Risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory: a matched case-control study

Background
Side effects of the medications used for procedural sedation and analgesia in the cardiac catheterisation laboratory are known to cause impaired respiratory function. Impaired respiratory function poses considerable risk to patient safety as it can lead to inadequate oxygenation. Having knowledge about the conditions that predict impaired respiratory function prior to the procedure would enable nurses to identify at-risk patients and selectively implement intensive respiratory monitoring. This would reduce the possibility of inadequate oxygenation occurring.

Aim
To identify pre-procedure risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory.

Design
Retrospective matched case–control.

Methods
21 cases of impaired respiratory function were identified and matched to 113 controls from a consecutive cohort of patients over 18 years of age. Conditional logistic regression was used to identify risk factors for impaired respiratory function.

Results
With each additional indicator of acute illness, case patients were nearly two times more likely than their controls to experience impaired respiratory function (OR 1.78; 95% CI 1.19–2.67; p = 0.005). Indicators of acute illness included emergency admission, being transferred from a critical care unit for the procedure or requiring respiratory or haemodynamic support in the lead up to the procedure.

Conclusion
Several factors that predict the likelihood of impaired respiratory function were identified. The results from this study could be used to inform prospective studies investigating the effectiveness of interventions for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory.

Clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory: a modified Delphi study

Aim : To develop clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory.

Background : Numerous studies have reported that nurse-administered procedural sedation and analgesia is safe. However, the broad scope of existing guidelines for the administration and monitoring of patients who receive sedation during medical procedures without an anaesthetist present means there is a lack of specific guidance regarding optimal nursing practices for the unique circumstances where nurse-administered procedural sedation and analgesia is used in the cardiac catheterization laboratory.

Methods : A sequential mixed methods design was used. Initial recommendations were produced from three studies conducted by the authors: an integrative review; a qualitative study; and a cross-sectional survey. The recommendations were revised according to responses from a modified Delphi study. The first Delphi round was completed by nine senior cardiac catheterization laboratory nurses. All but one of the draft recommendations met the predetermined cut-off point for inclusion with 59 responses to the second round. Consensus was reached on all recommendations.

Implications for nursing : The guidelines that were derived from the Delphi study offer 24 recommendations within six domains of nursing practice: Pre-procedural assessment; Pre-procedural patient and family education; Pre-procedural patient comfort; Intra-procedural patient comfort; Intra-procedural patient assessment and monitoring; and Postprocedural patient assessment and monitoring.

Conclusion : These guidelines provide an important foundation towards the delivery of safe, consistent and evidence-based nursing care for the many patients who receive sedation in the cardiac catheterization laboratory setting.

It makes you realize, really, just how deep your subtext is : Literature, subjectivity and curriculum change

This paper draws on the notion of discourse to explore complex relationships between teachers and curriculum change. It uses poststructuralist views of discourse to explore ways in which school subjects, such as Literature, are discursively constructed across time, while teachers too are positioned within discourses that shape the ways they understand the subject and themselves as teachers of it. This paper reports on the experience of a small group of teachers of a new literature course in the Australian state of Victoria. Nine teachers were interviewed over 3 years, and the interview transcripts read for traces of discourses formative in shaping their response to the new course. I identified three discourses: Leavisite and New Critical formations of the subject Literature; charismatic pedagogy; and critical theory, which was embodied in the new subject's study design. These 3 discourses, together with the traditions and culture of the school, form the framework for analysis of the interviews. The paper explores ways in which the teachers' positioning within this mix of discourses and settings variously supported or undermined their preparedness to accept new configurations of the subject Literature as well as the implications of curriculum change not just for constructions of the subject but also for teacher subjectivity.

Fostering deep and elaborative learning and generic(soft) skill development: the strategic use of case studies in accounting education

It is vital that accounting educators take responsibility for the development of students' generic (soft) skills in conjunction with, discipline-specific skills. Research indicates that the typical learning styles of accounting students are not suited to the acquisition of generic skills. In this paper learning theory is used to provide a framework to support the use of case studies as a tool to promote appropriate learning styles and thereby enhance generic skill development. The paper details a number of strategies that may be implemented with case studies to achieve these goals. The implications for accounting educators, which are significant, are discussed.

