Evidence Based Care
Volume:13 Issue: 1, Spring 2023

Failure to wean a patient from mechanical ventilation after cardiac surgery is associatedwith poor outcome.

The present study was performed aimed to investigate the risk factors of prolonged mechanicalventilation (PMV) following isolated coronary artery bypass graft (CABG) surgery.

This retrospective cohort study was performed on 2155 consecutive adult patientsundergoing isolated coronary artery bypass graft surgery (May 2012 to November 2016 at Imam Rezahospital, Mashhad, Iran). The subjects were assessed for duration of weaning from mechanicalventilation, predictive risk factors for prolonged mechanical ventilation and associated outcomesincluding intensive care unit (ICU) and hospital length of stay (LOS), and mortality. Data wereanalyzed by SPSS (version 22). P<0.05 was considered statistically significant.

The median (25 -75 percentile) duration of mechanical ventilation was 360 (225-540)minutes. Also, 51.20%, 45.80% and 2.30% patients were weaned from mechanical ventilation in lessthan 6 hours, 7 to 24 hours, and more than 24 hours, respectively. Cerebral vascular accident was themost common cause of PMV (34.04%). After adjustment for confounder variables, on-pump CABG(P<0.05), duration of surgery (P<0.01), preoperative renal failure (P<0.05) and New York HeartAssociation (NYHA) class 4 were associated with PMV (P <0.05). PMV was associated withincreased length of ICU and hospital stay (P<0.01). There was a higher mortality rates in patients withPMV (P<0.001).

Implications for Practice: 

Most patients are weaned from mechanical ventilation within 24 hoursuneventfully after isolated CABG. Furthermore, on-pump CABG, prolonged surgery, preoperativerenal insufficiency, and NYHA class 4 were independent predictors of prolonged mechanicalventilation. Identifying the risk factors causing PMV can prevent its adverse consequences.

Spiritual distress negatively affects well-being, and its effects are much stronger and more permanent than the positive aspects of spirituality. Since spiritual distress has destructive effects, the introduction and validation of defining characteristics, which are most likely expressive of spiritual distress in the client, can be applied in the daily use of this nursing diagnosis for the quick identification of individuals with spiritual distress, designing targeted and culture-based nursing care, and cost reduction.

The present study was performed with aim to assess the content validity of the defining characteristics of nursing diagnosis of "spiritual distress".

This methodological study was performed based on the six steps of Fehring's diagnostic content validity model. A total of 40 nursing experts participated in the study to validate 74 defining characteristics. Descriptive statistics and Fehring's diagnostic content validity model were used for data analysis.

Contents validity of 74 defining characteristics was assessed. Six defining characteristics were identified as primary that four were introduced by North American Nursing Diagnosis Association (NANDA), four were considered as irrelevant and 64 were identified as secondary that 29 were introduced by NANDA. The total score of diagnostic content validity was 0.68.

Implications for Practice: 

Validation and identification of defining characteristics as representative of nursing diagnosis of spiritual distress can be effectively applied to help quick and correct identification and provide targeted and optimal nursing care.

