Unknown Pseudocholinesterase Deficiency in a Patient Undergoing TIVA with Planned Motor Evoked Potential Monitoring: A Case Report

Pseudocholinesterase abnormalities are a genetic cause of aberrant metabolism of the depolarizing muscle relaxant succinylcholine. This article examines a case where succinylcholine was chosen to facilitate intubation due to its ultra short duration and the request of the surgeon to monitor motor evoked potentials. Following succinylcholine administration the neurophysiologist was unable to obtain motor evoked potentials. This case study highlights the intraoperative and postoperative management of an elderly patient with an unknown pseudocholinesterase deficiency.

Evaluation and management of apparent life-threatening events in infants

Apparent life-threatening events (ALTEs) are frightening to caregivers and clinicians alike. This article provides a comprehensive review of the causes, management, and consequences of ALTEs. The information provided was collected from an extensive literature review using the search terms ALTE, sudden infant death syndrome, and apnea. There is a wide array of contributing factors to ALTE syndrome and sequalae for both infants and caregivers of infants experiencing an ALTE.

Can all neonatal resuscitation be managed by nurse practitioners?

AIM

To assess the ability of nurse practitioners to manage the care of all babies requiring resuscitation at birth in a unit without on site medical assistance.

METHOD

A prospective review, and selective external audit, of the case records of all 14 572 babies born in a maternity unit in the north of England during the first eight years after nurse practitioners replaced resident paediatric staff in 1996.

RESULTS

Every non-malformed baby with an audible heart beat at the start of delivery was successfully resuscitated. Twenty term babies and 41 preterm babies were intubated at birth. Eight term babies only responded after acidosis or hypovolaemia was corrected following umbilical vein catheterisation; in each case the catheter was in place within six minutes of birth. Early grade 2-3 neonatal encephalopathy occurred with much the same frequency (0.12%) as in other recent studies. Independent external cross validated review found no case of substandard care during the first hour of life.

CONCLUSION

The practitioners successfully managed all the problems coming their way from the time of appointment. There was no evidence that their skill decreased over time even though, on average, they only found themselves undertaking laryngeal intubation once a year. It remains to be shown that this level of competence can be replicated in other settings.

A primer on Apnea of prematurity

Apnea, the cessation of respiratory airflow, can begin in many preterm infants in the first week of life and can last until the day of discharge or beyond. This article provides an overview of the complex anatomic, physiological, and developmental mechanisms related to immaturity of both the central nervous system and musculature of the pulmonary system, that contribute to apnea of prematurity. Apnea of prematurity is a diagnosis of exclusion; an array of other conditions and stimuli can also cause apnea, including infections, pulmonary disease, and intracranial pathology. The standard clinical management of apnea, including cutaneous stimulation, methylxanthine therapy, and continuous positive airway pressure or ventilatory support, are discussed as well as newer investigational therapies, such as olfactory stimulation. Emerging evidence on the long-term neurodevelopmental impact of apnea is reviewed. Nursing measures to prevent and manage apnea are reviewed with an emphasis on parent education and preparation for discharge. Apnea resolves in most preterm infants as they approach term corrected gestational age; however, if it does not, options include continued hospitalization or, for infants with stable apnea, discharge with a home apnea monitor.

Theophylline or caffeine: which is best for apnea of prematurity?

Apnea of prematurity is a common problem of the premature infant under 30 weeks gestation. Theophylline and caffeine, two methylxanthines, are widely used to treat this condition. The drugs are equally effective in preventing apnea in the premature infant. Caffeine citrate has many advantages over theophylline, however, including once-a-day dosing, more predictable plasma concentrations, earlier onset of action, and minimal side effects. Caffeine is therefore the initial drug of choice for apnea of prematurity.

Apnea of prematurity: diagnosis, implications for care, and pharmacologic management

Apnea is a disorder of respiratory control commonly seen in premature infants. Several mechanisms have been proposed to explain apnea, and many clinical conditions have been associated with its development. Apnea of prematurity is seen in infants less than 37 weeks gestation, with the incidence increasing as gestational age decreases. Expert and consistent nursing care is essential for management of premature infants with apnea. This article reviews the differential diagnosis, pathogenesis, and implications for care of apnea of prematurity.

Parenting of at-risk infants in the face of uncertainty: home apnea monitoring of subsibs

This article describes the experiences of a group of parents in New Zealand who lost infants to sudden infant death syndrome (SIDS) and who monitored their subsequent infants or subsibs (infants born after the death of an infant due to SIDS) at home for signs of apnea. Their caregiving experiences are explored within the framework of the substantive theory developed by Cohen (1993) that describes how another group of parents, those caring for children with chronic life-threatening illnesses, copes with living under conditions of sustained uncertainty. Attention is drawn to the similarities in both the grieving processes and coping strategies used by both groups of parents in these parallel situations.

Apnea frequently persists beyond term gestation in infants delivered at 24 to 28 weeks

BACKGROUND

Apnea of prematurity remains among the most commonly diagnosed conditions in the Newborn Intensive Care Unit and may prolong hospital stays in some infants. Because survival of extremely premature infants has improved markedly, the natural history of apnea in this population needs to be reassessed.

