- Email: [email protected]
Nursing care for postanesthesia shivering
Kathleen P Lewis, RN, Irene Cressey, RN
Nursing care for postanesthesia shivering
Patient shivering during recovery from anesthesia is often observed by the recovery room nurse. This reaction usually passes quickly, and the recovery room nurse may be concerned mainly for the comfort of the patient who looks cold or who complains of feeling cold. However, gross untreated shivering may lead to increased muscle activity and to cardiac stress if muscle activity and hypoxia persist. What can be done to avoid hypoxia, reduce cardiac stress, and provide comfort for the patient who experiences postanesthesia shivering? Nurses on the postanesthesia recovery unit (PARU) at Seattle Veterans Administration Medical Center (VAMC) have assisted in medical research of postanesthetic shivering. As a result of this research, we believe patient shivering is a hypothermia problem. This paper presents a brief literature review and describes a nursing care plan we have developed. The recovery room nurse should first understand some of the physiological factors and postoperative difficulties t h a t predispose a patient to postanesthetic shivering. There are two types of postoperative muscle activity, according to Soliman. The first is spasticity, which is defined as “sustained muscular hypertonicity” observed in the jaw, neck, and pectoral muscles; flexors of the upper limbs: and the extensors and adductors ofthe lower
limbs. In Soliman’s studies, spasticity lasted six to seven minutes depending on the patient’s rate of return to consciousness and disappeared when the patient responded to oral commands. According to Soliman, spasticity seems to be a part of normal emergence from anesthesia. Shivering, the second type of postoperative muscle activity, is a “rhythmic contraction of muscle groups with irregular intermittent periods of relaxation.” Shivering occurred in fewer than half of the 215 patients Soliman studied. It seemed largely related to temperature loss during the operative procedure and occurred after the patient could respond to simple commands. Shivering lasted an average of nine to ten minutes. The patient complained of being cold, and piloerection was observed.2 Basic to body heat loss is the temperature gradient. The operating room temperature influences a change in body temperature, according t o Pflug. A patient with a normal temperature of 37 C experiences an operating room temperature of 20 C to 25 C. The possible degrees of heat loss or ambient temperature gradient is 12 C to 17 C.3 Several factors occurring during surgery allow cool environmental temperature to lower the patient’s core temperature. One is the length of time the patient is exposed to inhalation a n e ~ t h e s i aHalothane .~ anesthesia is a
dAORN Journal, August 1979, Vo130, No 2
357
vasodilator. Under halothane anestheisa, the patient’s tympanic temperature decreases and skin temperature initially increases. With prolonged anesthesia and surgery, toe, tympanic, and esophageal temperatures show a decline.5 Other factors include inadequate skin covering during surgery. Without the benefit of blanket insulation, extremities already vasodilated may be subject to low ambient operating room temperatures.6 In addition, general anesthetics are central nervous system depressants. The heat-regulating center of the brain at the hypothalmus normally responds to lowering of core temperature by activating the response of shivering. During surgery, however, this heat-generating response is absent. Finally, whenever there is incisional opening, exposing muscle mass and vital organs, there is core heat loss. Postoperative shivering can lead to cardiopulmonary problems in the patient. In one study, Pflug documents t h a t out of ten patients with postanesthetic shivering, one developed bradycardia with nodal rhythm. Arterial blood gases collected during the shivering period showed that three patients had Pa02 levels in the range of 50 to 60 mg Hg, and one patient demonstrated severe hypoxia with a Pa02 of26 mg Hg.7 Soliman has also documented mild metabolic acidosis and some respiratory acidosis in shivering patients.a Also, if a patient undergoing peripheral Kathleen P Lewis, RN, is recovery room head
nurse at the Seattle Veterans Administration Medical Center. She holds a BSN from the University of Washington School of Nursing,
Seattle. Irene Cressey, RN, is a staff nurse in the
postanesthetic recovery unit at Seattle Veterans Administration Medical Center. She is an associatedegree graduate of Bellevue (Wash) Community College.
