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Objective: To report on the creation and development of an interdisciplinary anesthesiology and nursing team to provide anesthesia outside the operating room., Material and Methods: We describe the creation of an interdisciplinary team and preanesthesia evaluation protocols for using nurses specializing in anesthesia for procedures outside the operating room. We analyzed the anesthetic procedures performed outside the operating room, the rate of suspensions due to failure of the procedure, and their impact on the rate of associated complications, from October 2006 to October 2007., Results: Since the start of the project, 586 procedures outside the operating room have been performed. No suspensions or delays were observed that were due to comorbidity not detected in the preanesthesia evaluation carried out by the nurses. The incidences of complications and inadequate sedations were comparable to those reported for other similar interdisciplinary groups in this area., Conclusions: The creation of an interdisciplinary team of anesthesiologists and specialized nurses for providing anesthesia outside the operating room optimizes resources and improves routine clinical practice. It has allowed for universal preanesthesia evaluation, improved the distribution of resources, and proven a stimulus to the care-giving process.

The use of sedatives is relatively frequent in hospital care. However the evaluation of the effects of sedatives continues to be carried out in a non-standardized manner. There are two forms to do so, either by use of subjective evaluation scales like Ramsay or RASS, among others, or by means of an objective evaluation instrument, the bispectral index or BIS, produced by Aspect. BIS monitoring permits medical personnel to measure objectively the degree of anesthesia. This technology make it possible to administer an adequate anesthesia to patients and thus prevent unnecessary overdoses, since the evaluation scales are ineffective on patients treated with muscle relaxants. BIS is especially recommended for patients who have undergone neurological surgery since it is essential to maintain a high degree of comfort plus an adequate sedation in order to practice an adequate clinical evaluation, avoiding an inappropriate sedation which could hide signs and symptoms.

Introduction: Propofol is becoming a widely used drug in patient sedation for patients that undergo endoscopic procedures. There are no reports on the use of propofol in public hospitals in Peru., Objective: To describe our experience in propofol use in colonoscopies performed at Hospital Nacional Cayetano Heredia administered by a dedicated nurse with clinical and pulse oximetry monitorization in procedures performed by gastroenterologists and in-training residents of gastroenterology., Material and Methods: An observational and prospective study was performed at the Gastroenterology unit of Hospital Nacional Cayetano Heredia from Lima, Peru from January 2007 to April 2008. Patients were chosen on arrival to get an appointment for colonoscopy provided they did not have any exclusion criteria. Midazolam and meperidine IV premedication was administered prior to attack dose administration of propofol followed by boluses administered according to the nurse and physician assessment of the patient's pulse oximetry, ventilation, sedation and tolerance to the procedure., Results: 163 colonoscopies were performed. Medium dose of propofol was 89.51mg (range 30mg - 220mg). 5,5% of patients had oxygen saturation less than 90% during the procedure but none required mask ventilation. There were no other complications. Procedure was performed by a gastroenterologist and by an in-training resident of gastroenterology. The same and only nurse was in charge of sedation in every procedure. Sedation degree achieved by patients in SAS scale (sedation agitation scale) was 3 (Sedated) in 66,26% and 4 (Calm and cooperative) in 29,45%. No patient had scales 1 (unarousable), 6 (very agitated) or 7 (dangerous agitation)., Conclusion: Propofol sedation can be safely administered by a trained nurse with only pulse oximetry and clinical monitorization in colonoscopies performed by gastroenterologist as well as in-training residents of gastroenterology, being a very comfortable procedure both for patients and endoscopists.

Introduction: Mechanically ventilated patients require sedation during ventilatory support. Our study has aimed to determine if the effects on the sedation level of a nursing-driven sedation protocol has any influence in the accidental removal of tubes and catheters., Material and Methods: A quasi-experimental intervention study was performed in a medical-surgical intensive care unit. A 17-month pre-intervention observational period was followed by a 17-month intervention period where a nursing-driven sedation protocol based on the Glasgow Coma Score modified by Cook and Palma was implemented. In both periods, we registered the accidental removals of endotracheal tube, nasogastric tube, urinary catheter and intravascular catheters., Results: A total of 176 patients (age: 65 +/- 17 years; SAPS II: 43 +/- 14) were included in the observation period and 189 patients (age: 65 +/- 15 years; SAPS II: 40 +/- 13) in the intervention period. In second period, the percentage of patients excessively sedated decreased (20% vs. 41%; p = 0.001) and the percentage of patients with optimal sedation increased (53% vs. 35%; p < 0.001). The rate of accidental removals of enteral tubes in the first period was 15.8 per 1,000 tube-days vs. 5.6 in the second period (p = 0.001). No accidental removal of intravascular catheters was found in the second period vs. a rate of 2.6 central venous catheters per 1,000 catheter-days and a rate of 3.4 intra-arterial catheters per 1,000 catheter-days during the first period., Conclusions: Implementation of a nursing-driven sedation protocol increases the percentage of patients with an optimal sedation and decreases the incidence of accidental removal of tubes and catheters.

