bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of interpleural bupivacaine on pleural chest tube removal pain: a randomized controlled trial
Authors: Puntillo KA
Published: November 2019

BACKGROUND: Moderate to severe pain associated with the removal of pleural chest tubes is poorly controlled with opioids. New methods are needed to manage the pain associated with this procedure. OBJECTIVES: To compare the effects of interpleural injections of 0.25% bupivacaine without epinephrine to those of normal saline on chest tube removal pain in cardiothoracic surgery patients. METHODS: A randomized, double-blind, placebo-controlled trial was used, with a repeated measures design. Pain intensity and distress were measured before, immediately after, and 1 hour after chest tube removal. Pain sensations and affect were evaluated immediately after chest tube removal. The experimental group (n = 21) received bupivacaine and the control group (n = 20) received normal saline. RESULTS: In both groups pain intensity and distress scores were significantly higher at the time of chest tube removal than immediately before or 1 hour after. No significant differences in pain intensity, distress, sensation, or affect scores were found between the two treatment groups. The 13 patients who received intramuscular ketorolac an average of 3.5 hours before the procedure, independent of the study design, had significantly lower pain intensity scores at the time of chest tube removal than the 26 who did not. CONCLUSIONS: These data demonstrate that chest tube removal pain is of moderate to severe intensity and that pleural chest tube injections of bupivacaine were not effective in decreasing chest tube removal pain. However, the decrease in pain associated with the administration of ketorolac warrants future study.
Technology assessment in critical care: understanding statistical analyses used to assess agreement between methods of clinical measurement
Authors: Szaflarski NL , Slaughter RE
Published: November 2019

Many new measurement methods that employ various technologies to measure physiological parameters have been introduced into the field of critical care. Clinical assessment of these new methods occurs through the conduct of method-comparison studies in which the level of agreement between a new measurement method and a clinical standard method is determined. Clinicians and researchers are often faced with the complicated task of analyzing and interpreting the results of method-comparison studies. Use of correlation and linear regression techniques has been prevalent in method-comparison studies but has proven inappropriate and inadequate in determining how well methods compare. The purposes of this article are to briefly review the terms of accuracy, agreement, and the precision in context with method-comparison studies, and discuss inappropriate and appropriate statistical analyses and their interpretation. Appropriate data analysis of method-comparison studies will aid in determining not only whether new monitoring methods can be interchanged or used in place of existing methods, but whether new methods warrant further research of their effect on patient outcomes.
Reducing time in bed after cardiac catheterization (TIBS II)
Authors: Keeling A , Taylor V , Nordt LA , Powers E , Fisher C
Published: November 2019

BACKGROUND: More than 500,000 cardiac catheterizations are done annually in the United States for both the diagnosis and treatment of patients with coronary artery disease. A femoral artery catheter insertion site is usually used for these procedures, and postprocedure protocols call for prolonged bed rest with restricted patient movement. Time-in-bed standards vary widely, from 3 to 12 hours after cardiac catheterization to more than 24 hours of bed rest after angioplasty. Bed rest with restricted movement causes patient discomfort, increases nursing workload, and prolongs length of hospital stay. OBJECTIVE: To determine if there would be a significant difference in the incidence of bleeding from femoral artery insertion sites between cardiac catheterization patients who remained in bed for 4 hours and those who remained in bed for 6 hours after sheath removal. METHODS: An experimental-control group design was used with a convenience sample (N = 86) of adult patients undergoing diagnostic coronary angiography. Patients were randomly assigned to remain in bed for 4 hours (experimental) or 6 hours (control) after arterial sheath removal. Both groups had pressure dressings and sandbags in place over the insertion site during time in bed. RESULTS: There was no significant difference in the incidence of bleeding related to out-of-bed activity between the groups (chi-square = .31, df = 1). CONCLUSIONS: Requisite time in bed after cardiac catheterization can be safely decreased from 6 to 4 hours. This change has implications for enhancing patient comfort and decreasing both length of hospital stay and healthcare costs.
Lung transplant rejection: obliterative bronchiolitis
Authors: Spector NM , Connolly MA , ERJr Garrity
Published: November 2019