360
vascular surgery shivers and vasoconstricts, the incidence of venous or arterial thrombosis increase^.^ Shivering is believed to be a method of heat generation. According to Rush, there is a “set-point” mechanism at the level of the heat-regulating center of the brain. He refers to the set-point mechanism as a reference temperature. It is not an actual temperature in the brain, but any deviation from the reference point activates a negative feedback system of motor responses t o correct the core temperature.l0 When core temperature is lower than the set-point, an appropriate motor response may be shivering. Pflug measures core temperature at the tympanic membrane and also esophageal temperatures at the level of the mediastinum. A t present, there is no method to measure a patient’s setpoint. Some patients shiver and some don’t; some patients shiver more than others. This may be because some patients do not have a great difference between set-point and core temperature. A patient may slowly rewarm himself by means of peripheral vasoconstriction and not necessarily by shivering.” If the patient is not visibly shivering, the nurse may not be able to observe that he is cold. Pflug was able to show by means of leg limb flow studies that some patients show shivering-like muscle movements that are only visible electronically.12In a study using heated anesthetic gases to maintain normothermia in patients, Pflug studied vasoconstriction as a peripheral vascular response to change in core temperature. A large leg cuff was attached to the thighs of study patients. A plethysmograph attached to the cuff recorded electrocardiographlike recordings on a strip. The recordings reflected arterial blood flow in the limb and the degree of vasoconstriction. Because some of the recordings on
AORN Journal, August 1979, V0130,No 2
Figure 1
Seattle VAMC nursing care plan for postanesthesia shivering Nursing orders
Problems
Expectedoutcomes
Dead1ine
Patient says he feels cold
The patient will say he feels warm
5 to 10 min
Pain potentiated by increased muscular activity
The patient will complain of less pain and will begin to rest quietly
5 to 10 min
1. Apply warm blankets 2. Apply heated nebulization 3. If pain persists, evaluate for pain medication
Slow responsiveness and prolonged recovery time
The patient will open eyes, respond to oral commands, and begin to remain awake
5 to 10 min
1. Consult anesthetic record for depressants given. Evaluate need for reversing agents 2. Take temperature and apply warm blankets 3. OZ@ 1OL until responding 4. Heated nebulization if needed
Decreased BP in conjunction with decreased temperature and decreased level of consciousness
Increased BP Increased T
5 to 15 min 30 rnin
1. Lower head of bed 2. 0 2 by mask and/or heated nebulizer 3. ECG monitoring 4. Evaluate fluid need and consider IV fluid bolus 5. Take temperature and consider warm blankets 6. Heated nebulization if needed
is maintained at 40% heated nebulizer or 1OL per mask on all general anesthetic patients until patient begins to respond and re(02
362
1. Take temperature 2. Apply warm blankets 3. Apply heated nebulization 4. Take temperature upon discharge
main wakeful per orders of Dr Eugene Pflug. Patients with chronic obstructive pulmonary disease are treated with 0 2 < 5L.)
