Explore the risk perception and evaluate the effectiveness of competency-based intervention (CBI) on knowledge and lifestyle changes among type 2 diabetes mellitus patients

OBJECTIVE

This is a study to explore the risk perception among T2DM patients and to compare the pre-test and post-test levels of knowledge and lifestyle changes among T2DM patients at selected hospitals in Chennai. Most diabetics have type 2 diabetes, accounting for 85-90% of cases. Diabetes is a worldwide epidemic disease with distressing human, societal, and economic effects. It affects an estimated 382 million people worldwide in 2021.

PATIENTS AND METHODS

The research design used mixed-method research, such as Exploratory Sequential Design. The phenomenological approach, in that sequential exploratory design for the qualitative and true experimental design for the quantitative study, was chosen. 60 samples of T2DM patients were selected using a simple random sampling technique through the lottery method and divided into experimental and control groups for every 30 samples in quantitative. Five samples were selected using convenient sampling for qualitative.

RESULTS

In the quantitative study, the pre-test showed 4 (13.3%), and 5 (16.7%) adequate knowledge and lifestyle changes in both groups. Post-test experimental group showed that 23 (76.7%) had adequate knowledge and 23 (76.7%) changes in lifestyle found a drastic transformation from the pre-test as well as in the control group. The calculated Chi-square value showed a significant difference in the post-test level of lifestyle change among the T2DM patients between the groups at p<0.001 level.

CONCLUSIONS

This inferred that Competent Based Intervention (CBI) on knowledge and lifestyle changes administered to T2DM patients in the experimental group was found to be effective. Competent Based Intervention is a nursing intervention that is well accepted and adopted by patients and easily implemented by nurses. It can be included in the nursing curriculum. In-service education can be arranged once a month for staff nurses and faculty members regarding Competent Based Intervention. The Nurse educator should encourage the nurses to effectively utilize research evidence-based practice related to Competent Based Intervention for patients with type 2 diabetes mellitus.

Ventilation by mask before and after the administration of neuromuscular blockade: a pragmatic non-inferiority trial

Background

Test ventilating prior to administration of neuromuscular blockade (NMB) in order to avoid a cannot intubate-cannot ventilate situation is a classic anesthesia teaching. The primary aim of our study was to show that facemask ventilation (FMV) after NMB was not inferior to FMV prior to NMB with respect to exhaled gas volumes before and after their administration.

Methods

This study was approved by the University of Washington Human Subjects Division (Seattle, Washington, USA). Written informed consent was obtained from all patients. Measurements of tidal volume (Vte) as well as other respiratory parameters during FMV were made for 60 s after induction of anesthesia and again after NMB. Difficult, impossible, inadequate, and dead-space only mask ventilation was graded using published definitions. Difficult intubation was defined as >2 attempts at intubation. The primary outcome was non-inferiority in Vte during both study periods defined as a mean difference of <50 mL. Multivariate analysis was performed to assess for interaction between operator experience, patient risk factors for difficult mask ventilation, exhaled volumes, and use of airway adjuncts.

Results

Two-hundred and ten patients were studied. Overall, FMV improved after NMBD. The mean (SD) V_te in mL/breath increased from 399 (169) to 428 (166) (mean dif. 30 mL, p = 0.001) and the minute ventilation in L/min from 5.6 (2.5) to 6.3 (2.5) (mean dif. 0.6, p < 0.001). No patient who was difficult to ventilate after induction became impossible after NMB.

Discussion

In patients at risk for or judged to be a difficult FMV by clinical grading scales, tidal volumes improved after administration of NMBDs. None of these patients exhibited a decline in ventilation or became impossible to ventilate after NMBDs. Several limitations are noted, including the use of hand-delivered breaths and inability to account for time-related changes in ventilation conditions independent of NMBDs.

Conclusion

We conclude that FMV is no worse after NMB than before and is likely to improve airway conditions.

Trial Registration

ClinicalTrials.gov Identifier: NCT02237443. Registered August 28, 2014

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-015-0111-z) contains supplementary material, which is available to authorized users.

