Baguio Central University

Sto. Niño Jesus Medical Center

No. 28 Lower P. Burgos, Baguio City 2600

Journal Reading

In partial fulfillment of requirements

in
Related Learning Experience

Presented to:
Mrs. Mary Monte Mayor
Clinical Instructor

Presented by:
Shehada M. Bondad
1. Nursing Journal Reading:
The Effects of Perioperative Infusions of Amino Acid on Core Body Temperature
Reference: Yun Liu. (2016, June 18). The Effects of Perioperative Infusions of Amino
Acid on Core Body Temperature. Longdom Publishing SL | Open Access Journals.
Retrieved  17, 2020, from https://www.longdom.org/open-access/the-effects-of-
perioperative-infusions-of-amino-acid-on-core-bodytemperature-jpcic-1000119.pdf

a. Synthesis:
- Hypothermia occurs relatively when the core body temperature drops to
below 36°C (96.8°F). Factors resulting in perioperative hypothermia include
operating room temperature, type of surgical procedure and length of
anaesthesia. Inadvertent hypothermia during the perioperative period has
been linked to adverse outcomes such as surgical site infections, coagulation
disorders, postoperative shivering, ischemic myocardial events, and increased
postoperative hospitalization . The prevalence of perioperative hypothermia is
up to 70%, and the American Society of Perianesthesia Nurses has stated that
all medical personnel should institute preventive measures to minimize
perioperative hypothermia . Different interventions are used to treat patients
who are hypothermic. Current nursing approaches for preventing
perioperative hypothermia include increasing the operation room
temperature, warming intravenous and irrigating solutions, covering the
patient’s head and body, and applying circulating set-temperature water
devices. However, these techniques are seldom completely effective.
Furthermore, a recent survey showed that intraoperative temperature
monitoring was often neglected, and only 39% of all patients were actively
warmed . Therefore, evidence- based techniques for minimizing perioperative
hypothermia should be actively explored. A systematic review recently
reported that circulating water garments offered more effective temperature
control than forced-air warming systems, and that both were better for
temperature control than passive warming devices. Another systematic
review reported that the use of room temperature irrigation fluid led to
greater decreases in core body temperature and increased the risk of
perioperative hypothermia and shivering compared with warmed irrigation
fluid .
An alternative technique is to promote the patients’ own ability to generate
heat by the infusion of amino acids, which are known to be effective at
enhancing thermogenic effects and alleviating shivering during the
perioperative period . Studies have shown that amino acid infusions cause
significantly greater increases in core body temperature than infusions of
crystalloid solutions. In addition, a randomized controlled trial showed that
preoperative infusion of amino acids was able to maintain normothermia,
 increase the speed of tracheal extubation, and reduce the amount of time
spent in the ICU and in hospital. Clearly, the ability of perioperative amino acid
infusions to increase core body temperature and reduce the incidence of
shivering remains controversial.Effects of Amino Acid Infusions
According to Moriyama et al., esophageal core temperatures became
significantly higher in the amino acid infusion group than in the saline
infusion group from 150 min after induction of anesthesia until the end of
surgery (P0.005). At the end of surgery, temperatures in the two groups
were 35.6°C (35.3–35.8)°C in the control group vs. 36.1°C (35.9–36.3)°C in the
amino acid group (P0.01). Zhou et al. searched PubMed, EMBASE, CINAHL,
and the Cochrane Register of Controlled Trials for controlled trials that meet
the inclusion criteria. Eleven eligible randomised controlled trials enrolling
506 participants were identified with meta-analysis. Ten of the studies were
in English, and 1 study was in Japanese. The results showed that crystalloid
solution infusions caused a greater drop of core body temperature in
patients, compared to amino acid infusions (SMD: 1.57; 95% CI: 0.79 to 2.35,
I2=91%; p<0.00001). The occurrence of shivering (RR=2.96; 95% CI: 1.71 to 5.15,
I2=14%; p=0.0001) in the groups having amino acid infusions were lower than
the group of studies having crystalloid solution infusions. Additionally,
compared with crystalloid solution infusions, amino acid infusions shorten
duration of postoperative mechanical intubation (WMD: 119.72; 95% CI: 60.15
to 179.29, I2=48; p<0.0001) and duration of hospitalization (WMD: 1.80; 95%
CI: 1.54 to 2.06, I2=0; p<0.00001).