Introduction: Among the intensive care specialized nursing staff, knowing the sedation level of the patient under their responsibility is of crucial importance. The present study evaluated the knowledge that nurses specialized in intensive care (NSIC) have on the Ramsay Scale (RS) and the way in which they apply it., Material and Methods: Those personnel who were developing their activity in the intensive care units (ICU) of four public hospitals of the cities of Merida, Yucatan, Mexico were enrolled during May 2003. The information was obtained by applying an expressly designed questionnaire that contained both demographic endpoints (age, years of experience as NSIC and type of ICU) and those related with the RS (clinical components that it evaluates, operative definitions, frequency of use per week or day). 95% (95% CI) confidence intervals were applied and odds ratio (OR) was used to determined the likelihood of the event., Results: Of the 60 nurses interviewed, 75% did not know the RS. Age was a significant factor associated with its knowledge, since 11 of 23 with an age equal to or less than 38 years (47.8%) and 4 of 37 over 38 years (10.8%) knew what it evaluated (OR of 4 for the group of lower age, 95% CI 1.5 to 12.3, p = 0.002). Of 15 NSIC who knew what it evaluated, 9 (60%) also knew its operative definitions, and stated that they applied it adequately per day., Conclusions: In this sample, there is an elevated percentage of NSIC who did not know the RS. Age was the factor associated with lack of knowledge.

The usefulness of three clinical scales for monitoring sedation in intensive care units was compared. The Ramsay scale, Cook modification of the Glasgow scale, and combined Ramsay-Cook scale were evaluated. Thirty-five patients with continuous intravenous sedation were monitored using all three clinical scales. The scores were collected simultaneosly with a two-observer method carried out by the nurse in charge of the patient and a second observer (nurse or physician). The three scales were considered valid and reproductible, with "good" agreement for the Ramsay scale and "very good" agreement for the Cook modified coma scale and the combined Ramsay-Cook scale. In conclusion, since the Cook modified Glasgow scale was the most reproducible, it is preferred for use in research and daily practice. The Ramsay scale is more subjective, but may be useful for daily nursing activities.

A study was made of the degree of orientation, cooperation, and anxiety of patients admitted to the Intensive Care Unit of the Hospital de la Santa Creu i Sant Pau (level III), at the conclusion of prolonged continuous sedation. Recovery time was evaluated, understood as the time required to achieve orientation in time, place, and person. The study was descriptive. An analysis was made of 37 patients who met inclusion criteria between July 1995 and March 1996. After discontinuing sedation, the Glasgow assessment was carried out (modified by Cook and Palma) every four hours until a score of > or = 14 was obtained. From then on, the degree of anxiety, using the Hamilton scale, and cooperation and orientation, using our own scales, were evaluated four times a day. The assessment concluded when the patient was oriented in time, space, and person. We recorded age, sex, disease, disease severity, previous admissions, type of sedation, need for additional bolus injections, and the state of anxiety as perceived by family members. Mean age of patients was 65.1 +/- 13.3 years; 81.1% were men. Respiratory disease was the most common pathology, mean SAPS was 10.7 +/- 2.6, and the most frequently administered drug was midazolam (81%). Patients required an average of 15 hours (164-0) to awaken and tended to taken longer to awake with midazolam. Once the were awake, the required 10 hours (48-0) hours before the were completely oriented. The degree of anxiety was mild and cooperation was regular during all measurements. No relation was found between variables. Our results suggest that a care plan designed to shorten temporal disorientation and promote cooperation would improve the quality of awakening.

The objective of this work is to identify the degree of preoperatory anxiety which patients who must undergo cardiac surgery present, and evaluate the influence of sedation with Propofol or Midazolam in the appearance of anxiety in the immediate and late postoperatory. The study population was formed by 22 patients, being appointed at random to receive Propofol or Midazolam in infusions. We used the scale of Max Hamilton in three consecutive stages (preoperatory, post-extubation, and pre-discharge) to measure the level of anxiety. Both groups were similar according to their distribution in sex, age, weight, conscience level and severity level at entrance. The patients who were sedated with propofol showed a level of postoperatory anxiety significatively lower than those patients who were treated with midazolam (p < 0.05). To conclude, we believe that the type of sedative used has a significant influence in the development of post-operatory anxiety.