Extraglottic airway devices: A review

Extraglottic airway devices (EAD) have become an integral part of anesthetic care since their introduction into clinical practice 25 years ago and have been used safely hundreds of millions of times, worldwide. They are an important first option for difficult ventilation during both in-hospital and out-of-hospital difficult airway management and can be utilized as a conduit for tracheal intubation either blindly or assisted by another technology (fiberoptic endoscopy, lightwand). Thus, the EAD may be the most versatile single airway technique in the airway management toolbox. However, despite their utility, knowledge regarding specific devices and the supporting data for their use is of paramount importance to patient's safety. In this review, number of commercially available EADs are discussed and the reported benefits and potential pitfalls are highlighted.

Rapid-sequence intubation and cricoid pressure

Airway management is the most important clinical skill for anesthesiologist, emergency physician, and other providers who are involved in oxygenation and ventilation of the lungs. Rapid-sequence intubation is the preferred method to secure airway in patients who are at risk for aspiration because it results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis). Application of cricoid pressure (CP) for patients undergoing rapid-sequence intubation is controversial. Multiple specialty societies have recommended that CP is not effective in preventing aspiration; rather it may worsen laryngoscopic view and impair bag-valve mask ventilation. Some experts think that CP should be applied in trauma and patients at risk for aspiration; however CP, if necessary, should be altered or removed to facilitate intubation.

Pediatric airway management

Securing an airway is a vital task for the anesthesiologist. The pediatric patients have significant anatomical and physiological differences compared with adults, which impact on the techniques and tools that the anesthesiologist might choose to provide safe and effective control of the airway. Furthermore, there are a number of pathological processes, typically seen in the pediatric population, which present unique anatomical or functional difficulties in airway management. The presence of one of these syndromes or conditions can predict a "difficult airway." Many instruments and devices are currently available which have been designed to aid in airway management. Some of these have been adapted from adult designs, but in many cases require alterations in technique to account for the anatomical and physiological differences of the pediatric patient. This review focuses on assessment and management of pediatric airway and highlights the unique challenges encountered in children.

Videolaryngoscopy

The approach to airway management has undergone a dramatic transformation since the advent of videolaryngoscopy (VL). Videolaryngoscopes have quickly gained popularity as an intubation device in a variety of clinical scenarios and settings, as well as in the hands of airway experts and non-experts. Their indirect view of upper airway improves glottic visualization, including in suspected or encountered difficult intubation. Yet, more studies are needed to determine whether VL actually improves endotracheal intubation (ETI) success rates, intubation times, and first attempt success rates; and thereby a potential replacement to traditional direct laryngoscopy. Furthermore, advances in technology have heralded a wide array of models each with their own strengths, weaknesses, and optimal applications. Such limitations need to be better understood and alternative strategies should be available. Thus, the role of VL continues to evolve. Though it is clear VL expands the armamentarium not only for anesthesiologists, but all healthcare providers potentially involved in airway management.

Pediatric neurotrauma

Traumatic brain injury (TBI) is the leading cause of death and disability in children over 1 year of age. Knowledge about the age-specific types of injury and how to manage children with neurotrauma is essential to understanding and recognizing the extent and degree of injury and to optimize outcomes. In this article, we review the epidemiology, pathophysiology, and clinical management of pediatric neurotrauma.

Trauma care today, what's new?

Injury is the fourth leading cause of death in the US, and the leading cause of death in younger age. Trauma is primarily a disease of the young and accounts for more years of productive life lost than any other illness. Consequently, almost every health care provider encounters trauma patients from time to time. Many of these patients are critically ill and pose several challenges in the acute phase, including airway and ventilation, fluid management, intracranial pressure control, etc. In the last decade, several strategies and treatment options have been studied in trauma care along with improvement in technologies. In this review, we will discuss a few of the new developments and updates in trauma care.