Although laparoscopic surgery causes less postoperative pain than open surgery, however, the pain at the site of the laparoscopic port incision and in the shoulder and upper abdomen are the main complaints. Moreover, since postoperative nausea and vomiting (PONV) is the other complaints of these patients, it is important to adopt measures to address this issue (1-5).Today, acetaminophen is one of the most widely used analgesics due to its efficacy, safety, low side effects, and rare drug interactions (5, 6). Acetaminophen has different mechanism of actions that some of them have not been identified yet. It controls pain by preventing the production of prostaglandin E2, indirectly activating the cannabinoid receptor type 1, inhibiting the nitric oxide system by involving N-methyl-D-aspartate and substance P, and directly by stimulating descending serotonergic pathways that hinder pain signals transmitted by the spinal cord. Serotonin 5-Hydroxytryptamine (5-HT3) receptor antagonists, such as ondansetron, are at the front line of PONV treatment (7, 8). Furthermore, use of intravenous acetaminophen can also reduce PONV and the rate of antiemetic consumption (9-12). PONV is a common complication with a prevalence rate of 20-30% (3, 10). Ondansetron is the selective 5-HT3 antagonist which is effective in the prevention of PONV particularly if administered prior to the onset (3). In laparoscopic cholecystectomy, ondansetron administration can reduce the incidence of PONV in the first 4 h after the surgery (1). Ondansetron, in addition to triggering zone chemoreceptor in the medulla oblongata, affects the 5-HT3 receptor in the spinal cord on the pathway that modulates pain transmission signals. Some studies proposed that since ondansetron has antagonistic effects on 5ht3 receptors, it can reduce analgesic effects of acetaminophen. Therefore,ondansetron may be present at the 5-HT3 receptor of acetaminophen antagonist since the two medications have opposite effects on the 5-HT3 pathway (7).However, other studies have not concluded that co-administration of 5ht3 antagonists such as ondansetron and tropisetron could reduce the analgesic effects of acetaminophen. Moreover, review of literature showed one study which claimed direct analgesic effects for 5-HT3 antagonists (7, 12-17).Metoclopramide is another medication used to control PONV, and some studies reported the analgesic effects of this medication (18-22). Khazaei et al. and Karacabey et al. examined the effect of metoclopramide on migraine headaches and confirmed the results of previous studies regarding the positive effect of metoclopramide in reducing such headaches (19, 20). Ceyhan and colleagues conducted an experimental study on male rats and reported that metoclopramide could reduce incisional pain (22).Contrary to the laboratory results, the findings of some clinical studies have indicated that ondansetron did not reduce or even increased the analgesic effect of acetaminophen; however, the results of some studies have reported the blockage or reduction of this effect. According to our researches, there was no study on analgesic effect of co-administration of metoclopramide and acetaminophen and comparing its analgesic effect with ondansetron; therefore, this study was performed aimed to evaluate the effect of adding ondansetron and metoclopramide to intravenous acetaminophen on pain control and postoperative nausea and vomiting of patients undergoing laparoscopic cholecystectomy.

This double-blind clinical trial study with a parallel design was conducted in 2019 on patients undergoing laparoscopic cholecystectomy in the central operating room of Ghaem Hospital in Mashhad, Iran. According to the study by Koyunco et al. (7), the sample size was estimated to be 25 patients in each group by confidence level of 95% and power of 80%; finally, considering the possibility of 10% drop, 28 patients were considered in each group The study population consisted of all patients undergoing laparoscopic cholecystectomy. Participants were selected by Convenience Sampling method and entered the study after obtaining the written informed consent. The subjects were randomly allocated to three groups using the selection of sealed envelopes by the researcher. The first group (group A) received 1 g of intravenous acetaminophen by infusion 30 minutes before the end of surgery plus 4mg of ondansetron at the end of procedure. The second group (group B) was administered 1 g of intravenous acetaminophen by infusion 30 minutes before the end of surgery plus 8 mg of ondansetron at the end of procedure. The third group (group C) took 1 g of intravenous acetaminophen by infusion 30 minutes before the end of surgery plus 10 mg of metoclopramide at the end of procedure. Postoperative pain was measured as a primary outcome using the Numeric Rating Scale (NRS) after transferring the patient to the recovery room when patients' consciousness returned, before leaving the recovery room and 6 h after the operation in the ward. According to this scale, patients were asked to score their pain from a score of 0= no pain to 10= the most pain they have ever experienced. The validity and reliability of this scale have been investigated in various studies (23,24). Analgesic drug (other than acetaminophen) was injected for patients who had NRS score of ˃ 4.Demographic data, including age, weight, gender, and the duration of surgery were also recorded. The severity of nausea and vomiting before leaving the recovery was assessed by the PONV scale, which was developed by Wengritzky et al., who alsoevaluated its validity and reliability. In this 4-item scale, the highest score of items one or two is multiplied by the scores of items three and four to render the PONV score in the first 6 h after surgery (25).The inclusion criteria were: class I and II ASA age of 18-64 years, ability to communicate, no drug addiction, no analgesic administration in the last 24 h, no ondansetron or metoclopramide intake in the last 24 h, no chronic pain, and no history of sensitivity to acetaminophen, ondansetron, and metoclopramide.The exclusion criteria were: unusual and severe side effects of anesthesia, such as a severe drop (more than 50% of the baseline) in systolic blood pressure and heart rate that doesn’t respond to initial treatment, surgical complications which turned the procedure into an open surgery or despite managing the surgery with the closed approach, the operation lasted for more than 50% of the average of other operations, and the incidence of PONV, which required treatment with any of the medications in the family of 5-hydroxytryptamine inhibitors.All participants were completely monitored. General anesthesia was induced with propofol 2.5 mg/kg, atracurium 0.5 mg/kg, fentanyl 2 mcg/kg, and midazolam 20 mcg/kg. Maintenance of anesthesia was continued with propofol at a dose of 100-200 mcg/kg/min and remifentanil at a dose of 0.2-0.3 mcg/kg/min. The laparoscopic procedure and employed equipment were identical for all patients.In addition to the patients and the statistical analyzer, the person completing the NRS and PONV scales was also blinded to the groups.  Kolmogorov-Smirnov test was applied to assess the normal distribution of quantitative variables. Qualitative variables were expressed in the form of frequency and percentage, quantitative variables in the form of mean (standard deviation), or with median (1st and 3rd quarters) in the case of a non-normal distribution. Chi-square and Fisher's exact test were used to evaluate the equality of proportions of qualitative variables among the three groups. Analysis of variance was used to compare the mean of quantitative normal variables in the three groups. The marginal model of generalized estimate equations (GEE) was used for intragroup and intergroup comparisons. Bonferroni's post hoc test was used for pairwise comparisons. Data was analyzed using SPSS software (version 25.0). P< 0.05 was considered statistically significant.

