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no. 1: Pain and post-anesthesia management
BOOK REVIEWS
377
important topic that is little known to most of us. All too often, the anesthesiologist does not appreciate the in-depth psychologic factors that entail recovery from an anesthetic. The author rightly points out that awareness is the common goal between the anesthesiologist and the psychologist. With the advent of more and more day surgery, the goal for shorter-acting agents that can be reversed is of primary concern. There is a very good discussion on three phases of recovery: (1) vital reflexes; (2) return to physical and mental cognizance; and (3) the patient returning to his previous baseline state. The author then discusses upcoming studies of objective measures versus subjective measures to obtain these goals. This field of study could indeed be an exciting one and is rightly a combination of anesthesia and psychology. If anything, this chapter really should enlighten the reader to how little is known about this important topic that deals with all aspects of recovery from anesthesia. In conclusion, the book is an overall very good edition that discusses recovery from anesthesia. I would give it some excellent marks, but some things are lacking; in particular: (1) discussion of when to transport critically ill patients to the intensive care unit; (2) what provisions are made for overnight recovery room stays; (3) a chapter devoted to monitoring in the recovery room; (4) a chapter discussing transport of the critically ill from the operating room to recovery room and from recovery room to other places; and (5) a chapter devoted exclusively to the treatment of pain in the recovery room. I think there was too much emphasis placed on reversal drugs. A whole chapter devoted to these topics would have made it more valuable to the reader. My praise goes to the chapter on recovery from anesthesia. It brings out a lot of key ideas that anesthesiologists often take for granted in objectively evaluating their patients for discharge from day surgery. I would recommend this book to all readers, in particular the young novice resident. It is good book for a quick review for certain aspects of recovery room management. However, it is not an all-encompassing, detailed book that discusses everything about recovery room management. Eric Bloomjield, MD Staff Anesthesiologist Cleveland Clinic Cleveland, OH
Critical Care Nursing Clinics of North America, vol3/no. 1: Pain and Post-Anesthesia Management. Edited by Kim Litwack. Philadelphia, PA, W.B. Saunders Co, 1991,164 pp. This is a unique book, as it heavily emphasizes the importance of pain management of the post-anesthesia patient. The book consists of 18 chapters divided into two parts. Each chapter is well written by a total of 29 physicians, registered nurses, and pharmacists established in their respective fields. This multidisciplinary approach gives the reader a wide variety of viewpoints and clinical applications. Fifty percent of the text presents aspects of pain management related to the post-anesthesia patient. The first chapter reviews the concept of pain from the historical perspective, meshing history and religion. However, barely one page is directed toward current concepts of pain. More emphasis on current concepts of pain is needed to give a conceptual framework on pain management. A brief and basic review of pain assessment is provided. A wellwritten summary of generic pharmacologic agents for pain management is included. The next two chapters were written by the same two physicians and provide very clear descriptions of postoperative epidural analgesia and patient-controlled analgesia for postoperative pain. The advantages and disadvantages of continuous infusion of epidural
morphine to treat post-thoracotomy pain are discussed in detail. The diagrams and figures in both chapters are especially clear and helpful and the references are current. Both chapters would be an excellent adjunct to the post-anesthesia practitioner’s orientation. The chapter on regional anesthetic techniques for postoperative analgesia is well written. Illustrations would have assisted the presentation. Complications and treatment thereof are clearly delineated. The text covering pediatric pain intervention in the postanesthesia care unit (PACU) is well organized, up to date, and thoroughly referenced. It includes anatomy, pediatric misconceptions, caregiver bias, pain assessment techniques, and both physiologic and behavioral cues. It includes a detailed review of common pain assessment tools used with children and discusses their reliability. Nonnarcotic and narcotic pain management, patient-controlled analgesia, and epidural analgesia advantages, disadvantages, complications, and treatments are described. The nonpharmacologic pain management techniques were especially interesting. The chapter on the differential diagnoses of chest pain gives a thorough yet concise discussion organized on the