AORN Journal, August 1979,VoE30, No 2
unwarmed patients showed shiveringlike muscle movements, Pflug concluded that patients who have low temperatures and who rewarm rapidly without observable shivering may be experiencing subclinical shivering.13 Therefore, we can say that many more patients may be experiencing hypothermia than we are aware. At Seattle Veterans Administration Medical Center, PARU nurses have assisted in the research of A Eugene Pflug, MD, in the prevention of postanesthetic shivering. In this research, Pflug attached a Bennett Cascade humidifier to the anesthesia machine to maintain a constant normothermic core temperature intraoperatively. The upper airways and lung become a heat exchange unit. Heat from warm inhaled gases is transferred across the 50 to 75 square meters of lung alveolar tissue to pulmonary blood. Heat transfer occurs in a n area containing the esophagus, myocardium, and superior vena cava. Instead of heating the periphery and hoping to eventually warm core tissues or decrease heat loss to the environment, Pflug has tried to influence temperature directly at a core level where interchange takes place between pulmonary and circulatory tissues.14 During t h e postoperative period, shivering in the responding patient was observed and arterial blood gases measured. Of the 20 patients kept warm intraoperatively, none shivered in the recovery room. In 10 of the 20 unwarmed patients, the mean duration of shivering was 29 minutes. In the recovery room, previously unwarmed patients responded to warming measures via warmed humidified 02 and warm blankets within 15 to 20 minutes.15 As their part of the study, nurses observed patients for shivering and recorded temperature readings at specific intervals. The nurses also followed a regimen of extra blankets and heated
364
nebulization. Patients had arterial lines and tympanic and toe temperature probes that were monitored for working order and patient safety. In the recovery room a t the Seattle VAMC, nurses care for debilitated elderly who would normally maintain body temperature by means of more clothing. Younger men with larger muscle mass sometimes shiver uncontrollably before they feel cold. Because we see many patients who experience shivering during recovery, we have developed a special care plan for them, using warm blankets and humidified 02. Warm blankets have long been part of nursing care for patient comfort. However, with the data that Pflug's research provides, we can find a n even more basic rationale for our action. Warming methods support t h e body's normothermic activities to achieve homeostasis postoperatively. While we have used warm blankets for years, warm, humidified 02 is a new idea. The Seattle VA uses a Puritan nebulizer@', which is a n oxygen, or air-driven, water-filled container with a heating device, a hose, and a mask. Heated nebulization loosens thick airway secretions and soothes traumatized airways after dental or ear, nose, and throat procedures. Normally, our patients receive 5 to 10 liters of 02 by mask until they remain awake and responsive. We also apply heated blankets if the patient feels cold, has mottled skin, is slow to wake up, has a temperature of 35.5 C or below, shivers, or complains of being cold. As a result of this treatment, we have observed t h a t some p a t i e n t s recover more quickly, are more relaxed, rest quietly without discomfort, and register a temperature rise upon recovery room discharge. We now place heated nebulizers a t each patient care panel. These nebulizers are readily supplied and maintained
AORN Journal, August 1979, Vol30, No 2
by r e s p i r a t o r y t h e r a p y p e r s o n n e l . H e a t e d n e b u l i z a t i o n i s a n u r s i n g o rd e r us ed f o r p a t i e n t s w h o n e e d warming support. W e believ e p a t i e n t s h i v e r i n g in t h e recovery r o o m i s a h y p o t h e r m i a probl e m . In fact, m o r e postanesthetic pat i e n t s may b e h y p o t h e r m i c than w e a r e aware, depending u p o n observable s h i v e r i n g o r t h e i r ability t o r e p o r t t h e i r discomfort. Gross u n t r e a t e d s h i v e r i n g may also l e a d t o increased o x y g e n cons u m p t i o n d u e t o muscle a c t i v i t y and t o increased cardiac stress i f muscle a c t i v i t y and h y p o x i a persist. T h e r e ar e measures nurses c a n use t o support t h e patient’s n o r m o t h e r m i a in t h e recovery room, i n c l u d i n g w a r m e d oxygenated h u m i d i f i e r and warm blankets. T h e k e y s a re t o a n ti c i p a te t h e poss i b i l i t y o f a p a t i e n t s h i v e r i n g postoperat i v e l y and t o b e p re p a re d t o i m p l e m e n t a special care plan f o r t h i s p a t i e n t . Notes 1. M G Soliman, D M M Gillies, “Muscular hyperactivity after general anesthesia,” Canadian Anaesthetists’ Society Journal20 (September 1972) 529. 2. Ibid, 531. 3. A E Pflug, et al, “Temperature on limb blood flow during halothane anesthesia in man,” unpublished manuscript,p 5 (has been accepted by Annals of Surgery). 4. M Cohen, “An investigation into shivering following anesthesia-a preliminary report,” Proceedings of the Royal Society of Medicine 60 (August
1967) 752.