BACKGROUND: More centers are performing lung transplants for a variety of pulmonary conditions. Chronic rejection, manifested as obliterative bronchiolitis, is the most common cause of late death (greater than 6 months after transplant) in this population. OBJECTIVES: To review published literature on obliterative bronchiolitis to determine the current terminology and definition, pathophysiology, incidence, diagnosis, treatment, and outcome of this condition. DATA SELECTION: A MEDLINE search was done using the medical subject headings of bronchiolitis obliterans and lung transplantation. Studies were selected based on sample size and reporting of obliterative bronchiolitis statistics. Sources that were not data-based discussions also were selected if they were comprehensive reviews or provided insight into relevant issues. SUMMARY: Obliterative bronchiolitis terminology is not used consistently in the literature. It is an obstructive defect that affects the airways, causing progressive occlusion. Diagnosis is based on clinical findings or on histological analysis; early markers are sought, to aid in diagnosis. Incidence of obliterative bronchiolitis varies from 7% to 54%, with a mortality rate of 30% to 40%. Currently, enhanced immunosuppression is the treatment of choice, although research is being carried out to evaluate methods of inhibiting growth factor activity for use in future treatment strategies. CONCLUSIONS: Obliterative bronchiolitis is a common complication in lung transplant recipients, and future research will focus on treatment and early diagnosis. Efforts are under way to standardize nomenclature and reporting of incidence and mortality rates.
Nursing care of the thoracoscopic lung volume reduction patient
Authors: Vaca KJ , Osterloh JF , Daake CJ , Noedel NR
Published: November 2019

BACKGROUND: Several methods to surgically enhance pulmonary function and improve the quality of life in patients with bullous emphysema are currently being evaluated. One of these methods, lung volume reduction, is performed in patients with bullous emphysema that can no longer be well managed with medical therapy. OBJECTIVES: The focus of this article is to review bullectomy via unilateral thoracoscopy with an endoscopic stapler in the management of end-stage pulmonary emphysema, and to discuss nursing care of these patients. METHODS: An experimental study was used, including review of the literature and analysis of clinical experience using chi-square and t test analyses of pre- and postoperative variables. RESULTS: At 3-month follow-up there were significant improvements in forced expiratory volume in 1 second, forced vital capacity, minute volume ventilation, partial pressure of oxygen, residual volume, and 6-minute walk when pre- and postoperative parameters were compared. Operative mortality was 4%, with the most common complication being prolonged air leak, occurring in 30% of patients studied. CONCLUSIONS: There is now consistent preliminary information to support the concept that lung volume reduction improves pulmonary function and quality of life in a significant percentage of patients.
Implementation and evaluation of a liberalized visiting policy
Authors: Simpson T , Wilson D , Mucken N , Martin S , West E , Guinn N
Published: November 2019

BACKGROUND: Visiting policies have been liberalized in ICUs, but the process and outcome of policy modifications have not been well described. OBJECTIVES: To describe the process by which nurses in one critical care unit modified visiting from a restricted to a liberalized (i.e., modified open) policy, and to evaluate the nurses' perceptions about visiting before and after the policy was liberalized. METHODS: A group of ICU/coronary care unit nurses met to discuss changes in their unit's visiting policy. Before the change was initiated, nurses (N = 36) in the unit were informally surveyed regarding their perceptions and attitudes about visiting. After a 3-month trial of liberalized visiting, in which visiting hours were increased at the discretion of the nursing staff, nurses (N = 32) were surveyed using a questionnaire about their beliefs, attitudes, level of satisfaction, and perceptions of their actual visiting policy. RESULTS: Nurses confirmed that the visiting policy had become liberalized, and they believed that liberalized visiting had positive effects on patients' emotional well-being. Nurses had more positive attitudes about the effects of liberalized visiting on families than on patients and unit function. Most nurses were satisfied with liberalized visiting. However, attitudes differed about how liberalized visiting affected patients' physiological responses or the unit function. CONCLUSIONS: Effective implementation of liberalized visiting depends on assessment of the following: nurses' beliefs, attitudes, and satisfaction about a change toward a more open visiting policy; staff involvement in determining the policy; and nurse manager and clinical nurse specialist support.
The impact of the implantable cardioverter defibrillator on quality of life
Authors: Gallagher RD , McKinley S , Mangan B , Pelletier D , Squire J , Mitten-Lewis S
Published: November 2019

