- Email: [email protected]
Unanesthetized Infants Question Raised Again
JUNE 1988, VOL. 47, NO 6
AORN JOURNAL
Letters to the Editor Sterilization Definition Questioned
I
n the March 1988 “Clinical Issues” column, a sterilized item is defined as one that has been exposed to the sterilization process and is believed to be free of microorganisms. This definition is totally inadequate because “belief’ has nothing to do with whether or not an item is sterile. In the August 1982 issue of the Journal, my article, “Microbiological safety index,” discussed the problems in defining “sterile” and suggested that there were three conflicting definitions. Briefly they are: 1. The absolute definition-a sterile object is one that is free of any living contamination. Unfortunately, this cannot be scientificallyproven. 2. The manufacturer’s definition-an object is sterile if the probability of living contamination is less than one in one million. This can be statistically demonstrated, and is sometimes referred to as the statistical definition. 3. The regulatory definition-an object may be labeled and sold as sterile if certain steps are taken (including cleaning and quality assurance) during the manufacture of the object. The OR nurse is no longer responsible for the sterilizing of most objects. It is essential, however, that he or she clearly understand what is meant by the word “sterile” when it appears on a package. And in some cases, it may be appropriate to ask “Who says it is sterile and how do they know?” ROBERTF. SMKH VICE PRESIDENT, OPERATIONS DIACK,INC BEULAH, MICH Author’s response. Words are meant to convey meaning, but there is no assurance that a single 1360
word will convey the same meaning to every person. According to Mr Smith’s article, “traditionally, sterile has referred to the complete absence of living microorganisms.” This is the absolute definition Mr Smith refers to in his letter. As he points out, it is not possible to prove that any item is free of all living microorganisms. Even though it is possible to prove that something does exist, it is virtually impossible to prove that something does not exist. We may not be aware of some species of microorganisms, and we may not have a suitable culture media for demonstrating unknown organisms. Because achievement of a negative absolute, as in the absolute definition of sterility, cannot be proven, a sterilized item may be defined as one that has been exposed to the sterilization process and is expected to be free of known microorganisms. Perioperative nurses may no longer be responsible for the sterilization of most objects, but they continue to be responsible for the sterilization of many objects. Mr Smith has expanded on information provided in the “Clinical Issues” column by sharing alternate definitions of sterility. He makes an important point. It is essential that the OR nurse clearly understand what is meant by the word “sterile” when it appears on a package. RUTHE. VAIDEN,RN, CNOR DIRECTOR OF NEUROSURGICAL NURSING NEUROSURGICAL ASSOCIATES, PC RICHMOND, VA
UnanesthetizedInfants Question Raised Again
I
nherent in the “Letters to the Editor” column entitled “Unanesthetized infants article challenged” in the March issue of the Journal is the assumption
J U N E 1988, VOL. 47, NO 6
that physicians know their business and they should not be questioned. It was that mentality that led surgeons in Victorian England to excise women’s clitorides because husbands were offended by their wives’ passion. Physicians make errors individually and in groups, much like the rest of society in which they are a necessary part. Granted, it is intimidating and possibly economically unwise for a nurse to confront a physician, but sometimes the patient would be better off for it. I am the mother referred to in the December 1987 “Ethics” column whose son had a one and one-half hour thoracotomy with no anesthesia or pain relief. My son was not comatose or moribund;
AORN JOURNAL
rather, he was distressingly alert. If nurses and physicians had done the right thing, it would not be necessary for me to speak out. This is an issue of right and wrong, not a technical debate. The shame is not that a non-nurse was a Journal author; rather that in 1988 it is still necessary to say such things. In addressing the issue of unanesthetized surgery, adults have historically reserved exclusive rights to anesthesia even though we know its risks. We accept these very substantial risks to avoid inordinate suffering. It is time to accord the same rights to infants who can not speak for themselves. JILLR. LAWSON SILVER SPRING, MD
Weight Loss, Physiologic Impairment, Indicate Risk Researchers at Auckland Hospital, Auckland, New Zealand, have concluded that weight loss indicates a risk of postoperative complications only when it is accompanied by physiologic impairment, according to an article in the March 1988 issue of Annals of Surgery. They examined 102 patients before major surgery and took complete histories to determine whether the patients experienced a recent weight loss or reduction in capacity for activity. They assessed patients’ moods, skeletal muscle function, respiratory muscle function, and wound healing. Researchers looked for tiredness, malaise, depression, and apathy. Major changes in the patient’s activity were noted as physiologic impairments. Based on the information gathered, patients were placed in one of three groups. Group I patients were normal, group I1 patients had weight loss of more than 10%in three months, but no clinical evidence of physiologic impairment, and group 111 patients had weight loss of more than 10%in three months in addition to dysfunction of two or more organ systems. Researchers measured patients’ total body fat
and protein stores; liver and psychologic function; and respiratory and skeletal muscle function. The 42 patients in group 111 were, on average, older than those in the other groups, and their average weight was less. The loss of body weight was similar in group I1 and group 111 patients and was significantly less than in group I patients. Only group 111 patients had significantly lower body fat and protein stores than group I patients. The liver, skeletal muscle, respiratory, and psychologic function of group 111 patients also was significantly lower than in the other groups. Patients in group 111 suffered more postoperative complications, had more septic complications, and had longer hospital stays. The results of the study show that weight loss is a basic indicator of surgical risk only when associated with organ function impairment. They also suggest that adequate body protein stores are necessary for normal body function and for minimizing the risks of surgery.