cardiovascular system, pulmonary system, gastrointestinal system, and musculoskeleta1 system. It appears out of place with the other post-anesthesia topics, but is needed to complete the discussion on pain. The final chapter on pain management emphasized nonpharmacologic interventions, which can actually foster the release of pain-blocking endorphins. I found the research data of the interventions, preoperative teaching, positioning, relaxation techniques, music, massage, distraction, and acupressure most interesting. The 14 authors who discussed pain management have succeeded in clearly presenting every aspect of pain relevant to the postanesthesia patient. The last half of this book contains the conceptual basis for post-anesthesia care: postoperative pulmonary complications, hemodynamic monitoring, arrhythmias, fluid therapy, bleeding and coagulation, malignant hyperthermia, hypothermia, emergence delirium, muscle relaxants, and reversal agents. In discussing pulmonary complications, the author focuses on obstruction, hypoxemia, and hypoventilation. The correlation with anesthesia agents and other disease entities is described. A basic, yet very comprehensive, review of hemodynamic monitoring is presented. Nursing interventions are concisely presented. Tables and figures are well done and clear. The clinical features of each arrhythmia are described, followed by an excellent description of the management of each. The emphasis on clinical management, rather than arrhythmia identification, makes this chapter of great interest to the post-anesthesia practitioner. The chapter on fluid therapy in the PACU gives an in-depth discussion of body fluids, fluid therapy replacement, fluid challenges, blood component therapy, and discusses crystalloid versus colloid replacement. The author provides many clearly done tables and figures to support his views. Bleeding and coagulation in the PACU is discussed by addressing the causes of postoperative bleeding, the loss of vascular integrity, and alteration in coagulation. Diagnostic parameters and treatments are discussed. Disseminated intravascular coagulation diagnosis and treatment are summarized. The author takes a complex subject and presents it well, giving the reader a good understanding of the normal clotting mechanism. A clear, up-to-date review of malignant hyperthermia is given: causes, pathophysiology, assessment factors, anesthesia management, clinical manifestations, and treatment. Provided on the last page is a complete, well-done plan of care. The article on hypothermia in the PACU begins by defining hypothermia as “a core body temperature of less than 36°C.” It
BOOK
378
goes on to explain that hypothermia represents a patient management problem when “key physiologic processes are negatively altered.” It recommends that active rewarming therapy should be used in the PACU for “temperatures less than 36°C orally or 36.5”C axillary.” If this is true, it would mean a large change in practice in many PACUs across the country that use 35.5”C orally as discharge criteria. I would like to see research data to support this recommendation and identify the key physiologic processes that are negatively altered in patients with oral temperatures between 35.5” and 35.9”C. This chapter reviews all the modalities used to treat hypothermia and concludes that the only effective treatment for hypothermia in the extubated patient in the PACU is the convective warming system. Two research articles are presented to support the author’s claim. If the above is true, the course of PACU practice could be dramatically changed. The phenomenon of emergence delirium in the PACU was discussed with nonanesthesia and anesthesia factors. The author states that “the primary cause should be considered hypoxemia until proven otherwise.” This chapter took the problem of emergence delirium with various causes, gave a succinct review, and identified the treatment of each based on the cause. The last chapter gives a basic review of muscle relaxants and
REVIEWS
reversal agents. It repeatedly used the outdated term “recovery room,” which distracted the reader from the content. This chapter is brief, but gives an excellent summary of muscle relaxants and factors affecting reversals. In summary, I took great interest and pleasure in reading this unique book, as it heavily emphasized the importance of pain management in the post-anesthesia patient. The last half of the book contains the conceptual bases for post-anesthesia care. To make this text complete, a chapter is needed on anesthesia agents. inhalation agents, and intravenous agents. Although this text is not particularly focused on cardiothoracic or cardiovascular anesthesia, all of the content is pertinent to the post-anesthesia patient. Pain and Post-Anesthesia Management would be helpful to the post-anesthesia physician and nurse practitioner and would be worthwhile to include as part of orientation Maria T. Zickuhr RN, BS, C‘PAIb’ Head Nurse Post Anesthesia Care Unit TCI CenteriPreCare The Cleveland