The implantable cardioverter defibrillator may prolong survival and prevent sudden cardiac arrest in patients with ventricular arrhythmias. Whereas previous research focused on mortality, attention is now turning to the impact of the device on the recipient. We reviewed the literature on the effects of the implantable cardioverter defibrillator on recipients and their families; our aim was to consolidate our current understanding and guide further research in this area. We found a number of effects on which researchers agree. Primarily, recipients are happy to have the device and generally feel more confident. However, recipients experience many psychological reactions such as fear and anxiety that can be related to the unpredictable nature of the shocks. Recipients also are affected by intellectual changes. Both recipients and their families experience similar effects and use a range of coping mechanisms; the most effective is optimism. Only one nursing intervention has been investigated that directly addresses these effects. Areas that need more research are the effects of the implantable cardioverter defibrillator during childhood, adolescence, and pregnancy; the impact of vigilance on recipients and their families; costs; and nursing interventions. More consistent, standardized quality-of-life measures are needed so that comparisons can be made between samples.
Patients' responses to the angioplasty experience: a qualitative study
Authors: Gulanick M , Bliley A , Perino B , Keough V
Published: November 2019

BACKGROUND: The number of coronary angioplasty procedures performed has increased more than tenfold in the past decade. Most research to date has focused on efficacy of the procedure, quality-of-life issues, and measures to promote comfort after percutaneous transluminal coronary angioplasty. Little or no research has examined the patient's experience during angioplasty. OBJECTIVE: The purpose of this study was to describe the angioplasty experience from the patient's unique perspective. METHOD: Focus-group interviews were used as the qualitative method for data collection. The sample consisted of 45 patients (26 male, 19 female) who had undergone percutaneous transluminal coronary angioplasty 3 to 18 months before the interviews. Seven focus groups (with four to nine subjects each) were conducted. Each 2-hour interview was tape recorded. Data were analyzed by using a constant comparative method. RESULTS: A wide range of themes emerged from the data. Positive themes included the following: contentment with comfort measures, satisfaction with supportive hospital care, and trust in medical competence. Negative themes included anger over unmet needs for comfort or support, feeling dehumanized, and frustration with lack of control in decision making. CONCLUSIONS: This study uncovered a broad range of experiences among patients undergoing percutaneous transluminal coronary angioplasty. Although most participants described very positive experiences, many patients expressed bitter dissatisfaction regarding several aspects of their care. Healthcare providers must be aware of these possible reactions so that they can anticipate, recognize, and intervene early and appropriately.
Effect of facial cooling on tympanic temperature
Authors: Thomas KA , Savage MV , Brengelmann GL
Published: November 2019

BACKGROUND: In clinical practice, tympanic temperature is used as an estimate of body temperature. Theoretically, temperature recorded directly from the tympanum reflects the temperature of arterial blood circulating to the brain. However, some studies do not support this connection. Ear-based thermometers in clinical use, commonly called tympanic thermometers, detect heat emission from the aural canal and tympanum. Dissociation of core body temperature and tympanic temperature would suggest that factors other than arterial blood perfusion affect tympanic temperature. METHODS: In a controlled laboratory experiment with four adult volunteers, esophageal and tympanic temperatures were recorded repeatedly at 2-minute intervals during whole-body heating and cooling. Facial cooling, produced by a small electrical fan, was used in three subjects. RESULTS: The gradient between tympanic and esophageal temperature was inconsistent across subjects, with tympanic temperature both higher and lower than esophageal temperature. Correlations between esophageal and tympanic temperature varied widely across subjects. Fanning the face produced a decrease in tympanic temperature without an accompanying decline in esophageal temperature. CONCLUSIONS: Facial cooling in the form of fanning altered the relationship between tympanic and esophageal temperature. This result suggests the possible lowering of tympanic temperature by cooled facial venous blood flow. Use of tympanic temperature in circumstances in which facial temperature may be different from that of other regions of the body deserves further study.
Comparison of heparinized and nonheparinized solutions for maintaining patency of arterial and pulmonary artery catheters
Authors: Zevola DR , Dioso J , Moggio R
Published: November 2019