Propofol infusion syndrome in a super morbidly obese patient (BMI = 75)

Propofol infusion syndrome (PRIS) is a rare but often fatal complication as a result of large doses of propofol infusion (4–5 mg/kg/hr) for a prolonged period (>48 h). It has been reported in both children and adults. Besides large doses of propofol infusion, the risk factors include young age, acute neurological injury, low carbohydrate and high fat intake, exogenous administration of corticosteroid and catecholamine, critical illness, and inborn errors of mitochondrial fatty acid oxidation. PRIS manifestation include presence of metabolic acidosis with a base deficit of more than 10 mmol/l at least on one occasion, rhabdomyolysis or myoglobinuria, acute renal failure, sudden onset of bradycardia resistant to treatment, myocardial failure, and lipemic plasma. The pathophysiology of PRIS may be either direct mitochondrial respiratory chain inhibition or impaired mitochondrial fatty acid metabolism mediated by propofol. We report a case of supermorbidly obese patient who received propofol infusion by total body weight instead of actual body weight and developed PRIS.

Trends in trauma transfusion

Trauma is the leading cause of death in young adults and acute blood loss contributes to a large portion of mortality in the early post-trauma period. The recognition of lethal triad of coagulopathy, hypothermia and acidosis has led to the concepts of damage control surgery and resuscitation. Recent experience with managing polytrauma victims from the Iraq and Afghanistan wars has led to a few significant changes in clinical practice. Simultaneously, transfusion practices in the civilian settings have also been extensively studied retrospectively and prospectively in the last decade. Early treatment of coagulopathy with a high ratio of fresh frozen plasma and platelets to packed red blood cells (FFP:platelet:RBC), prevention and early correction of hypothermia and acidosis, monitoring of hemostasis using point of care tests like thromoboelastometry, use of recombinant activated factor VII, antifibrinolytic drugs like tranexamic acid are just some of the emerging trends. Further studies, especially in the civilian trauma centers, are needed to confirm the lessons learned in the military environment. Identification of patients likely to need massive transfusion followed by immediate preventive and therapeutic interventions to prevent the development of coagulopathy could help in reducing the morbidity and mortality associated with uncontrolled hemorrhage in trauma patients.

Oseltamivir pharmacokinetics in critically ill adults receiving extracorporeal membrane oxygenation support

Extracorporeal membrane oxygenation (ECMO) is known to affect pharmacokinetics and hence optimum dosing. The aim of this open label, prospective study was to investigate the pharmacokinetics of oseltamivir (prodrug) and oseltamivir carboxylate (active metabolite) during ECMO. Fourteen adult patients with suspected or confirmed H1N1 influenza were enrolled in the study. Oseltamivir 75 mg was enterally administered twice daily and blood samples for pharmacokinetic assessment were taken on day 1 and 5. A multi-compartmental model to describe the pharmacokinetics of oseltamivir and oseltamivir carboxylate was developed using a non-linear mixed effects modelling approach. The median (range) clearance of oseltamivir carboxylate was 15.8 (4.8-36.6) l/hour, lower than the reported mean value of 21.5 l/hour in healthy adults. The median (range) steady state volume of distribution of oseltamivir carboxylate was 179 (61-436) litres, much greater than healthy adults but similar to previous reports in critically ill patients. Substantial 'between subject' variability in systemic exposure to oseltamivir carboxylate was revealed; median (range) area under the curve and Cmax were 4346 (644-13660) ng/hour/ml and 509 (54-1277) ng/ml, respectively. Both area under the curve and Cmax were significantly correlated with serum creatinine (r2=0.37, P=0.02 and r2=0.29, P=0.02, respectively). Systemic exposure to oseltamivir carboxylate following the administration of enteral oseltamivir 75 mg twice daily in adult ECMO patients is comparable to those in ambulatory patients and far in excess of concentrations required to maximally inhibit neuraminidase activity of the H1N1 virus. Dosage adjustment for ECMO, per se, appears not to be necessary; however, doses should be reduced in patients with renal dysfunction.