Ethical considerations:

This research was approved by the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran (Ir.mums.medical.rec.1397.593) and registered in the Iranian Registry of Clinical Trials (IRCT20160516027925N4). Informed consent was obtained from the patients before entering the study. All the conditions, the possibility of study withdrawal and how to access the results were explained to the participants orally and in written form. The data of this study can be obtained by sending an email request to the corresponding author while maintaining the confidentiality of the patients' information.

A total of 84 individuals participated in this study, among them 1 case in the third group  was excluded due to surgical complications leading to open surgery (Figure 1). In the acetaminophen + ondansetron 4mg (group A), acetaminophen + ondansetron 8mg (group B), and acetaminophen + metoclopramide (group C), 77.8%, 75.0%, and 74.1% of the patients were female, respectively. According to the Analysis of variance, Chi-square and Kruskal Wallis tests, all three groups were homogeneous in terms of gender (P=0.947), age (P>0.802), weight (P=0.724), and the duration of surgery (P>0.99). The summary of demographic information and the duration of surgery were presented in Table 1.The patients' PONV mean scores in the acetaminophen + ondansetron 4mg (group A), acetaminophen + ondansetron 8mg (group B), and acetaminophen + metoclopramide (group C) groups were

Acupressure as one of the complementary and alternative medicine (CAM) has become very popular in the management of various diseases such as diabetes. Although the increasing use of acupuncture, there are limited systematic reviews and meta-analyses in this field.

The present study was performed with aim to investigate the effectiveness of acupressure on the blood sugar parameters of patients with type 2 diabetes.

In this rapid systematic review and meta-analysis, the studies published globally between 2010 and 2022 were searched in the PubMed, Google Scholar, and Science Direct databases with the keywords of acupressure, diabetes, complementary medicine, blood sugar and glycosylated hemoglobin as separately and in combination. To analyze data, STATA software version 11 was used to analyze data, and the random effect model method was applied for meta-analysis of the studies.

Among the 411 articles found in the initial search, finally 8 articles were selected for this study. The results of the meta-analysis of studies showed that acupressure had a positive effect on blood sugar (95% CI = 0.816-1.553, P < 0.001, OR = 1.18) and fasting blood sugar (95% CI = 0.260 - 0.857, P˂0.001, OR = 0.559) in diabetic patients, while it had no effect on the level of glycosylated hemoglobin (95% CI = -0.139 - 0.389, P = 0.355, OR = 0.559).

Implications for Practice:

 This study showed the positive effect of acupressure in reducing blood sugar and fasting blood sugar in patients with diabetes, however more studies are required to confirm the effect of acupressure on glycosylated hemoglobin.

Autism spectrum disorder (ASD) children are characterized by increased proinflammatory agents. Previous studies found that administration of selenium can reduce inflammation; however, those studies were conducted on ASD mice model, and no study was conducted on the ASD patients. It is suspected that selenium could improve the development of ASD children by decreasing inflammation.

The present study aimed to evaluate the effect of selenium on inflammatory status in ASD children.

This study was a randomized control trial. A total of 66 ASD children were selected and were randomly allocated to the first selenium intervention group (n=22), second selenium intervention group (n=22), and group control (n=22). Selenium as functional food and supplement was given to the intervention group for three months. The inflammatory state was measured by IL-1β, IL-6, and TNF-α serum. The ASD severity was measured by the autism treatment evaluation checklist (ATEC). Moreover, the intention-to-treat analysis was used in this study. The Wilcoxon test was used to compare before and after the intervention and Kruskal-Wallis test to compare the changes after the intervention.

