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Aromatherapy's effect on postoperative nausea; intravenous lidocaine; ignition of drape material; rofecoxib
SEPTEMBER 2004, VOL 80, NO 3
E V I D E N C E
Evidence for Practice
FOR
PRACTICE
Aromatherapy‘s effect on postoperative nausea; intravenous lidocaine; ignition of drape material; rofecoxib
Aromatherapy as treatment for nausea Journal of PeriAnesthesia Nursing
February 2004 The significance of postoperative nausea, an adverse event that commonly occurs after surgery under anesthesia, generally is underestimated because it is self-limited, never becomes chronic, and almost never results in mortality. Postoperative nausea may be very distressing for patients, however, and after ambulatory procedures, it may lead to unanticipated hospital admission. The purpose of this randomized, double-blind, placebocontrolled study was to determine if aromatherapy with peppermint oil or isopropyl alcohol is effective in treating patients who develop nausea after outpatient surgery.’ Adult patients scheduled for ambulatory surgery were invited to participate. Thirty-three patients who spontaneously reported nausea in the postanesthesia care unit (PACU)were enrolled in the study. The severity of nausea was determined using a visual analogue scale (VAS) that consisted of a 100-mm line ranging from “no nausea” on one end to “worst possible nausea” on the other. Patients were randomly assigned to receive aromatherapy with either isopropyl alcohol, oil of peppermint, or saline (ie, placebo). Scented gauze pads were placed directly beneath the patients’ nostrils, and they were instructed to take three slow, deep breaths, inhaling the vapors through their noses and exhaling through their mouths. Presence and level of nausea were assessed using the VAS two and five minutes after aromatherapy. Just before discharge to home, patients
572
AORN JOURNAL
were asked to rate their overall satisfaction with the management of nausea using another VAS on which 0 mm equaled extremely dissatisfied and 100 mm equaled fully satisfied. Common statistical techniques, including Chi square analysis, were used to analyze differences. Findings. Overall nausea scores on the VAS decreased significantly, from 60 mm before aromatherapy to 43.1 mm two minutes after aromatherapy ( P < .005) and 28 mm five minutes after aromatherapy. Nausea scores did not differ among the treatment groups at any time, and 52% of the patients required conventional antiemetic therapy during their PACU stay. Patients’ overall satisfaction with nausea management was high (ie, 86.9 mm on the VAS), and regression analysis revealed a significant correlation between the decrease in nausea scores five minutes after initial aromatherapy and patients’ overall satisfaction (r2= .17, P = .028). Clinical implications. The results of this study suggest that the antiemetic effect of aromatherapy may not be related to the aroma itself but to the act of consciously controlling the patient’s breathing pattern. Perioperative nurses should consider using this relatively easy, inexpensive intervention as an initial response when patients complain of nausea in the PACU.
Peri o perative intravenous lidocaine for pain control Anesthesia and Analgesia April 2004
Controlling postoperative pain allows patients to return to normal function sooner after surgery and decreases the incidence of pneumonia
George Allen, RN
This information is intended for general use only. The clinical implicotiom are specific to the abstracted article only. Individuals intending to put these findings into practice are strongly encouraged to review the original article to determine its applicability to their setting.
SEPTEMBER 2004, VOL 80, NO 3
Evidence for Practice
and other complications. Consequently, ensuring patients’ comfort by reducing the level and intensity of pain they experience after a surgical procedure is a primary goal of perioperative personnel. The purpose of tlus prospective, double-blind, randomized study was to determine the effect of systemic lidocaine on morphine consumption in the postoperative period.2 Forty patients undergoing major abdominal surgery were randomly assigned to one of two groups. The study group received an intravenous infusion of 2% lidocaine 30 minutes before skin incision. The control group received intravenous saline. Infusion was stopped 60 minutes after the end of the surgical procedure. Postoperative pain was assessed using a VAS that ranged from zero to 10, with zero denoting “no pain” and 10 denoting “worst imaginable pain.” Morphine consumption by patientcontrolled analgesia was assessed up to 72 hours after surgery. Standard statistical techniques, including Student’s f test and the MannWhitney U test, were used to determine differences between the two groups. Findings. Use of morphine during the 72-hour observation period was significantly lower in the study group ( P = .05).Patients who received lidocaine reported less pain during movement and needed less morphme during the first 72 hours after surgery (103.1k
72 mg versus 159 f 73.3 mg; Student’s f test P < .05). The control group exhibited significantly more pain during movement, especially during the second and third 24-hour postoperative periods ( P < .05), and their pain intensities exceeded four on the VAS. Clinical implications. This study revealed that systemic lidocaine used perioperatively reduced patients’ postoperative pain and morphine consumption. Perioperative nurses should be prepared for the administration of IV 2% lidocaine 30 minutes before an incision is made by having it readily available in the unit.