BACKGROUND: Arterial and pulmonary artery catheters are often used in the management of critically ill patients. If heparin were not necessary to maintain the patency of arterial and pulmonary artery catheters, these patients could avoid exposure to heparin. OBJECTIVES: The purpose of this study was to determine if the failure rate of arterial and pulmonary artery catheters differs depending on whether a nonheparinized or heparinized solution is used. The null hypothesis was that catheter failure rates would not differ. METHODS: The study was done at a large tertiary medical center in the northeastern United States, and all subjects who had pulmonary artery or arterial catheters inserted were included in the study. A solution of 1 U of heparin per 1 mL of normal saline was used to maintain the patency of the arterial catheter and the distal portion of the pulmonary artery catheter in one group; normal saline alone was used in the other group. Variables used to monitor catheter patency and the reasons for catheter removal were recorded. RESULTS: Failure rates of pulmonary artery catheters were not significantly different between the two groups. For arterial catheters, however, the failure rate was significantly different between the two groups, regardless of whether the subjects had received other anticoagulants. CONCLUSION: The failure rate of pulmonary artery catheters was not affected by the use of nonheparinized solutions. Arterial catheters failed less often when they were maintained with heparinized solutions. The authors recommend that all arterial catheters be maintained with heparinized solutions, unless use of heparin is contraindicated.
Sleep in the pediatric ICU: an empirical investigation
Authors: Cureton-Lane RA , Fontaine DK
Published: November 2019

BACKGROUND: Although sleep is important for physical and psychological health, no research has assessed the sleep of children in a pediatric ICU and the factors that affect sleep. OBJECTIVES: To observe the sleep of children in a pediatric ICU and to determine the relationship of noise, light, contact with caregivers, parental presence, and severity of illness to the sleep obtained by children in a pediatric ICU during a 10-hour night. METHODS: At 5-minute intervals from 8 PM until 6 AM, a convenience sample of nine patients was observed. Sleep state, noise and light levels, contact with caregivers, and parental presence were recorded. Severity of illness was measured on admission and within 26 hours of data collection. RESULTS: Subjects slept for a mean total of 4.7 hours (SD = 0.49) during the 10-hour night, interrupted by a mean of 9.8 awakenings (SD = 2.48). The mean length of a sleep episode was only 27.6 minutes (SD = 25.85). Mean noise level was 55.1 dB(A) (SD = 6.82), with sudden, sharp elevations of up to 90 dB(A). Probit analysis indicated that noise, light, and contact with caregivers were significant predictors of sleep. Parental presence and severity of illness were not. CONCLUSIONS: Patients in the pediatric ICU sleep significantly less than is normal for children of the same ages, and their patterns of sleep are seriously disturbed. Because noise, light, and contact with caregivers are significant predictors of sleep state, health professionals can use these findings to structure the environment and the care they give to promote the sleep of critically ill children.
International normalized ratio in anticoagulant therapy: understanding the issues
Authors: Severson AL , Baldwin LR , DeLoughery TG
Published: November 2019