5. Pflug, et al, “Temperature on limb blood flow,” 9. 6. A E Pflug, et al, “Prevention of postanesthesia shivering,” Canadian Anaesthetists’ Society Journal 25 (January 1978) 46. 7. Ibid, 45. 8 . Soliman, Gillies, “Muscular hyperactivity after general anesthesia,” 532. 9. Pflug, et al, ”Temperature on limb blood flow,”
5. 10. G Brengelmann, Physiology and Biophysics, Ruch-Patton,20th ed. (Philadelphia: W B Saunders Co, Vol Ill, 1973) 124. 11. Pflug, et al, “Prevention of postanesthesia shivering,” 48. 12. lbid, 48.
366
13. Ibid. 14. Ibid, 43, 47. 15. Ibid, 45.
Good results reported for e/der/ypatients with breast cancer Elderly women with operable breast cancer can have prospects for survival comparable to younger women, according to one study. This may in part be due to the kinds of tumors elderly patients tend to develop. William L Betsill, MD, reported his findings to the San Francisco meeting of the US-Canadian division of the International Academy of Pathology. The report is summarized in Medical World News. Dr Betsill, assistant professor of pathology, University of Virginia, Charlottesville, made retrospective studies of women treated at Memorial Sloan-Kettering Cancer Center, New York City, and at the University of Virginia Medical Center, Charlottesville. In one group were 87 patients over 80-years-old, treated between 1960 and 1969; in the other were 108 breast cancer patients from 40- to 55-years-old, treated in 1967 and 1968. Dr Betsill said more elderly patients delayed seeking treatment, resulting in larger and more inoperable tumors. However, of 75 operable patients, only 32 (43%) died of malignancy. Seven deaths occurred five years following surgery. The survival was attributed in part by Dr Betsill to differences in the types of tumors the elderly women developed. The older patients had fewer infiltrating duct carcinomas and more papillary carcinomas. In commenting on the study, William H Goodson 111, MD, clinical instructor in surgery, University of California, San Francisco, said older women may be at an advantage because their tumors tend to grow more slowly. He also said that while few surgeons would not perform surgery solely because of age, he believes surgeons tend to do less extensive procedures on older women.
AORN Journal, August 1979, Vol30, No 2
Nursing care for postanesthesia shivering
Patient shivering during recovery from anesthesia is often observed by the recovery room nurse. This reaction usually passes quickly, and the recovery room nurse may be concerned mainly for the comfort of the patient who looks cold or who complains of feeling cold. However, gross untreated shivering may lead to increased muscle activity and to cardiac stress if muscle activity and hypoxia persist. What can be done to avoid hypoxia, reduce cardiac stress, and provide comfort for the patient who experiences postanesthesia shivering? Nurses on the postanesthesia recovery unit (PARU) at Seattle Veterans Administration Medical Center (VAMC) have assisted in medical research of postanesthetic shivering. As a result of this research, we believe patient shivering is a hypothermia problem. This paper presents a brief literature review and describes a nursing care plan we have developed. The recovery room nurse should first understand some of the physiological factors and postoperative difficulties t h a t predispose a patient to postanesthetic shivering. There are two types of postoperative muscle activity, according to Soliman. The first is spasticity, which is defined as “sustained muscular hypertonicity” observed in the jaw, neck, and pectoral muscles; flexors of the upper limbs: and the extensors and adductors ofthe lower
limbs. In Soliman’s studies, spasticity lasted six to seven minutes depending on the patient’s rate of return to consciousness and disappeared when the patient responded to oral commands. According to Soliman, spasticity seems to be a part of normal emergence from anesthesia. Shivering, the second type of postoperative muscle activity, is a “rhythmic contraction of muscle groups with irregular intermittent periods of relaxation.” Shivering occurred in fewer than half of the 215 patients Soliman studied. It seemed largely related to temperature loss during the operative procedure and occurred after the patient could respond to simple commands. Shivering lasted an average of nine to ten minutes. The patient complained of being cold, and piloerection was observed.2 Basic to body heat loss is the temperature gradient. The operating room temperature influences a change in body temperature, according t o Pflug. A patient with a normal temperature of 37 C experiences an operating room temperature of 20 C to 25 C. The possible degrees of heat loss or ambient temperature gradient is 12 C to 17 C.3 Several factors occurring during surgery allow cool environmental temperature to lower the patient’s core temperature. One is the length of time the patient is exposed to inhalation a n e ~ t h e s i aHalothane .~ anesthesia is a
dAORN Journal, August 1979, Vo130, No 2
357
