participant's anamnesis carried out an assessment using the Foundational Four and Sacred Seven, on the physical examination the participant did not carry out BMI and peripheral nerve disorders. And in the pre-anesthesia documentation, the participant wrote the assessment results on the documentation sheet during the operation and post-operation. The anesthesia technician in carrying out the assessment of the patient's anamnesis, reviewing the physical examination, supporting examination and the patient's psychology almost in accordance with the applicable SOP, except for the examination of BMI, peripheral nerve disorders, providing therapeutic greetings at the end of the procedure and in documenting the procedure did not comply with the applicable SOP, this was due to the short time during pre-anesthesia.

Clipping vs. coiling in acute aneurysmal subarachnoid haemorrhage: Should the patient's medical condition influence treatment modality?

Unstable angina pectoris or angina sitting is a chronic syndrome in which the client gets a typical attack of left chest pain, which is like being pressed or stabbed. Based on data from the World Health Organization (WHO) in 2015, it showed that as many as 17.5 billion people in the world died from cardiovascular disease. Indonesia ranks fourth as the country with the highest number of deaths from cardiovascular disease. The main symptom that often appears is chest pain, and one of the non-pharmacological techniques that can be used to reduce pain is non-pharmacological foot massage. The objective of this study is to present care with foot massage technical interventions to overcome chest pain scales and pain scale measurement tools using the Numerical Rating Scale (NRS) for unstable Angina Pectoris clients with acute pain in the Memory Room of the Banjar City Hospital. The research design method used is descriptive analysis with a case study approach. Subjects in this case study were adult patients who experienced unstable angina pectoris with acute pain problems. Data collection techniques include interviews, observation, physical examination, and documentation studies. Result The results of the case study at the assessment stage found that the client complained of chest pain. The intervention and implementation used to reduce chest pain is giving foot massage techniques for 60 minutes when chest pain complaints occur. After the intervention, the client's pain scale decreased from 4 (0–10) to 1 (0–10), while subjective data from anamnesis showed that the client said chest pain had decreased. Conclusion The conclusion of nursing care for patients who experience unstable angina pectoris with chest pain problems is well resolved. Intervention with foot massage technique is effective against pain scale.

Review objectives The specific review objectives are: To synthesize the evidence on the impact of nurse-led pre-operative assessment clinic for elective orthopaedic patients on health service outcomes, including cancellation or delay of surgery, length of hospital stay and waiting time for pre-operative assessment and surgery. To examine the effectiveness of nurse-led pre-operative assessment clinic on orthopaedic patient outcomes such as levels of satisfaction with the process of pre-operative assessment, incidence of post-operative complications, post-operative recovery, as well as levels of fear and anxiety before surgery. Inclusion criteria Types of participants: This review will consider all studies that included adult patients who were 18 years old or above, required elective orthopaedic surgeries e.g. total knee replacement, total hip replacement, reduction of fracture or procedure of arthroscopy etc in hospitals or day surgery centers, and had attended a nurse-led POAC. Adult elective orthopaedic surgical patients within the American Society of Anesthesiologist (ASA) Physical Status Classification of 1 or 2 will be eligible for inclusion in the review. ASA classification 1 patients are considered to be healthy and normal, and ASA classification 2 patients are patients with mild systemic disease such as mild asthma, well-controlled hypertension, or well-controlled diabetes. Studies will be excluded: - if the participants had received emergency orthropaedic surgery. - if they were primitively related to preoperative teaching or education. Types of interventions: The review will consider studies that evaluate the effectiveness of attending a nurse-led POAC for elective orthopaedic surgery. A POAC is defined as a clinic that provides a general medical and anaesthetic pre-operative assessment includes history taking, health assessment and physical examination. Routine investigations such as laboratory and blood tests may be carried out. Referral to specialists before surgery work-up and health education will also be provided. Patients would attend a POAC 2 to 4 weeks prior to the scheduled elective orthopaedic surgery. The nurse-led POAC could be solely run by nurses, or nurses worked collaboratively with physicians.TRUNCATED AT 350 WORDS

A hybrid hierarchical decision support system for cardiac surgical intensive care patients. Part II. Clinical implementation and evaluation