Clinic Foundation Cleveland, OH
377
important topic that is little known to most of us. All too often, the anesthesiologist does not appreciate the in-depth psychologic factors that entail recovery from an anesthetic. The author rightly points out that awareness is the common goal between the anesthesiologist and the psychologist. With the advent of more and more day surgery, the goal for shorter-acting agents that can be reversed is of primary concern. There is a very good discussion on three phases of recovery: (1) vital reflexes; (2) return to physical and mental cognizance; and (3) the patient returning to his previous baseline state. The author then discusses upcoming studies of objective measures versus subjective measures to obtain these goals. This field of study could indeed be an exciting one and is rightly a combination of anesthesia and psychology. If anything, this chapter really should enlighten the reader to how little is known about this important topic that deals with all aspects of recovery from anesthesia. In conclusion, the book is an overall very good edition that discusses recovery from anesthesia. I would give it some excellent marks, but some things are lacking; in particular: (1) discussion of when to transport critically ill patients to the intensive care unit; (2) what provisions are made for overnight recovery room stays; (3) a chapter devoted to monitoring in the recovery room; (4) a chapter discussing transport of the critically ill from the operating room to recovery room and from recovery room to other places; and (5) a chapter devoted exclusively to the treatment of pain in the recovery room. I think there was too much emphasis placed on reversal drugs. A whole chapter devoted to these topics would have made it more valuable to the reader. My praise goes to the chapter on recovery from anesthesia. It brings out a lot of key ideas that anesthesiologists often take for granted in objectively evaluating their patients for discharge from day surgery. I would recommend this book to all readers, in particular the young novice resident. It is good book for a quick review for certain aspects of recovery room management. However, it is not an all-encompassing, detailed book that discusses everything about recovery room management. Eric Bloomjield, MD Staff Anesthesiologist Cleveland Clinic Cleveland, OH
Critical Care Nursing Clinics of North America, vol3/no. 1: Pain and Post-Anesthesia Management. Edited by Kim Litwack. Philadelphia, PA, W.B. Saunders Co, 1991,164 pp. This is a unique book, as it heavily emphasizes the importance of pain management of the post-anesthesia patient. The book consists of 18 chapters divided into two parts. Each chapter is well written by a total of 29 physicians, registered nurses, and pharmacists established in their respective fields. This multidisciplinary approach gives the reader a wide variety of viewpoints and clinical applications. Fifty percent of the text presents aspects of pain management related to the post-anesthesia patient. The first chapter reviews the concept of pain from the historical perspective, meshing history and religion. However, barely one page is directed toward current concepts of pain. More emphasis on current concepts of pain is needed to give a conceptual framework on pain management. A brief and basic review of pain assessment is provided. A wellwritten summary of generic pharmacologic agents for pain management is included. The next two chapters were written by the same two physicians and provide very clear descriptions of postoperative epidural analgesia and patient-controlled analgesia for postoperative pain. The advantages and disadvantages of continuous infusion of epidural
morphine to treat post-thoracotomy pain are discussed in detail. The diagrams and figures in both chapters are especially clear and helpful and the references are current. Both chapters would be an excellent adjunct to the post-anesthesia practitioner’s orientation. The chapter on regional anesthetic techniques for postoperative analgesia is well written. Illustrations would have assisted the presentation. Complications and treatment thereof are clearly delineated. The text covering pediatric pain intervention in the postanesthesia care unit (PACU) is well organized, up to date, and thoroughly referenced. It includes anatomy, pediatric misconceptions, caregiver bias, pain assessment techniques, and both physiologic and behavioral cues. It includes a detailed review of common pain assessment tools used with children and discusses their reliability. Nonnarcotic and narcotic pain management, patient-controlled analgesia, and epidural analgesia advantages, disadvantages, complications, and treatments are described. The nonpharmacologic pain management techniques were especially interesting. The chapter on the differential diagnoses of chest pain gives a thorough yet concise discussion organized on the cardiovascular system, pulmonary system, gastrointestinal