vasodilator. Under halothane anestheisa, the patient’s tympanic temperature decreases and skin temperature initially increases. With prolonged anesthesia and surgery, toe, tympanic, and esophageal temperatures show a decline.5 Other factors include inadequate skin covering during surgery. Without the benefit of blanket insulation, extremities already vasodilated may be subject to low ambient operating room temperatures.6 In addition, general anesthetics are central nervous system depressants. The heat-regulating center of the brain at the hypothalmus normally responds to lowering of core temperature by activating the response of shivering. During surgery, however, this heat-generating response is absent. Finally, whenever there is incisional opening, exposing muscle mass and vital organs, there is core heat loss. Postoperative shivering can lead to cardiopulmonary problems in the patient. In one study, Pflug documents t h a t out of ten patients with postanesthetic shivering, one developed bradycardia with nodal rhythm. Arterial blood gases collected during the shivering period showed that three patients had Pa02 levels in the range of 50 to 60 mg Hg, and one patient demonstrated severe hypoxia with a Pa02 of26 mg Hg.7 Soliman has also documented mild metabolic acidosis and some respiratory acidosis in shivering patients.a Also, if a patient undergoing peripheral Kathleen P Lewis, RN, is recovery room head
nurse at the Seattle Veterans Administration Medical Center. She holds a BSN from the University of Washington School of Nursing,
Seattle. Irene Cressey, RN, is a staff nurse in the
postanesthetic recovery unit at Seattle Veterans Administration Medical Center. She is an associatedegree graduate of Bellevue (Wash) Community College.
360
vascular surgery shivers and vasoconstricts, the incidence of venous or arterial thrombosis increase^.^ Shivering is believed to be a method of heat generation. According to Rush, there is a “set-point” mechanism at the level of the heat-regulating center of the brain. He refers to the set-point mechanism as a reference temperature. It is not an actual temperature in the brain, but any deviation from the reference point activates a negative feedback system of motor responses t o correct the core temperature.l0 When core temperature is lower than the set-point, an appropriate motor response may be shivering. Pflug measures core temperature at the tympanic membrane and also esophageal temperatures at the level of the mediastinum. A t present, there is no method to measure a patient’s setpoint. Some patients shiver and some don’t; some patients shiver more than others. This may be because some patients do not have a great difference between set-point and core temperature. A patient may slowly rewarm himself by means of peripheral vasoconstriction and not necessarily by shivering.” If the patient is not visibly shivering, the nurse may not be able to observe that he is cold. Pflug was able to show by means of leg limb flow studies that some patients show shivering-like muscle movements that are only visible electronically.12In a study using heated anesthetic gases to maintain normothermia in patients, Pflug studied vasoconstriction as a peripheral vascular response to change in core temperature. A large leg cuff was attached to the thighs of study patients. A plethysmograph attached to the cuff recorded electrocardiographlike recordings on a strip. The recordings reflected arterial blood flow in the limb and the degree of vasoconstriction. Because some of the recordings on
AORN Journal, August 1979, V0130,No 2
Figure 1
Seattle VAMC nursing care plan for postanesthesia shivering Nursing orders
Problems
Expectedoutcomes
Dead1ine
Patient says he feels cold
The patient will say he feels warm
5 to 10 min
Pain potentiated by increased muscular activity
The patient will complain of less pain and will begin to rest quietly
5 to 10 min
1. Apply warm blankets 2. Apply heated nebulization 3. If pain persists, evaluate for pain medication
Slow responsiveness and prolonged recovery time
The patient will open eyes, respond to oral commands, and begin to remain awake
5 to 10 min
1. Consult anesthetic record for depressants given. Evaluate need for reversing agents 2. Take temperature and apply warm blankets 3. OZ@ 1OL until responding 4. Heated nebulization if needed
Decreased BP in conjunction with decreased temperature and decreased level of consciousness
Increased BP Increased T
5 to 15 min 30 rnin
1. Lower head of bed 2. 0 2 by mask and/or heated nebulizer 3. ECG monitoring 4. Evaluate fluid need and consider IV fluid bolus 5. Take temperature and consider warm blankets 6. Heated nebulization if needed
is maintained at 40% heated nebulizer or 1OL per mask on all general anesthetic patients until patient begins to respond and re(02
362
1. Take temperature 2. Apply warm blankets 3. Apply heated nebulization 4. Take temperature upon discharge
main wakeful per orders of Dr Eugene Pflug. Patients with chronic obstructive pulmonary disease are treated with 0 2 < 5L.)