Laser ignition of surgical drape materials Anesthesiology May 2004
Fire in an OR is a devastating occurrence for both patients and health care providers. Three elements-xygen, fuel, and an ignition source-must be available for a fire to start. All three elements are readily available in O h , so preventing fires is a high priority for perioperative personnel. The purpose of this study was to determine the time to ignition of currently used surgical drape materials.’ Materials currently being used in the OR, including nonwoven cellulose/polyester blend surgical drape; polypropylene surgical drape;
reusable woven cotton/ polyester blend surgical drape; huck towel; and an experimental fabric (ie, phenol polymer drape); were tested in air and in 50% and 95% oxygen to determine time to ignition. A carbon dioxide laser was used as the ignition source. Materials that were not penetrated by the laser were retested with a piece of filter paper stapled in front of the drape. Findings. Polypropylene and the experimental phenol polymer fabric did not ignite in air. The laser instantly vaporized a hole in the polypropylene fabric. After filter paper was placed directly behind them, the polypropylene and phenol polymer fabrics were retested. The mean time to ignition of the polypropylene/filter paper combination (4.7 k 1.3 seconds) was not significantly different from the mean time to ignition of the filter paper alone (5.2 + 2.8 seconds, P = .054). All the materials tested ignited in 50% and 95% oxygen. Clinical implications. This study revealed that all materials tested ignited in high oxygen concentrations. In addition, increasing oxygen concentration shortened the time to ignition. Perioperative nurses should be aware that when oxygen concentration in the surgical field is increased, the risk of fires increases. Consequently supplemental oxygen must be used judiciously. Additionally personnel should AORN JOURNAL
577
SEPTEMBER 2004, VOL 80, NO 3
consider the relative flammability characteristics, proximity to oxygen, and proximate use of ignition sources when selecting surgical drapes.
of anesthesia administration, immediately before rescue analgesic medication was administered, and at the time the patient was discharged to home. The first dose of the study medication was administered 30 to 40 minutes before the patient entered the OR. "Home readiness" was determined using standard postanesthetic discharge criteAnesthesia and Analgesia ria. Before discharge, all April 2004 Rofecoxib is a nonsteroidal patients were asked to assess the quality of their recovery anti-inflammatory medicausing a standardized question that reduces substances that cause inflammation, tionnaire. Follow-up evaluapain, and fever. This medica- tions were performed at 36 tion has been demonstrated hours, seven days, and 14 to decrease postoperative days after surgery to assess pain and improve patient sat- postdischarge pain, analgesic isfaction when it is adminisrequirements, resumption of tered preoperatively for normal activities, and patient satisfaction with postoperaotorhinolaryngology procetive pain management. dures. The purpose of this Standard statistical techrandomized, double-blind, placebo-controlled study was niques were used to analyze the findings. to test the hypothesis that preoperative administration Findings. Recovery time of rofecoxib would lead to was significantly decreased earlier hospital discharge and in the group that received rofecoxib, leading to earlier resumption of normal actividischarge home after surgery ties after outpatient inguinal (88 f 44 minutes, P < .05). herniorraphy procedures.' Sixty patients undergoing Quality of recovery score was significantly higher for elective hernia repair were patients in the study group, randomly assigned to one of two treatment groups-a con- and pain score 60 minutes after surgery was significanttrol group that received 500 ly lower. Significantly fewer mg of vitamin C or a study patients in the study group group that received 50 mg of rofecoxib. Patients were asked required rescue analgesic to complete an ll-point verbal medication (37%versus 67% in the control group, P < .05). rating scale in the preoperative holding area to determine During the 36-hour follow-up their baseline level of pain and period, patients treated with nausea. The verbal rating scale rofecoxib required significantranged from zero (ie, no pain) ly less oral analgesic medication (0 [0 - 201 versus 9 [l to 10 (ie, worst imaginable pain), and patients were asked 331 pills, P < .05) and reported a significantly higher level of to complete the scale at 30satisfaction with their postopminute intervals after the end