OBJECTIVE

To document the natural history of recurrent apnea and/or bradycardia events in infants delivered at 24 to 28 weeks' gestation.

METHODS

Medical records of all infants delivered at 24 to 28 weeks' gestation admitted to the Brigham and Women's Hospital Newborn Intensive Care Unit between January 1989 and March 1994 were reviewed to document the clinical course of apnea of prematurity. Subjects were included in the study sample if they were discharged home from the Brigham and Women's Hospital or after transfer to an affiliated hospital. Recordings of apnea and/or bradycardia events were based on nursing observations of monitor alarms and assessment of the infant's condition.

RESULTS

Of 457 eligible infants, 226 were included in the study sample and stratified by gestational age at birth assigned by the attending neonatologist. The time to resolution of recurrent apnea/bradycardia events was longer with lower gestational age at birth. Apnea/bradycardia events were frequently observed beyond 36 weeks' postconceptional age in all gestational age groups. The incidence of apnea persisting beyond 38 weeks postconceptional age was significantly higher in the 24- to 27-week infants combined compared with the 28-week infants.

CONCLUSIONS

Apnea of prematurity frequently persists beyond term gestation in infants delivered at 24 to 28 weeks' gestational age. These persistent apnea and/or bradycardia events may contribute to prolonged hospitalization. Programs to promote earlier discharge of premature infants should take into account the variability in resolution of apnea and specifically address management of persistent apnea.

Pharmacologic management of apnea of prematurity

Apnea of prematurity is one of the most common problems in the neonatal intensive care unit. Management of premature infants with apnea involves pharmacologic and nonpharmacologic therapies. Drugs such as theophylline and caffeine are used when nonpharmacologic measures are ineffective. The article discusses the different types of apnea seen in premature infants, how these drugs affect premature infants, how to recognize early signs of toxicity, and implications for nursing assessment and management.

Recent advances in home infant apnea monitoring

Appropriate and effective nursing intervention is an essential element in determining how the family responds to the monitor in the home. Accurate assessment of the family system and dynamics provides the basis for a plan of care. The family's and infant's specific needs must be addressed. Careful implementation of the plan allows for changes and unexpected outcomes. Frequent evaluation of monitoring is necessary to determine if a change in the plan of care is needed. Recent changes in home apnea monitoring technology are rapidly altering the care of infants at risk for apnea and SIDS. The advent of the documented or recording monitor has the potential to demystify the events occurring while the infant is being monitored. Parents can get answers about their infant as quickly as a telephone call. The clinician can differentiate between a true and a false alarm and reassure the parents accordingly. Documenting false events and shallow-breathing alarms will potentially reduce the duration of monitoring, decreasing costs to the entire health care system. Documented monitoring is a valuable tool for nurses. For the staff nurse, clinical observation can be validated through trending and print out of events can be done at the bedside. For the advanced practice nurse, management of care can become more efficient through remote monitoring via modem. Patient teaching can be followed with immediate feedback. Monitors may assist in allaying anxiety in families who have lost children to SIDS or had an unexpected death in a previous sibling. Families may feel less anxious about having an "at risk" child in the home if the events are continuously being recorded. Length of hospital stay may decrease initially, with fewer rehospitalizations. Nursing research in these areas is necessary. Evaluating events occurring in the home may also help shed light on the enigma of SIDS. Several SIDS deaths have been recorded on documented monitors. If we can pinpoint exactly what takes place prior to and immediately after a SIDS episode, the enigma that has had physicians puzzled for so long may finally begin to unravel.

The art and science of home infant apnea monitoring in the 1990s

The use of home apnea monitoring (HAM) continues as an accepted or recommended intervention for infants with certain signs and symptoms or medical diagnoses. Results of HAM in terms of case outcomes versus cost-effectiveness and efficacy remain matters of controversy in relation to the limited number of studies that show conflicting results. There are no studies that document the effectiveness of apnea monitoring. When an apnea monitor is prescribed, nursing can provide quality care through education and emotional support of families using HAM.

Home apnea monitoring. A systems approach to the family's home care needs

Parents who bring home an infant requiring constant home apnea monitoring often face a stressful situation with their child's medical difficulties and their own financial concerns. The home care nurse must be aware of the difficulties facing these families to offer the necessary support and education.

The difficult first week at home with a premature infant

The results reported were obtained from the findings of a larger descriptive study that surveyed the support needs of 56 mothers of high-risk premature infants. Forty-eight percent of the mothers found the first week after their infant's discharge home difficult. Data analysis indicated the more premature the infant (birth weight r = 0.29, P = 0.03; gestational age r = 0.34, P = 0.008), and the greater the severity of illness as determined by length of hospital stay (r = -0.27, P = 0.04), the more likely the mother was to have a difficult first postdischarge week. The visit of the community health nurse during that first week was a significant factor in whether the mothers perceived the time as difficult (Fisher's exact test, P = 0.02). It was found, as well, that the community health nurses were less likely to visit mothers of very low-birth-weight infants during that week (Fisher's exact test, P = 0.02). Other variables related to difficulty during the first week were whether the infants had apnea in hospital (r = 0.33, P = 0.01), mothers' need for specific kinds of information such as knowledge about colic (chi 2 = 24.31, df = 12, P = 0.02), and an earlier scheduled visit to a physician for mothers whose infants were of lower birth weight (r = -0.26, P = 0.05), earlier gestational age (r = -0.34, P = 0.009), and had spent longer time in hospital (r = 0.37, P = 0.006).