Relative Contraindications of Amino Acid Infusions

Adverse effects accompanying the clinical use of amino acids were not
reported in any of the included studies, but the risk of harmful complications
should be considered. Amino acid infusions may be harmful for patients with
insufficient cardiopulmonary, hepatic, or renal function and those with
severe metabolic disorders. Nurses involved in decision making about the
use of amino acid infusions should be aware that amino acids might be
contraindicated or only suitable for use in low doses in such patients .
Mechanisms of beneficial outcomes of amino acid
Thus, infusions of amino acids may be superior to external heating with regard
to other postoperative complications, such as disturbances of the coagulation
system and surgical site infections. The beneficial effects of amino acid
infusions challenge the speculation that it is ‘‘internal heating’’ from amino
acids that increases body heat during surgery. The mechanisms responsible
for thermoregulatory effects are not completely understood, but the central
thermoregulatory system may be involved by stimulating resting energy
expenditure, and hence heat production. Various other mechanisms may also
 explain these beneficial outcomes . One potential mechanism may be the
better maintenance of core body temperature by patients who receive amino
acid rather than crystalloid solution infusions. Furthermore, amino acid
infusions during surgery reduce nitrogen excretion, which leads to better
patient outcomes after surgery. A third possibility is a decrease in bacterial
translocation. Numerous reports have shown that amino acids administered
via a gastric tube reduce translocation of intestinal bacteria.

b. Reason for choosing this journal

- Unintentional perioperative hypothermia is a common event during general
anesthesia. The best management for hypothermia is prevention. We
need more attention to be paid to stimulate the body's own heat generation.
Amino acid infusion before anesthesia and surgery restored core body
temperature and almost eliminated post-operative shivering and the related
adverse effects of hypothermia without uncompensated extra-hemo-dynamic
or metabolic loads.
c. Expound the implication of the journal to the following:
c.1 nursing education :
-Amino acid infusions which is associated with a shorter period of
mechanical ventilation and hospitalization is recommended to be
warmed to decrease the drop of core body temperature, the occurrence of
perioperative shivering, duration of postoperative mechanical intubation
and hospitalization in surgical patients without hepatic, renal, or severe
metabolic disorders. This suggests that nurses should actively use amino
acid infusions during surgery. However, in most countries, this decision is
made by surgeons or the anesthesia provider but not nurses. It is therefore
crucial to raise awareness of the importance of amino acid infusions among
these disciplines. It is important that all disciplines involved in the care of
the perioperative patient unite regarding the implementation of amino
acid infusions and other effective thermal strategies for maintaining
normothermia throughout surgery.
C2. c.2 nursing practice :
- Nurses are often involved in selecting the most appropriate
intraoperative warming method for preventing hypothermia. Maintaining
normothermia in the operating room is important for nurses, and currently
available systems for preventing intraoperative heat loss (forced air warming,
warmed blankets, electric heating pads, devices for warming infusion fluids,
and circulating set-temperature water devices) provide hope that patients will
leave the surgical suite without shivering. Because effective methods of
reducing heat loss have been available for a number of years, maintenance of
intraoperative normothermia to minimize procedure-related risk and improve
patient comfort is indicated [10]. However, heating strategies is not standard.
 Nurses still face the challenge of keeping patients warm before, during, and
after the surgery. The current literature attaches more importance to
combining several techniques for minimizing heat loss of surgical patients
rather than focusing on a single preventive strategy. Further research is
essential to expand and support research findings regarding the most
effective nursing interventions for minimizing the incidence of hypothermia
and shivering throughout the perioperative period. This suggests that efforts
would be best focused on further optimizing the effectiveness of amino acid
infusions rather than those of currently available systems. The favourable
effects of reducing the incidence of postoperative shivering cannot be
questioned. Notably, the benefits of all systems of amino acid infusions need
to be considered in the light of initial and on-going maintenance costs, which
may preclude advocacy of widespread use of the technique. Studies of costs
remain scant and further research is required to determine the cost-benefit
ratio of the various infusions.

2. CASE STUDY
2.1 DU has just arrived on the nursing unit from the post anesthesisa care
unit (PACU) following a hysterectomy this morning. She is complaining
of pain and nausea. You are the nurse assigned to care for her.
a. What critical assessment data do you need to identify and collect?
- The nurse has to inquire about the pain that the patient is
experiencing. Asking where exactly the pain is gives the location of
the pain. Asking if the patient has turned around or moved helps the
nurse to establish mobility status as well as severity of pain. Asking
the patient to rate the pain on a scale of 0-10 helps to assess the
severity of pain.
- Check Vital signs

b. Formulate 5 (3 to 4 part Nursing Diagnosis - PES or PES 2 nd to)