system, and musculoskeleta1 system. It appears out of place with the other post-anesthesia topics, but is needed to complete the discussion on pain. The final chapter on pain management emphasized nonpharmacologic interventions, which can actually foster the release of pain-blocking endorphins. I found the research data of the interventions, preoperative teaching, positioning, relaxation techniques, music, massage, distraction, and acupressure most interesting. The 14 authors who discussed pain management have succeeded in clearly presenting every aspect of pain relevant to the postanesthesia patient. The last half of this book contains the conceptual basis for post-anesthesia care: postoperative pulmonary complications, hemodynamic monitoring, arrhythmias, fluid therapy, bleeding and coagulation, malignant hyperthermia, hypothermia, emergence delirium, muscle relaxants, and reversal agents. In discussing pulmonary complications, the author focuses on obstruction, hypoxemia, and hypoventilation. The correlation with anesthesia agents and other disease entities is described. A basic, yet very comprehensive, review of hemodynamic monitoring is presented. Nursing interventions are concisely presented. Tables and figures are well done and clear. The clinical features of each arrhythmia are described, followed by an excellent description of the management of each. The emphasis on clinical management, rather than arrhythmia identification, makes this chapter of great interest to the post-anesthesia practitioner. The chapter on fluid therapy in the PACU gives an in-depth discussion of body fluids, fluid therapy replacement, fluid challenges, blood component therapy, and discusses crystalloid versus colloid replacement. The author provides many clearly done tables and figures to support his views. Bleeding and coagulation in the PACU is discussed by addressing the causes of postoperative bleeding, the loss of vascular integrity, and alteration in coagulation. Diagnostic parameters and treatments are discussed. Disseminated intravascular coagulation diagnosis and treatment are summarized. The author takes a complex subject and presents it well, giving the reader a good understanding of the normal clotting mechanism. A clear, up-to-date review of malignant hyperthermia is given: causes, pathophysiology, assessment factors, anesthesia management, clinical manifestations, and treatment. Provided on the last page is a complete, well-done plan of care. The article on hypothermia in the PACU begins by defining hypothermia as “a core body temperature of less than 36°C.” It
BOOK
378
goes on to explain that hypothermia represents a patient management problem when “key physiologic processes are negatively altered.” It recommends that active rewarming therapy should be used in the PACU for “temperatures less than 36°C orally or 36.5”C axillary.” If this is true, it would mean a large change in practice in many PACUs across the country that use 35.5”C orally as discharge criteria. I would like to see research data to support this recommendation and identify the key physiologic processes that are negatively altered in patients with oral temperatures between 35.5” and 35.9”C. This chapter reviews all the modalities used to treat hypothermia and concludes that the only effective treatment for hypothermia in the extubated patient in the PACU is the convective warming system. Two research articles are presented to support the author’s claim. If the above is true, the course of PACU practice could be dramatically changed. The phenomenon of emergence delirium in the PACU was discussed with nonanesthesia and anesthesia factors. The author states that “the primary cause should be considered hypoxemia until proven otherwise.” This chapter took the problem of emergence delirium with various causes, gave a succinct review, and identified the treatment of each based on the cause. The last chapter gives a basic review of muscle relaxants and
REVIEWS
reversal agents. It repeatedly used the outdated term “recovery room,” which distracted the reader from the content. This chapter is brief, but gives an excellent summary of muscle relaxants and factors affecting reversals. In summary, I took great interest and pleasure in reading this unique book, as it heavily emphasized the importance of pain management in the post-anesthesia patient. The last half of the book contains the conceptual bases for post-anesthesia care. To make this text complete, a chapter is needed on anesthesia agents. inhalation agents, and intravenous agents. Although this text is not particularly focused on cardiothoracic or cardiovascular anesthesia, all of the content is pertinent to the post-anesthesia patient. Pain and Post-Anesthesia Management would be helpful to the post-anesthesia physician and nurse practitioner and would be worthwhile to include as part of orientation Maria T. Zickuhr RN, BS, C‘PAIb’ Head Nurse Post Anesthesia Care Unit TCI CenteriPreCare The Cleveland
Clinic Foundation Cleveland, OH