AORN Journal, August 1979,VoE30, No 2
unwarmed patients showed shiveringlike muscle movements, Pflug concluded that patients who have low temperatures and who rewarm rapidly without observable shivering may be experiencing subclinical shivering.13 Therefore, we can say that many more patients may be experiencing hypothermia than we are aware. At Seattle Veterans Administration Medical Center, PARU nurses have assisted in the research of A Eugene Pflug, MD, in the prevention of postanesthetic shivering. In this research, Pflug attached a Bennett Cascade humidifier to the anesthesia machine to maintain a constant normothermic core temperature intraoperatively. The upper airways and lung become a heat exchange unit. Heat from warm inhaled gases is transferred across the 50 to 75 square meters of lung alveolar tissue to pulmonary blood. Heat transfer occurs in a n area containing the esophagus, myocardium, and superior vena cava. Instead of heating the periphery and hoping to eventually warm core tissues or decrease heat loss to the environment, Pflug has tried to influence temperature directly at a core level where interchange takes place between pulmonary and circulatory tissues.14 During t h e postoperative period, shivering in the responding patient was observed and arterial blood gases measured. Of the 20 patients kept warm intraoperatively, none shivered in the recovery room. In 10 of the 20 unwarmed patients, the mean duration of shivering was 29 minutes. In the recovery room, previously unwarmed patients responded to warming measures via warmed humidified 02 and warm blankets within 15 to 20 minutes.15 As their part of the study, nurses observed patients for shivering and recorded temperature readings at specific intervals. The nurses also followed a regimen of extra blankets and heated
364
nebulization. Patients had arterial lines and tympanic and toe temperature probes that were monitored for working order and patient safety. In the recovery room a t the Seattle VAMC, nurses care for debilitated elderly who would normally maintain body temperature by means of more clothing. Younger men with larger muscle mass sometimes shiver uncontrollably before they feel cold. Because we see many patients who experience shivering during recovery, we have developed a special care plan for them, using warm blankets and humidified 02. Warm blankets have long been part of nursing care for patient comfort. However, with the data that Pflug's research provides, we can find a n even more basic rationale for our action. Warming methods support t h e body's normothermic activities to achieve homeostasis postoperatively. While we have used warm blankets for years, warm, humidified 02 is a new idea. The Seattle VA uses a Puritan nebulizer@', which is a n oxygen, or air-driven, water-filled container with a heating device, a hose, and a mask. Heated nebulization loosens thick airway secretions and soothes traumatized airways after dental or ear, nose, and throat procedures. Normally, our patients receive 5 to 10 liters of 02 by mask until they remain awake and responsive. We also apply heated blankets if the patient feels cold, has mottled skin, is slow to wake up, has a temperature of 35.5 C or below, shivers, or complains of being cold. As a result of this treatment, we have observed t h a t some p a t i e n t s recover more quickly, are more relaxed, rest quietly without discomfort, and register a temperature rise upon recovery room discharge. We now place heated nebulizers a t each patient care panel. These nebulizers are readily supplied and maintained
AORN Journal, August 1979, Vol30, No 2