Recently, a change in anticoagulation therapy occurred that is still partially ignored by the healthcare community. Understanding the controversy over the use of the internal normalized ratio in monitoring patients receiving warfarin therapy is important for nurses who provide care to these patients. Five questions related to current monitoring of patients treated with anticoagulants are addressed. Nurses must recognize the importance to their practice of changes in laboratory methods and move toward using the most useful measures available to influence patients' outcomes. The international normalized ratio is the most appropriate way to evaluate the effects of warfarin therapy. All healthcare providers should use this ratio as the standard in evaluating the effects of anticoagulation therapy.
Stress and distress in pediatric nurses: lessons from Baby K
Authors: Perkin RM , Young T , Freier MC , Allen J , Orr RD
Published: November 2019

BACKGROUND: Nurses experience stress and suffering when they care for critically ill and dying patients. Moral distress occurs when nurses are unable to translate their moral choices into moral action. In response to this stress, nurses may experience burnout. OBJECTIVE: To investigate the attitudes and perceptions of the nurses who were ordered by the court to provide long-term care for Baby K, a female child with anencephaly. METHOD: A questionnaire was developed to provide descriptive insight into the stress and distress the nurses experienced while caring for Baby K. RESULTS: Nurses caring for Baby K experienced stress and suffering. Although they felt supported and respected as nurses in their workplace, they felt conflict with the legal system. To compensate for feelings of powerlessness, the nurses simply put on a professional face and continued to provide care. They feared making mistakes, many felt guilty and angry, and all felt that they were not included in decision making. CONCLUSIONS: (1) Suffering among caregivers occurs and must be recognized, (2) measures must be taken to reduce the stress and distress of healthcare professionals as they provide care to patients who cannot recover, and (3) in addition to these measures, society must provide guidance to healthcare professionals, especially concerning the care of patients who are permanently unconscious.
Nursing care of patients undergoing thoracoscopic minimally invasive bypass grafting
Authors: Vaca KJ , Daake CJ , Lambrechts DS
Published: November 2019

Recent efforts in cardiac surgery to decrease cost, length of hospitalization, and morbidity without compromising care or outcomes include a method of treatment of coronary heart disease called minimally invasive coronary artery bypass grafting. This article describes the use of thoracoscopy without sternotomy, cardiopulmonary bypass, or cardioplegic arrest for grafting of the left anterior descending branch of the coronary artery with the left internal mammary artery. Preliminary information supports the concept that thoracoscopic minimally invasive bypass grafting is a less costly and less invasive procedure for patients with disease of the left anterior descending branch of the coronary artery.
Effect of a monitored care unit on resource utilization in a pediatric ICU
Authors: Joseph C
Published: November 2019

OBJECTIVE: To determine the effect of a monitored care unit on resource utilization in a pediatric ICU. METHODS: The study was done at a 205-bed pediatric medical center located in northern California. Efficiency of resource utilization in the pediatric ICU was evaluated by comparing the following factors before and after the implementation of a monitored care unit: (1) efficiency in the pediatric ICU, (2) number of patients turned away for lack of beds, (3) hours of nursing care per patient day, and (4) cost (as estimated from charge ratios) in the monitored care unit for care of patients admitted because of some common reasons. RESULTS: Efficiency in the pediatric ICU increased significantly after implementation of a monitored care unit. The number of patients not admitted to the pediatric ICU because not enough beds were available was identical before and after establishment of the monitored care unit. After the monitored care unit was established, hours of nursing care per patient day were significantly reduced, enabling the number of patient days to be increased without increasing cost. In addition, cost comparisons showed a decrease in both length of stay and total cost per admission for patients undergoing ventriculoperitoneal shunt revision and lambdoidal suture synostectomy. CONCLUSIONS: Use of beds in the pediatric ICU was more efficient when a high-observation setting was available for low-risk monitored patients. Key differences in patterns of use were observed. Compared with the pediatric ICU, the monitored care unit requires fewer personnel and less expensive equipment and supplies, but it still allows potentially life-threatening complications to be recognized and treated. For patients who meet its admission criteria, the monitored care unit is a safe alternative to the pediatric ICU.
Readiness of critical care physicians and nurses to handle requests for organ donation
Authors: Evanisko MJ , Beasley CL , Brigham LE , Capossela C , Cosgrove GR , Light J , Mellor S , Poretsky A , McNamara P
Published: November 2019