Introduction: Thalassemia can cause major health problems in children and adversely affect their quality of life, which includes reduced physical, psychological, social, and educational functioning. A family empowerment program is a process or effort to increase the knowledge and willingness of families to maintain and improve the Quality Of Life of children with thalassemia Objective: The purpose of this case study is to carry out nursing care for children with thalassemia and quality of life problems with the Family Empowerment Program (FEP) approach. Method: The method used is descriptive-qualitative with a case study approach. As well as pre-test intervention and post-test intervention. Nursing care was carried out with the author for three days and the family intervened using the Family Empowerment Program (FEP) approach for three weeks. The subject of this case study is a thalassemia child with poor quality of life. Data collection techniques include interviews, observation, physical examination, and documentation. Results: The results of the case study at the assessment stage found that An.S. had problems in the dimensions of social function and school function due to complex or long-term treatment or treatment programs and unsatisfactory interpersonal interactions. Intervention and implementation used in An.S. are using family empowerment with the Family Empowerment Program (FEP) approach. Conclusion: The conclusion of nursing care in children with thalassemia was that during the intervention of three meetings, there were few changes that were positive for the family and the client in handling social function and school function. After the intervention of the Family Empowerment Program (FEP) approach for three weeks, the results of filling out the PedsQL questionnaire show that the dimensions of physical function are good (90.6), the dimensions of emotional function are good (95), the dimensions of social function are good (80) and the dimensions of school function are good (85).

Preface. Acknowledgments. CHAPTER 1 Introduction. Themes. Case Study: A CFO's Dilemma. CHAPTER 2 Why Are Ethics Critical? What Is the Objective? The Research. Stakeholder Approach. All Animals Are Equal, but ... A Two-Way Street. Uncle Sam. Toward a Workable Model. CHAPTER 3 Why Ethics Is Not Just about Corporations. Case Study: The Duke University Lacrosse Scandal. 20/20 Hindsight. The Burden of Expectations. Case Study: The United Way. A Broad Impact. CHAPTER 4 A Historical Review. The Ancient World. Greek Citizens' Code. Military Codes. Cardinal Virtues and Vices. Business Ethics in Times Past. Timbuktu. Case Study: Saint Thomas Aquinas. Case Study: Arthur Andersen. The Nature of Man. CHAPTER 5 Why Do People Behave Badly? Moral Development. Fraud Triangle. Propensity. Hierarchy of Needs. Case Study: Walt Pavlo. There but for the Grace of God. Broken Windows. Rending Moral Fabric. CHAPTER 6 Work Environment and Group Dynamics. Social Animals. Relative Ethics. Social Control Theory. Case Study: The Stanford Prison Experiment. Elements of Social Bonding. Case Study: The Milgram Experiment. Power, Authority, and Proximity. Positive Peer Pressure. CHAPTER 7 Leadership. Tone at the Top. Authenticity. Case Study: Vaclav Havel. Outside Perspectives. Case Study: The Smithsonian Institution. Leadership Bonding. CHAPTER 8 The Common Element-Trust. Prisoners' Dilemma. Trust. The Cost of Trust. Case Study: The Tylenol Poisonings. A Well of Goodwill. Case Study: Firestone-Ford Tire Recalls. Two Approaches. CHAPTER 9 Building an Army of Davids. Herding Cats. 1 Samuel 17. Breaking the Chains. Basic Principles. Evangelize. Case Study: Jordan's Furniture. Back to Maslow. Moral Hazard. Causes and Culture. CHAPTER 10 The Positive Power of Peer Pressure. The Gentleman at Dinner. Belief. I Fly SWA. Attachment. Commitment. Involvement. In the Trenches. Why Are We Doing This? The Whole Picture. CHAPTER 11 How to Develop Leadership. Fore! Case Study: Whirlpool and Leadership Development. Investing in the Future. Emerging Leaders. A Bias. CHAPTER 12 The Logic of William of Ockham. Law of Parsimony. Is It the Means or the Ends? The Whole View. All Organizations Are Businesses. Case Study: University versus Nation. All about Me. Case Study: Charles Ponzi and His Scheme. Enjoying the Kool-Aid. CEO and Trust. Feeding the Wolf. Index.

Background: Nursing theories provide structured frameworks that guide practice and enhance care quality. The Betty Neuman Systems Model, widely utilized in the care of patients with chronic diseases, adopts a holistic approach by addressing various dimensions of a patient's health. Therefore, this study aims to apply the model in the nursing care of a patient with breast cancer. Methods: This case study, conducted in Iran in 2021, involved a 47-year-old breast cancer patient selected through purposive sampling. Data were collected via interviews, medical records, and physical examinations. Using the Betty Neuman Systems Model, the interactions among five key variables—physiological, psychological sociocultural, developmental, and spiritual—were assessed, and intra-, inter-, and extra-personal stressors, along with the patient's reactions, were identified. This, in turn, informed the formulation of nursing diagnoses and the development of a comprehensive care plan, which included goals, targeted interventions across three levels of prevention, and outcomes. Results: Analysis of the five variables and stressors resulted in 13 nursing diagnoses, including 8 actual and 5 risk diagnoses. The model's evaluation of the nursing care plan indicated positive outcomes for the patient. Conclusion: This study demonstrated the practical application of the Betty Neuman Systems Model in developing a personalized nursing care plan for a breast cancer patient. The findings highlight the model utility in addressing patients' holistic needs and provide practical insights for oncology nursing practice.