An ecologically mixed brachiopod fauna from Changhsingian deep-water basin of South China: consequence of end-Permian global warming

The Late Permian Shaiwa Group of the Ziyun area of Guizhou, South China is a deep-water facies succession characterized by deep-water assemblages of pelagic radiolarians, foraminifers, bivalves, ammonoids and brachiopods. Here we report 20 brachiopod species in 18 genera from the uppermost Shaiwa Group. This brachiopod fauna is latest Changhsingian in age and dominated by productides. The palaeoecologic and taphonomic analysis reveals that the brachiopod fauna is preserved in situ. The attachment modes and substratum preference demonstrate that the Shaiwa brachiopod fauna comprises admixed elements of deep-water and shallow-water assemblages. The presence of the shallow-water brachiopods in the Shaiwa faunas indicates the involuntary settlement of shallow-water brachiopods. The stressed ecologic pressure, triggered by warming surface waters, restricted ecospace and short food sources, may have forced some shallow-water elements to move to hospitable deep-water settings and others to modify their habiting behaviours and exploit new ecospace in deep-water environments. We infer that the end-Permian global warming and subsequent transgression event may have accounted for the stressed environmental pressure in the shallow-water communities prior to the end-Permian mass extinction.

Sedation and analgesia management for mechanically ventilated adults: literature review, case study and recommentations for practice.

The quality of sedation management in mechanically ventilated patients has been a source of concern in recent years. This paper summarises the literature on the principles of optimal sedation, discusses the consequences of over and undersedation, highlighting the importance of appropriate pain management, and presents a case study using the results of an audit of 48 mechanically ventilated adults. As a result of the review and audit, we are implementing changes to practice.

The most important recommendations from the literature are the use of a sedation scale, setting of a goal sedation score, appropriate pain management and implementation of a nurse initiated sedation algorithm. Other recommendations include use of bolus rather than continuous sedative infusions and recommencing regular medications for anxiety, depression and other phychiatric disorders as soon as possible. A recommendation arising from our audit was the need to identify patients at high risk of oversedation and undersedation and adopt a proactive rather than reactive approach to management. The practice goal is to provide adequate and appropriate analgesia and anxiolysis for patients. This will improve patient comfort while reducing length of mechanical ventilation and minimising risk of complications.

Staff perceptions on the use of a sedation protocol in the intensive care setting

Sedation protocols are increasingly being investigated as a method of achieving improved patient outcomes whilst guiding the decision making of both nursing and medical practitioners. However, only a limited number of studies have investigated the perceptions of staff towards a sedation protocol during its implementation. This study was designed to survey the perceptions of staff regarding the implementation of a sedation protocol in an Australian intensive care unit (ICU). Questionnaires were distributed to all multidisciplinary team members who had used the sedation protocol. The response rate was 50% (n=70). The questionnaire combined the use of visual analogue scales plus a comments section to obtain qualitative data.

The results revealed that staff perceived sedation management to be enhanced with the use of a protocol and therefore should be incorporated into routine clinical practice. Staff perceived that providing clear guidelines that facilitated decision making and assisted beginner practitioners enhanced sedation management. In addition, there was a perceived improvement in the patient outcomes, including a decrease in the frequency of over-sedation resulting in a reduced ICU stay.

Positive perceptions may assist in the introduction of other interventional protocols. Other protocols may target areas where variability in clinical decision making exists, despite research evidence that supports specific therapeutic interventions. Further studies addressing protocol implementation for clinical interventions are warranted in other ICU settings.

Fat content of chips, quality of frying fat and deep-frying practices in New Zealand fast food outlets

Objectives: To collect baseline data on the fat content of hot chips, quality (degradation) of cooking fat, deep-frying practices and related attitudes in fast food outlets in New Zealand. To identify the key determinants of the fat content of chips and quality of cooking fat. Methods: A nationally representative sample of fast food outlets (n=150, response rate 80%) was surveyed between September 1998 and March 1999. Data collected included a questionnaire, observation of cooking practices and analysis of cooked chips and frying fat. Results: Only 8% of independent operators had formal training in deep frying practices compared with 93% of chain operators. There was a wide range of fat content of chips (5%-20%, mean 11.5%). The use of thinner chips, crinkle cut chips and lower fryer fat temperature were associated with higher chip fat content. Eighty-nine per cent of chain outlets used 6–10 mm chips compared with 83% of independent outlets that used chips ≥12 mm. A wide range of frying temperatures was recorded (136–233°C) with 58% of outlets frying outside the reference range (175–190°C). As indices of fat degradation, fat acid and polar compound values above the recommended levels occurred in 54% and 5% of outlets respectively. Operators seemed willing to learn more about best practice techniques, with lack of knowledge being the main barrier to change. Conclusions and implications: Deep frying practices could be improved through operator training and certification options. Even a small decrease in the mean fat content of chips would reduce the obesogenic impact of this popular food.