Based on findings of the present research, some insignificant changes in IL-1β, IL-6, and TNF-α were observed in the selenium intervention and control groups. The selenium intervention groups experienced a significant decrease in ATEC scores compared to the control group (P<0.05).

Implications for Practice:

 Although selenium did not decrease inflammatory status in ASD children, it could decrease the ASD severity. Appropriate interventions are needed to improve the inflammation in ASD children.

Tonsillectomy is a common painful surgery in children. One of the methods of pain relief is the use of non-pharmacological treatments.     

This study was performed with aim to determine the effect of distraction Techniques on pain intensity and acetaminophen received after tonsillectomy in children aged 5-12 years old.

This experimental study was conducted on 75 children aged 5-12 years old from September 2020 to March 2021. The subjects by random allocation method were divided into two intervention groups (1: watching cartoons, 2: listening to music) and one control group. Wong-Baker Faces Pain Rating Scale and the Numerical Pain Rating Scale (NRS) were used to report pain intensity. Data were analysed by SPSS software (version 25) and inferential statistical tests, such as Wilcoxon, kruskal-wallis, chi-square, and Mann-Whitney U. P<0.05 was considered statistically significant.

In the intervention group 1, significant difference was found between before and after the intervention in terms of pain intensity (p <0.001). After the intervention, there was a significant difference in the pain intensity and acetaminophen received between the intervention group1 and 2 and between the intervention group 1 and the control group (p <0.001).

Implications for Practice:

 Distraction techniques by watching cartoons reduce postoperative pain and acetaminophen received. Therefore, it is recommended that these techniques be used by patients or their caregivers to reduce pain after tonsillectomy.

Fatigue and re-admissions are the important consequences of heart failure that cause limitations in patients’ daily activities, personal, and social affairs. Energy conservation techniques are among evidence-based and non-pharmacological approaches that can reduce fatigue in patients with chronic disease.      

The present study was performed with aim to determine the effects of tailored energy conservation training on fatigue and readmissions of patients with heart failure (HF).

This randomized clinical trial study was performed from May 2019 to March 2020 on 96 patients with HF admitted to CCU and cardiovascular clinics affiliated to Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. Patients who met the inclusion criteria were randomly assigned to the intervention and control groups. A three-part tool (demographic-clinical questionnaire and need assessment), the Fatigue Severity Scale (FSS) and a readmissions record checklist were used to collect data. After determining the training needs of each individual, the intervention group received five 45-minute face-to-face individual training sessions of energy conservation strategies reinforced by telephone support every two weeks and followed up for 12 weeks. The control group only received routine post-discharge training. Fatigue scores by FSS and the readmissions recorded were tested at baseline and three months after the end of the intervention.

At baseline, the two groups were comparable in the mean hospital admissions and fatigue scores. However, after the intervention, the mean frequency of hospital admissions and the mean fatigue score were significantly lower in the intervention group (1.36±1.26, P< 0.001; 2.86±1.01,P< 0.001) than in the control group (0.42±0.77, P< 0.001; 5.25±1.03, P< 0.001) respectively.

Implications for Practice: 

Nurses and physicians are recommended to teach energy conservation methods to patients with HF and chronic conditions who are prone to fatigue and its side effects.

Low quality of surgical field is a common problem during open radical prostatectomy (ORP).

This study was performed aimed to survey the effects of Trendelenburg position on the quality of surgical field, mean arterial blood pressure (MABP), heart rate (HR), regional cerebral oxygen saturation (rSO2) and cognitive function in patients undergoing ORP.

This randomized controlled clinical trial study was done on 60 patients candidates for ORP in Shahid Beheshti Hospital of Hamadan in 2022. Patients were selected by the convenience sampling method and were divided into two intervention and control groups using the random blocking method. In intervention group, patients were placed in a 15° head-down tilt before surgery. The control group was remained in a sleeping position on the back during surgery. The surgical field quality was assessed after surgery. The MABP, HR, and rSO2 were assessed after anesthesia induction, after positioning, and consecutively in 30-minute intervals during the surgery.

The mean age was 60.93±4.24 years. A significant difference was found between the two groups regarding the surgeon's satisfaction with the surgical field quality (P=0.04). There was a significant difference between the two groups regarding surgery time (t=-3.00, P=0.004). No significant differences were found between the two groups in terms of MABP, HR, and rSO2 in either of the measurements (P>0.05).

Implications for Practice: 

It is recommended to use Trendelenburg position, as a safe position, to improve exposure to the pelvis during surgery.