Perioperative rofecoxib and early recovery
578
AORN JOURNAL
Evidence for Practice
erative pain management (3 [l - 41 versus 2 [0 - 31, P < .05). There was no difference between the two groups, however, in the time required for patients to resume their normal activities. Clinical implications. The results of this study demonstrated that the preoperative use of rofecoxib decreased postoperative pain but failed to shorten patients' time to resumption of normal activities after surgery. Perioperative nurses should be prepared for the preoperative use of rofecoxib in an increasing number of adult ambulatory surgery procedures by having rofecoxib readily available and being prepared to answer patients' questions about the medication. GEORGE ALLEN RN, PHD, CNOR, CIC DIRECTOR OF INFECTION CONTROL DOWNSTATE MEDICALCENTER BROOKLYN, NY
NOTES 1.L A Anderson, J B Gross, "Aromatherapy with peppermint, isopropyl alcohol, or lace bo is equally effective in rerev- ing postoperative nausea," Journal of PeriAnesfResin Nursing 19 (February 2004) 29-35. 2. W Koppert et al, "Perioperative intravenous lidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery," Anesthesia nrid Armipirr 98 (April 2004) 1050-1055. 3. G L Wolf et al, "Laser ignition of surgical drape materials in air, 50% oxygen, and 95% oxygen," Anesthesiology 100 (May 2004) 1167-1171. 4. H Ma et al, "Perioperative rofecoxib improves early rccovery after outpatient hemiorrhaphy," Anesthesia and Annlgcsin 98 (April 2004) 970-975.
E V I D E N C E
Evidence for Practice
FOR
PRACTICE
Aromatherapy‘s effect on postoperative nausea; intravenous lidocaine; ignition of drape material; rofecoxib
Aromatherapy as treatment for nausea Journal of PeriAnesthesia Nursing
February 2004 The significance of postoperative nausea, an adverse event that commonly occurs after surgery under anesthesia, generally is underestimated because it is self-limited, never becomes chronic, and almost never results in mortality. Postoperative nausea may be very distressing for patients, however, and after ambulatory procedures, it may lead to unanticipated hospital admission. The purpose of this randomized, double-blind, placebocontrolled study was to determine if aromatherapy with peppermint oil or isopropyl alcohol is effective in treating patients who develop nausea after outpatient surgery.’ Adult patients scheduled for ambulatory surgery were invited to participate. Thirty-three patients who spontaneously reported nausea in the postanesthesia care unit (PACU)were enrolled in the study. The severity of nausea was determined using a visual analogue scale (VAS) that consisted of a 100-mm line ranging from “no nausea” on one end to “worst possible nausea” on the other. Patients were randomly assigned to receive aromatherapy with either isopropyl alcohol, oil of peppermint, or saline (ie, placebo). Scented gauze pads were placed directly beneath the patients’ nostrils, and they were instructed to take three slow, deep breaths, inhaling the vapors through their noses and exhaling through their mouths. Presence and level of nausea were assessed using the VAS two and five minutes after aromatherapy. Just before discharge to home, patients
572
AORN JOURNAL
were asked to rate their overall satisfaction with the management of nausea using another VAS on which 0 mm equaled extremely dissatisfied and 100 mm equaled fully satisfied. Common statistical techniques, including Chi square analysis, were used to analyze differences. Findings. Overall nausea scores on the VAS decreased significantly, from 60 mm before aromatherapy to 43.1 mm two minutes after aromatherapy ( P < .005) and 28 mm five minutes after aromatherapy. Nausea scores did not differ among the treatment groups at any time, and 52% of the patients required conventional antiemetic therapy during their PACU stay. Patients’ overall satisfaction with nausea management was high (ie, 86.9 mm on the VAS), and regression analysis revealed a significant correlation between the decrease in nausea scores five minutes after initial aromatherapy and patients’ overall satisfaction (r2= .17, P = .028). Clinical implications. The results of this study suggest that the antiemetic effect of aromatherapy may not be related to the aroma itself but to the act of consciously controlling the patient’s breathing pattern. Perioperative nurses should consider using this relatively easy, inexpensive intervention as an initial response when patients complain of nausea in the PACU.