Third-party payor billing and reimbursement for nursing services: infant apnea management

This article examines the process of implementing a program for billing third-party payors for the services of the pediatric clinical nurse specialist. Factors to consider when initiating a billing program are discussed, as well as guidelines for structuring the charges, obstacles to reimbursement and strategies to overcome them, and benefits (both direct and indirect) of implementing such a program. Examples are cited from apnea management programs at two major children's hospitals in the southwestern United States. Implications are made regarding generalizing these methods to other nursing services and practices.

The effect of home nursing visits on parental anxiety and CPR knowledge retention of parents of apnea-monitored infants

The use of structured home nursing visits was evaluated for its effect upon parental anxiety and retention of cardiopulmonary resuscitation (CPR) knowledge in the family of the apnea-monitored infant. A two-group design was used, with treatment families receiving three visits by the researcher during the 6 weeks postdischarge. Anxiety levels and CPR knowledge of parents were measured at the discharge teaching sessions and again 6 weeks later in both groups. The difference between test scores was evaluated to assess for a treatment effect. Despite no statistically significant difference in anxiety or knowledge over time, the treatment families did show a greater decrease in anxiety scores and maintained or improved their CPR scores. Maternal scores tended to be higher than paternal scores for both variables. There was also some evidence of enhanced parental adaptation to the monitor and to the parental role in the treatment group.

Apnea of prematurity: current management and nursing implications

Apnea is a common occurrence in preterm infants. Neonatal nurses must have a clear understanding of the diagnosis, pathophysiology, and management of apnea of prematurity. In addition, there are many implications for the nurse caring for the preterm infant with apnea. Nurses play an essential role in monitoring for apnea and the effectiveness of its treatment.

Caffeine citrate in the NICU

Administering caffeine citrate is a safe, noninvasive way to treat premature infants with persistent apnea. This drug decreases the frequency of apneic episodes, thus reducing the need for mechanical ventilation. It is given once a day, either orally or intravenously. Ideally, caffeine citrate can treat apnea of prematurity and prevent insults to the premature infant's neurological status.

Infantile apnea monitoring and SIDS

Primary care practitioners are presented with many concerns and questions from families about Sudden Infant Death Syndrome (SIDS), apnea, and monitors. Clinicians need to know which symptoms are of concern, when to ask for consultation from an apnea center, and how to refer the parent for support and counseling. This article reviews the current knowledge of infantile apnea, monitoring, and SIDS. An approach to evaluation and management is presented.

Patient-centered high-technology home care

High-technology home care is a reality in today's health care system. Nurses, as health professionals, will be involved in high-technology home care for many patients, regardless of age or diagnosis. The nurse's involvement may be in the predischarge setting or in the home actually providing care. High-technology home care cannot and should not merely be care of the technology (the "machines and tubes") at home; rather, it should emphasize the care of the patients and families who are receiving technically complex therapies. To provide care for the patient and entire family, all nurses involved with the patient need to be aware of where the patient and family are developmentally, the structure of family relationships, the expectations with regard to home therapy, and the ability of the patient and family to physically or emotionally manage the therapy. Incorporating this information into a care plan for patient and family teaching can enable the nurse to provide care to the patient and family that surpasses that of merely seeing that the high-technology procedure is done safely and correctly.

Maternal responses to home apnea monitoring of infants

The purpose of this study was to describe types of upset experienced by mothers of infants who received apnea monitoring for 1 to 17 months. A 38-question, semistructured interview was used. Interrater reliability (90%) was established through analysis of 15 videotaped interviews and agreement on content analysis of 74 transcribed interviews. Results are discussed according to nine categories of upset identified by the mothers: (a) fear, (b) lack of credibility, (c) problems with the monitor, (d) disrupted family life, (e) emotional effects, (f) lack of support, (g) concerns for the infant, (h) unresolved problems, and (i) unhelpfulness of health professionals.

Patient education and the quality assurance process

As these three examples suggest, the QA conference at East Tennessee Children's Hospital is an excellent mechanism by which relevant patient education activities can be incorporated into the routine medical management of many patient groups. In this regard, many physicians respond better to the recommendations of their peers than to requests from patient education coordinators, nurses, or others who need physicians' approval and support in providing consistent patient education services. Although most of the medical staff at East Tennessee Children's Hospital readily offer such support, the cooperation of the child life department with the QA conference has helped to identify clearly the important role of patient education in a comprehensive approach to the QA process.