Pre-hospital care of pediatric patients with trauma

Prehospital pediatric care is an important component in the treatment of the injured child, as the prehospital responders are the first medical providers performing life saving and directed medical care. Traumatic injuries are the leading cause of morbidity and mortality in the pediatric patient population. Nevertheless, for most prehospital provider it is a rare event to treat pediatric trauma patients and there is a still existing gap between the quality of care for pediatric patients compared to adults. To improve pediatric prehospital trauma care more provider need to be trained in identifying the specific differences between adult and pediatric patients.

Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma

Trauma care in the general population has largely become protocol-driven, with an emphasis on fast and efficient treatment, good team communication at all levels of care including prehospital care, initial resuscitation, intensive care, and rehabilitation. Most available literature on trauma care has focused on adults, allowing the potential to apply concepts from adult care to pediatric care. But there remain issues that will always be specific to pediatric patients that may not translate from adults. Several new devices such as intraosseous (IO) needle systems and techniques such as ultrasonography to cannulate central and peripheral veins have become available for integration into our pre-existing trauma care system for children. This review will focus specifically on the latest techniques and evidence available for establishing intravenous access, rational approaches to fluid resuscitation, and blood product transfusion in the pediatric trauma patient.

Initial assessment and management of pediatric trauma patients

Injury is the leading cause of death and disability in children. Each year, almost one in six children in the United States require emergency department (ED) care for the treatment of injuries, and more than 10,000 children die from injuries. Severely injured children need to be transported to a facility that is staffed 24/7 by personnel experienced in the management of children, and that has all the appropriate equipment to diagnose and manage injuries in children. Anatomical, physiological, and emotional differences between adults and children mean that children are not just scaled-down adults. Facilities receiving injured children need to be child and family friendly, in order to minimize the psychological impact of injury on the child and their family/carers. Early recognition and treatment of life-threatening airway obstruction, inadequate breathing, and intra-abdominal and intra-cranial hemorrhage significantly increases survival rate after major trauma. The initial assessment and management of the injured child follows the same ATLS^® sequence as adults: primary survey and resuscitation, followed by secondary survey. A well-organized trauma team has a leader who designates roles to team members and facilitates clear, unambiguous communication between team members. The team leader stands where he/she can observe the entire team and monitor the “bigger picture.” Working together as a cohesive team, the members perform the primary survey in just a few minutes. Life-threatening conditions are dealt with as soon as they are identified. Necessary imaging studies are obtained early. Constant reassessment ensures that any deterioration in the child's condition is picked up immediately. The secondary survey identifies other injuries, such as intra-abdominal injuries and long-bone fractures, which can result in significant hemorrhage. The relief of pain is an important part of the treatment of an injured child.

Pediatric burn injuries

Pediatric burns comprise a major mechanism of injury, affecting millions of children worldwide, with causes including scald injury, fire injury, and child abuse. Burn injuries tend to be classified based on the total body surface area involved and the depth of injury. Large burn injuries have multisystemic manifestations, including injuries to all major organ systems, requiring close supportive and therapeutic measures. Management of burn injuries requires intensive medical therapy for multi-organ dysfunction/failure, and aggressive surgical therapy to prevent sepsis and secondary complications. In addition, pain management throughout this period is vital. Specialized burn centers, which care for these patients with multidisciplinary teams, may be the best places to treat children with major thermal injuries. This review highlights the major components of burn care, stressing the pathophysiologic consequences of burn injury, circulatory and respiratory care, surgical management, and pain management of these often critically ill patients.

Sedation and analgesia for the pediatric trauma patients

The number of children requiring sedation and analgesia for diagnostic and therapeutic procedures has increased substantially in the last decade. Both anesthesiologist and non-anesthesiologists are involved in varying settings outside the operating room to provide safe and effective sedation and analgesia. Procedural sedation has become standard of care and its primary aim is managing acute anxiety, pain, and control of movement during painful or unpleasant procedures. There is enough evidence to suggest that poorly controlled acute pain causes suffering, worse outcome, as well as debilitating chronic pain syndromes that are often refractory to available treatment options. This article will provide strategies to provide safe and effective sedation and analgesia for pediatric trauma patients.