Peri o perative intravenous lidocaine for pain control Anesthesia and Analgesia April 2004
Controlling postoperative pain allows patients to return to normal function sooner after surgery and decreases the incidence of pneumonia
George Allen, RN
This information is intended for general use only. The clinical implicotiom are specific to the abstracted article only. Individuals intending to put these findings into practice are strongly encouraged to review the original article to determine its applicability to their setting.
SEPTEMBER 2004, VOL 80, NO 3
Evidence for Practice
and other complications. Consequently, ensuring patients’ comfort by reducing the level and intensity of pain they experience after a surgical procedure is a primary goal of perioperative personnel. The purpose of tlus prospective, double-blind, randomized study was to determine the effect of systemic lidocaine on morphine consumption in the postoperative period.2 Forty patients undergoing major abdominal surgery were randomly assigned to one of two groups. The study group received an intravenous infusion of 2% lidocaine 30 minutes before skin incision. The control group received intravenous saline. Infusion was stopped 60 minutes after the end of the surgical procedure. Postoperative pain was assessed using a VAS that ranged from zero to 10, with zero denoting “no pain” and 10 denoting “worst imaginable pain.” Morphine consumption by patientcontrolled analgesia was assessed up to 72 hours after surgery. Standard statistical techniques, including Student’s f test and the MannWhitney U test, were used to determine differences between the two groups. Findings. Use of morphine during the 72-hour observation period was significantly lower in the study group ( P = .05).Patients who received lidocaine reported less pain during movement and needed less morphme during the first 72 hours after surgery (103.1k
72 mg versus 159 f 73.3 mg; Student’s f test P < .05). The control group exhibited significantly more pain during movement, especially during the second and third 24-hour postoperative periods ( P < .05), and their pain intensities exceeded four on the VAS. Clinical implications. This study revealed that systemic lidocaine used perioperatively reduced patients’ postoperative pain and morphine consumption. Perioperative nurses should be prepared for the administration of IV 2% lidocaine 30 minutes before an incision is made by having it readily available in the unit.
Laser ignition of surgical drape materials Anesthesiology May 2004
Fire in an OR is a devastating occurrence for both patients and health care providers. Three elements-xygen, fuel, and an ignition source-must be available for a fire to start. All three elements are readily available in O h , so preventing fires is a high priority for perioperative personnel. The purpose of this study was to determine the time to ignition of currently used surgical drape materials.’ Materials currently being used in the OR, including nonwoven cellulose/polyester blend surgical drape; polypropylene surgical drape;
reusable woven cotton/ polyester blend surgical drape; huck towel; and an experimental fabric (ie, phenol polymer drape); were tested in air and in 50% and 95% oxygen to determine time to ignition. A carbon dioxide laser was used as the ignition source. Materials that were not penetrated by the laser were retested with a piece of filter paper stapled in front of the drape. Findings. Polypropylene and the experimental phenol polymer fabric did not ignite in air. The laser instantly vaporized a hole in the polypropylene fabric. After filter paper was placed directly behind them, the polypropylene and phenol polymer fabrics were retested. The mean time to ignition of the polypropylene/filter paper combination (4.7 k 1.3 seconds) was not significantly different from the mean time to ignition of the filter paper alone (5.2 + 2.8 seconds, P = .054). All the materials tested ignited in 50% and 95% oxygen. Clinical implications. This study revealed that all materials tested ignited in high oxygen concentrations. In addition, increasing oxygen concentration shortened the time to ignition. Perioperative nurses should be aware that when oxygen concentration in the surgical field is increased, the risk of fires increases. Consequently supplemental oxygen must be used judiciously. Additionally personnel should AORN JOURNAL
577
SEPTEMBER 2004, VOL 80, NO 3
consider the relative flammability characteristics, proximity to oxygen, and proximate use of ignition sources when selecting surgical drapes.