BACKGROUND: Critical care nurses and physicians usually care for those patients whose condition progresses to brain death and are also often responsible for requesting organ donation from the family of a brain-dead patient. We hypothesized that staff support, knowledge, and training levels would be significantly associated with organ donation rates. OBJECTIVE: To assess the readiness of critical care staff to successfully handle requests for organ donation. METHODS: A total of 1061 critical care staff from 28 hospitals in four separate regions of the United States completed a questionnaire that assessed (1) factual knowledge about organ donation, (2) understanding of brain death, (3) previous training in procedures for requesting donations, and (4) comfort levels with the donation process. RESULTS: Staff training in effective procedures for requesting organ donations was significantly correlated with hospitals' donation rates. Less than a third of respondents, however, had received training in explaining brain death to and requesting organ donation from a grieving family. In hospitals with high rates of organ donation, 52.9% of staff had received training; in hospitals with low rates of organ donation, 23.5% of staff had received training. Levels of factual knowledge about organ donation and brain death were unexpectedly low but were not significantly related to hospitals' rates of organ donation. CONCLUSIONS: Training of critical care nurses and physicians in effective procedures for requesting organ donation is significantly associated with higher rates of organ donation, yet two thirds of critical care staff report no relevant training. Consequently, critical care staff cannot be considered ready to effectively handle requests for organ donation.
Patient-nurse synergy: optimizing patients' outcomes
Authors: Curley MA
Published: November 2019

Given the current demands of the healthcare environment, a clear sense of the unique contributions of nursing to patients' outcomes is critical. This paper articulates a model that describes nursing practice on the basis of the needs and characteristics of patients. The model was developed by the American Association of Critical-Care Nurses Certification Corporation to link certified practice to patients' outcomes. The fundamental premise of this model, known as the Synergy Model, is that patients' characteristics drive nurses' competencies. When patients' characteristics and nurses' competencies match and synergize, outcomes for the patient are optimal. This paper presents the major tenets of the Synergy Model: patients' characteristics of concern to nurses, nurses' competencies important to patients, and patients' outcomes that result when patients' characteristics and nurses' competencies are mutually enhancing. By creating safe passage for patients, nurses make a significant contribution to the quality of patients' care, containment of costs, and patients' outcomes. Although the Synergy Model will be used as a blueprint for the certification of acute and critical care nurses, it is conceptually relevant to the entire profession. Dissemination of this model may help situate nursing within the current healthcare environment and facilitate intradisciplinary dialogue.
Weaning from mechanical ventilatory support: refinement of a model
Authors: Knebel A , Shekleton ME , Burns S , Clochesy JM , Hanneman SK
Published: November 2019

The American Association of Critical-Care Nurses sponsored the third National Study Group to advance the science of weaning from mechanical ventilatory support and to guide clinical practice. The study group proposed a model of weaning in 1994 to provide an organizing framework for scientific inquiry. Since the model was first proposed, the ongoing work of the study group has led to refinement of the model. The purpose of this brief communication is to inform critical care clinicians and researchers about the refinements.
The safety of automatic versus manual blood pressure cuffs for patients receiving thrombolytic therapy
Authors: Saul L , Smith J , Mook W
Published: November 2019