Pediatric procedural sedation and analgesia outside the operating room: anticipating, avoiding and managing complications

In the new millennium, there has been a huge surge in the numbers of procedures performed under sedation in pediatric patients outside the operating room. Traditionally, these were performed by anesthesiologists. Increasingly, other specialists, such as emergency room physicians, pediatricians and radiologists, are involved in the management of procedural sedations under elective or emergency situations. Professional organizations such as the American Society of Anesthesiologists, American Academy of Pediatrics, Joint Commission on Accreditation of Healthcare Organizations and other organizations are working continuously to make procedural sedation for children safe, economical and tailored to the needs of the child and the diagnostic/therapeutic procedure being performed. Multi-institutional databases have been set up to investigate the complications related to procedural sedation and lessons are being learned from the analysis of these data. This article reviews these data and describes strategies to prevent and manage common adverse events following procedural sedation in children outside the operating room.

Analgesia and sedation for children undergoing burn wound care

Standard care of burn wounds consists of cleaning and debridement (removing devitalized tissue), followed by daily dressing changes. Children with burns undergo multiple, painful and anxiety-provoking procedures during wound care and rehabilitation. The goal of procedural sedation is safe and efficacious management of pain and emotional distress, requiring a careful and systematic approach. Achieving the best results needs understanding of the mechanisms of pain and the physiologic changes in burn patients, frequent evaluation and assessment of pain and anxiety, and administration of suitable pharmacological and nonpharmacological therapies. Pharmacological therapies provide the backbone of analgesia and sedation for procedural pain management. Opioids provide excellent pain control, but they must be administered judiciously due to their side effects. Sedative drugs, such as benzodiazepines and propofol, provide excellent sedation, but they must not be used as a substitute for analgesic drugs. Ketamine is increasingly used for analgesia and sedation in children as a single agent or an adjuvant. Nonpharmacological therapies such as virtual reality, relaxation, cartoon viewing, music, massage and hypnosis are necessary components of procedural sedation and analgesia for children. These can be combined with pharmacological techniques and are used to limit the use of drugs (and hence side effects), as well as to improve patient participation and satisfaction. In this article, we review the pathophysiologic changes associated with major thermal injury in children, the options available for sedation and analgesia for wound care procedures in these children and our institutional guidelines for procedural sedation.

Current trends and update on injury prevention

Injuries are a major and growing public health problem, a leading cause of death and disabilities among people aged 1-44 years around the world. Each year, 5.8 million people die from injuries, accounting for 10% of the world's deaths. Road traffic injuries (RTIs), self-inflicted injuries and violence are the top three leading causes of all injury deaths, while RTIs, falls and drowning are the top three leading causes of unintentional injury death. In many high-income countries, trends of injury death have been decreasing as a result of prevention measures. In contrast, trends in low- and middle-income countries have been rising. In this article, we review the prevention strategies for RTIs, violence, falls and drowning developed over decades to disseminate the knowledge and inform health care providers, especially acute care physicians, about the importance of injury prevention.

Postoperative cognitive dysfunction in the elderly

Despite improvement in surgical techniques, anesthetic management, and intensive care, a significant number of elderly patients develop postoperative cognitive decline. Postoperative cognitive dysfunction (POCD) is a postoperative memory or thinking impairment that has been corroborated by neuropsychological testing, for which increasing age is the leading risk factor. POCD is multifactorial in origin, but it remains unclear whether its occurrence is a result of surgery or general anesthesia. This article discusses the incidence, assessment, consequences, and prevention of POCD, as well as anesthetic strategies to improve cognitive outcome in elderly patients.

An analysis of 300 EEG referrals

Although the EEG suffers from limited diagnostic significance it is a useful adjuvant to diagnosis and demands for the examination are increasing. Three hundred consecutive referrals to one unit are analysed.