nursing diagnosis based on your assessment data.
- Grieving related to loss of body part and childbearing ability secondary
to hysterectomy.
- Risk for infection related to surgical intervention and presents of foley
catheter as evidence by patient post-opt day 1 from abdominal total
hysterectomy and indwelling foley catheter present.
- Pain related to tissue trauma secondary to Total Abdominal
Hysterectomy.
- Risk for Ineffective Tissue Perfusion
-Hyperthermia related to Anesthesia secondary to Hysterectomy.
 c. Identify nursing interventions to the identified problem
categorizing it into promotive, preventive and rehabilitative.
- Monitor the patient’s HR, BP, and especially the tympanic or rectal
temperature.
- Provide open environment in which client feels free to discuss realistic
feelings and concerns without confrontation.
- Palpate bladder. Investigate reports of discomfort, fullness, and
inability to void.
- Inspect dressings and perineal pads, noting color, amount, and odor
of drainage. Weigh pads and compare with the dry weight if the
patient is bleeding heavily.
- Turn the patient and encourage frequent coughing and deep-
breathing exercises.
- Administer IV fluids, blood products as indicated.
- Check for Homans’ sign. Note erythema, swelling of extremity, or
reports of sudden chest pain with dyspnea.

2.2 You just have finished discharging two clients to home when the charge
nurse informs you that you will be receiving a client from surgery following a
partial thyroidectomy. You will admit the client from the PACU and will be
assigned as the primary nurse. Since you have 2 more workdays scheduled,
you will be assigned to this client for a total of 3 days.
a. What supplies should you ask the nurse assistant to place in the room?
-Blankets
-IV fluids
-Gown
-water
-clean Towel
b. Why should vital signs be assessed every 15 minutes for 2 hours, then
hourly for 4 hours then every 2 to 4 hours for 24 hours?
- As it is post-op, this ensures that the nurse should be keenly monitor
the patient and observe for complications. The nurse should also keep
the vital signs stable.

c. What instructions about positioning and transferring the client to the

bedside chair should you give the nurse assistant or the primary
caregivers?
 Place in the position of semi-fowlers (head and torso at an angle o
 f 30-45 degrees), support should be provided to the head and nec
k at all times with sandbags or small pillows. Keep the head and n
eck in a neutral position and support during movement to avoid h
yper-extension of the neck.

d. What signs and symptoms should you assess?

 cardiopulmonary* Neurological status*pain level*metabolic state*
Watch surgical dressing for excessive bleeding and chyle
leaks( milky , opaque color of Fluid)
 ·  Airway clearance
 ·  Watch for s/s of hypothyroidism 24 to 72 post op hours( hypocalcium,
numbness and tingling in extremities, positive Trousseau’s and Chvostek’s
signs.

e. What should the client understand about daily thyroid medication?

 Foods such as soya flour, cotton seed meal, walnuts and dietary fiber m
ay cause you to absorb less Synthroid. Take it on an empty stomach
, one hour before breakfast.

3. DRUG CALCULATION (Show computation)

a. Dr. Axel orders 2 mg of Valium IV to a patient with seizure activity. You have a 5ml
vial that contains 10 mgs of Valium (10 mg/5 ml). How many mls are you going to
draw up into a syringe.
Ordered
x Volume Per Have  =  Y (Liquid Required)
Have
2 mg
x 5mL  =  1 mL
10 mg

b. Give patient 500 mcg of dopamine in 250 ml of D5W to infuse at 20 mg/hr.

Calculate the flow rate in ml/hr.
Ordered Per Hour
x Volume (mL)  =  Y (Flow Rate in mL/hr)
Stock
20 mg/hr
x 250 mL  =  10 mL/hr
500 mg
c. Calculate the IV flow rate for 1200ml of NS to be infused in 6 hours. The infusion set
is calibrated for a drop factor of 15 gtts/ mL.

Volume (mL) x Drop Factor (gtts/mL)  =  Y (Flow Rate in gtts/min)

 Time (min)
Convert 6 hours to minutes.
 min ← hr    ( x by 60 )
 6 hr x 60 = 360 min
1200 mL
x 15 gtts/mL  =  50 gtts/min
360 min

d. Calculate the IV flow rate for 200ml of 0.9%NaCl over 120 mins. Infusion set has a
drop factor of 20 gtts/ mL

Volume (mL)
x Drop Factor (gtts/mL)  =  Y (Flow Rate in gtts/min)
Time (min)
200 mL
x 20 gtts/mL  =  33 gtts/min
120 min