of anesthesia administration, immediately before rescue analgesic medication was administered, and at the time the patient was discharged to home. The first dose of the study medication was administered 30 to 40 minutes before the patient entered the OR. "Home readiness" was determined using standard postanesthetic discharge criteAnesthesia and Analgesia ria. Before discharge, all April 2004 Rofecoxib is a nonsteroidal patients were asked to assess the quality of their recovery anti-inflammatory medicausing a standardized question that reduces substances that cause inflammation, tionnaire. Follow-up evaluapain, and fever. This medica- tions were performed at 36 tion has been demonstrated hours, seven days, and 14 to decrease postoperative days after surgery to assess pain and improve patient sat- postdischarge pain, analgesic isfaction when it is adminisrequirements, resumption of tered preoperatively for normal activities, and patient satisfaction with postoperaotorhinolaryngology procetive pain management. dures. The purpose of this Standard statistical techrandomized, double-blind, placebo-controlled study was niques were used to analyze the findings. to test the hypothesis that preoperative administration Findings. Recovery time of rofecoxib would lead to was significantly decreased earlier hospital discharge and in the group that received rofecoxib, leading to earlier resumption of normal actividischarge home after surgery ties after outpatient inguinal (88 f 44 minutes, P < .05). herniorraphy procedures.' Sixty patients undergoing Quality of recovery score was significantly higher for elective hernia repair were patients in the study group, randomly assigned to one of two treatment groups-a con- and pain score 60 minutes after surgery was significanttrol group that received 500 ly lower. Significantly fewer mg of vitamin C or a study patients in the study group group that received 50 mg of rofecoxib. Patients were asked required rescue analgesic to complete an ll-point verbal medication (37%versus 67% in the control group, P < .05). rating scale in the preoperative holding area to determine During the 36-hour follow-up their baseline level of pain and period, patients treated with nausea. The verbal rating scale rofecoxib required significantranged from zero (ie, no pain) ly less oral analgesic medication (0 [0 - 201 versus 9 [l to 10 (ie, worst imaginable pain), and patients were asked 331 pills, P < .05) and reported a significantly higher level of to complete the scale at 30satisfaction with their postopminute intervals after the end
Perioperative rofecoxib and early recovery
578
AORN JOURNAL
Evidence for Practice
erative pain management (3 [l - 41 versus 2 [0 - 31, P < .05). There was no difference between the two groups, however, in the time required for patients to resume their normal activities. Clinical implications. The results of this study demonstrated that the preoperative use of rofecoxib decreased postoperative pain but failed to shorten patients' time to resumption of normal activities after surgery. Perioperative nurses should be prepared for the preoperative use of rofecoxib in an increasing number of adult ambulatory surgery procedures by having rofecoxib readily available and being prepared to answer patients' questions about the medication. GEORGE ALLEN RN, PHD, CNOR, CIC DIRECTOR OF INFECTION CONTROL DOWNSTATE MEDICALCENTER BROOKLYN, NY
NOTES 1.L A Anderson, J B Gross, "Aromatherapy with peppermint, isopropyl alcohol, or lace bo is equally effective in rerev- ing postoperative nausea," Journal of PeriAnesfResin Nursing 19 (February 2004) 29-35. 2. W Koppert et al, "Perioperative intravenous lidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery," Anesthesia nrid Armipirr 98 (April 2004) 1050-1055. 3. G L Wolf et al, "Laser ignition of surgical drape materials in air, 50% oxygen, and 95% oxygen," Anesthesiology 100 (May 2004) 1167-1171. 4. H Ma et al, "Perioperative rofecoxib improves early rccovery after outpatient hemiorrhaphy," Anesthesia and Annlgcsin 98 (April 2004) 970-975.