1361
AORN JOURNAL
Letters to the Editor Sterilization Definition Questioned
I
n the March 1988 “Clinical Issues” column, a sterilized item is defined as one that has been exposed to the sterilization process and is believed to be free of microorganisms. This definition is totally inadequate because “belief’ has nothing to do with whether or not an item is sterile. In the August 1982 issue of the Journal, my article, “Microbiological safety index,” discussed the problems in defining “sterile” and suggested that there were three conflicting definitions. Briefly they are: 1. The absolute definition-a sterile object is one that is free of any living contamination. Unfortunately, this cannot be scientificallyproven. 2. The manufacturer’s definition-an object is sterile if the probability of living contamination is less than one in one million. This can be statistically demonstrated, and is sometimes referred to as the statistical definition. 3. The regulatory definition-an object may be labeled and sold as sterile if certain steps are taken (including cleaning and quality assurance) during the manufacture of the object. The OR nurse is no longer responsible for the sterilizing of most objects. It is essential, however, that he or she clearly understand what is meant by the word “sterile” when it appears on a package. And in some cases, it may be appropriate to ask “Who says it is sterile and how do they know?” ROBERTF. SMKH VICE PRESIDENT, OPERATIONS DIACK,INC BEULAH, MICH Author’s response. Words are meant to convey meaning, but there is no assurance that a single 1360
word will convey the same meaning to every person. According to Mr Smith’s article, “traditionally, sterile has referred to the complete absence of living microorganisms.” This is the absolute definition Mr Smith refers to in his letter. As he points out, it is not possible to prove that any item is free of all living microorganisms. Even though it is possible to prove that something does exist, it is virtually impossible to prove that something does not exist. We may not be aware of some species of microorganisms, and we may not have a suitable culture media for demonstrating unknown organisms. Because achievement of a negative absolute, as in the absolute definition of sterility, cannot be proven, a sterilized item may be defined as one that has been exposed to the sterilization process and is expected to be free of known microorganisms. Perioperative nurses may no longer be responsible for the sterilization of most objects, but they continue to be responsible for the sterilization of many objects. Mr Smith has expanded on information provided in the “Clinical Issues” column by sharing alternate definitions of sterility. He makes an important point. It is essential that the OR nurse clearly understand what is meant by the word “sterile” when it appears on a package. RUTHE. VAIDEN,RN, CNOR DIRECTOR OF NEUROSURGICAL NURSING NEUROSURGICAL ASSOCIATES, PC RICHMOND, VA
UnanesthetizedInfants Question Raised Again
I
nherent in the “Letters to the Editor” column entitled “Unanesthetized infants article challenged” in the March issue of the Journal is the assumption
J U N E 1988, VOL. 47, NO 6
that physicians know their business and they should not be questioned. It was that mentality that led surgeons in Victorian England to excise women’s clitorides because husbands were offended by their wives’ passion. Physicians make errors individually and in groups, much like the rest of society in which they are a necessary part. Granted, it is intimidating and possibly economically unwise for a nurse to confront a physician, but sometimes the patient would be better off for it. I am the mother referred to in the December 1987 “Ethics” column whose son had a one and one-half hour thoracotomy with no anesthesia or pain relief. My son was not comatose or moribund;
AORN JOURNAL
rather, he was distressingly alert. If nurses and physicians had done the right thing, it would not be necessary for me to speak out. This is an issue of right and wrong, not a technical debate. The shame is not that a non-nurse was a Journal author; rather that in 1988 it is still necessary to say such things. In addressing the issue of unanesthetized surgery, adults have historically reserved exclusive rights to anesthesia even though we know its risks. We accept these very substantial risks to avoid inordinate suffering. It is time to accord the same rights to infants who can not speak for themselves. JILLR. LAWSON SILVER SPRING, MD
Weight Loss, Physiologic Impairment, Indicate Risk Researchers at Auckland Hospital, Auckland, New Zealand, have concluded that weight loss indicates a risk of postoperative complications only when it is accompanied by physiologic impairment, according to an article in the March 1988 issue of Annals of Surgery. They examined 102 patients before major surgery and took complete histories to determine whether the patients experienced a recent weight loss or reduction in capacity for activity. They assessed patients’ moods, skeletal muscle function, respiratory muscle function, and wound healing. Researchers looked for tiredness, malaise, depression, and apathy. Major changes in the patient’s activity were noted as physiologic impairments. Based on the information gathered, patients were placed in one of three groups. Group I patients were normal, group I1 patients had weight loss of more than 10%in three months, but no clinical evidence of physiologic impairment, and group 111 patients had weight loss of more than 10%in three months in addition to dysfunction of two or more organ systems. Researchers measured patients’ total body fat
and protein stores; liver and psychologic function; and respiratory and skeletal muscle function. The 42 patients in group 111 were, on average, older than those in the other groups, and their average weight was less. The loss of body weight was similar in group I1 and group 111 patients and was significantly less than in group I patients. Only group 111 patients had significantly lower body fat and protein stores than group I patients. The liver, skeletal muscle, respiratory, and psychologic function of group 111 patients also was significantly lower than in the other groups. Patients in group 111 suffered more postoperative complications, had more septic complications, and had longer hospital stays. The results of the study show that weight loss is a basic indicator of surgical risk only when associated with organ function impairment. They also suggest that adequate body protein stores are necessary for normal body function and for minimizing the risks of surgery.
1361