by r e s p i r a t o r y t h e r a p y p e r s o n n e l . H e a t e d n e b u l i z a t i o n i s a n u r s i n g o rd e r us ed f o r p a t i e n t s w h o n e e d warming support. W e believ e p a t i e n t s h i v e r i n g in t h e recovery r o o m i s a h y p o t h e r m i a probl e m . In fact, m o r e postanesthetic pat i e n t s may b e h y p o t h e r m i c than w e a r e aware, depending u p o n observable s h i v e r i n g o r t h e i r ability t o r e p o r t t h e i r discomfort. Gross u n t r e a t e d s h i v e r i n g may also l e a d t o increased o x y g e n cons u m p t i o n d u e t o muscle a c t i v i t y and t o increased cardiac stress i f muscle a c t i v i t y and h y p o x i a persist. T h e r e ar e measures nurses c a n use t o support t h e patient’s n o r m o t h e r m i a in t h e recovery room, i n c l u d i n g w a r m e d oxygenated h u m i d i f i e r and warm blankets. T h e k e y s a re t o a n ti c i p a te t h e poss i b i l i t y o f a p a t i e n t s h i v e r i n g postoperat i v e l y and t o b e p re p a re d t o i m p l e m e n t a special care plan f o r t h i s p a t i e n t . Notes 1. M G Soliman, D M M Gillies, “Muscular hyperactivity after general anesthesia,” Canadian Anaesthetists’ Society Journal20 (September 1972) 529. 2. Ibid, 531. 3. A E Pflug, et al, “Temperature on limb blood flow during halothane anesthesia in man,” unpublished manuscript,p 5 (has been accepted by Annals of Surgery). 4. M Cohen, “An investigation into shivering following anesthesia-a preliminary report,” Proceedings of the Royal Society of Medicine 60 (August
1967) 752.
5. Pflug, et al, “Temperature on limb blood flow,” 9. 6. A E Pflug, et al, “Prevention of postanesthesia shivering,” Canadian Anaesthetists’ Society Journal 25 (January 1978) 46. 7. Ibid, 45. 8 . Soliman, Gillies, “Muscular hyperactivity after general anesthesia,” 532. 9. Pflug, et al, ”Temperature on limb blood flow,”
5. 10. G Brengelmann, Physiology and Biophysics, Ruch-Patton,20th ed. (Philadelphia: W B Saunders Co, Vol Ill, 1973) 124. 11. Pflug, et al, “Prevention of postanesthesia shivering,” 48. 12. lbid, 48.
366
13. Ibid. 14. Ibid, 43, 47. 15. Ibid, 45.
Good results reported for e/der/ypatients with breast cancer Elderly women with operable breast cancer can have prospects for survival comparable to younger women, according to one study. This may in part be due to the kinds of tumors elderly patients tend to develop. William L Betsill, MD, reported his findings to the San Francisco meeting of the US-Canadian division of the International Academy of Pathology. The report is summarized in Medical World News. Dr Betsill, assistant professor of pathology, University of Virginia, Charlottesville, made retrospective studies of women treated at Memorial Sloan-Kettering Cancer Center, New York City, and at the University of Virginia Medical Center, Charlottesville. In one group were 87 patients over 80-years-old, treated between 1960 and 1969; in the other were 108 breast cancer patients from 40- to 55-years-old, treated in 1967 and 1968. Dr Betsill said more elderly patients delayed seeking treatment, resulting in larger and more inoperable tumors. However, of 75 operable patients, only 32 (43%) died of malignancy. Seven deaths occurred five years following surgery. The survival was attributed in part by Dr Betsill to differences in the types of tumors the elderly women developed. The older patients had fewer infiltrating duct carcinomas and more papillary carcinomas. In commenting on the study, William H Goodson 111, MD, clinical instructor in surgery, University of California, San Francisco, said older women may be at an advantage because their tumors tend to grow more slowly. He also said that while few surgeons would not perform surgery solely because of age, he believes surgeons tend to do less extensive procedures on older women.
AORN Journal, August 1979, Vol30, No 2