BACKGROUND: Patients receiving thrombolytic therapy for acute myocardial infarction require frequent monitoring of blood pressure. Historically, many nurses have been reluctant to use automatic blood pressure cuffs during thrombolytic therapy because of concern that the automatic cuffs might increase risk of bleeding. This concern is not based on research findings but on case reports, anecdotal observations, and possible myths in clinical practice. OBJECTIVE: To determine the safety of using automatic blood pressure cuffs during thrombolytic therapy in patients with acute myocardial infarction. METHODS: Ninety-six patients with acute myocardial infarction who received thrombolytic therapy (streptokinase or tissue plasminogen activator) were randomized to have blood pressure measurements obtained with either automatic or manual blood pressure cuffs. Patients were checked at least every 2 hours for purpuric lesions (petechiae, ecchymoses, or hematomas). The study ended after 24 hours of measurements or when a purpuric lesion was noted. RESULTS: We found no significant difference in frequency of purpuric lesions between patients who had blood pressure measured with a manual cuff and patients who had blood pressure measured with an automatic cuff. The most common purpuric lesions noted were ecchymoses. A significant difference was noted in the frequency of purpuric lesions depending on which thrombolytic agent was used, regardless of cuff type. CONCLUSIONS: Automatic blood pressure cuffs are as safe as manual blood pressure cuffs in patients with acute myocardial infarction who are receiving thrombolytic therapy.
Instillation of normal saline before suctioning in patients with pulmonary infections: a prospective randomized controlled trial
Authors: Ackerman MH , Mick DJ
Published: November 2019

OBJECTIVE: To determine the effect of instillation of normal saline before suctioning on oxygen saturation, heart rate, and blood pressure in patients with pulmonary infections. METHODS: A prospective randomized controlled trial was conducted in the surgical, medical, and burn/trauma ICUs of an academic medical center. Eighteen men and 11 women (mean age = 60 years) receiving mechanical ventilation who met the criteria for pulmonary infection were randomly assigned to 2 groups. One group had instillation of a 5-mL bolus of normal saline before suctioning; the other did not. Suctioning was done as needed during an 8-to 12-hour period. Oxygen saturation, heart rate, and blood pressure were measured noninvasively immediately before and after suctioning, at 1-minute intervals for 5 minutes after suctioning, and at 10 minutes after suctioning. RESULTS: Instillation of normal saline had an adverse effect on oxygen saturation, which worsened over time. Differences in saturation between the 2 groups were significant at 4, 5, and 10 minutes after suctioning. Differences in heart rate and blood pressure were not significant. CONCLUSION: Instillation of normal saline before suctioning has an adverse effect on oxygen saturation and should not be used routinely in patients receiving mechanical ventilation who have pulmonary infection.
Patients' outcomes: intrahospital transportation and monitoring of critically ill patients by a specially trained ICU nursing staff
Authors: Stearley HE
Published: November 2019

BACKGROUND: Intrahospital transportation of critically ill patients can contribute to patients' morbidity and mortality. OBJECTIVE: To determine adverse outcomes associated with intrahospital transportation of critically ill patients by a specially trained nursing transport team. METHODS: Monitoring and intervention data were collected for 237 instances of transportation of patients between a hospital's ICUs and radiology suites. These results were compared with the results of national studies on complication rates associated with intrahospital transportation of patients. RESULTS: The patients moved by the specially trained transport team has a 15.5% overall complication rate, with 10.2% minor, 2.5% moderate (compensated for with medications), and 2.8% severe complications that did not respond to intervention. No medications of therapies were delayed, and only 2 patients (0.8%) had decompensation that required the examinations to be aborted. Reported national complication rates for intrahospital transportation of patients are as high as 75%; the complications include adverse events such as delayed administration of medications, significant changes in vital signs, dislodgment of artificial airways and i.v. catheters, and cardiopulmonary arrest. CONCLUSION: Use of a specially trained ICU transport team can substantially reduce the rate of adverse outcomes generated by the transportation of critically ill patients for specialized radiological procedures.
Effect of a back massage and relaxation intervention on sleep in critically ill patients
Authors: Richards KC
Published: November 2019

BACKGROUND: Critically ill patients are deprived of sleep and its potential healing qualities, although many receive medications to promote sleep. No one has adequately evaluated holistic nonpharmacological techniques designed to promote sleep in critical care practice. OBJECTIVES: To determine the effects of (1) a back massage and (2) combined muscle relaxation, mental imagery, and a music audiotape on the sleep of older men with a cardiovascular illness who were hospitalized in a critical care unit. METHODS: Sixty-nine subjects were randomly assigned to a 6-minute back massage (n=24); a teaching session on relaxation and a 7.5-minute audiotape at bedtime consisting of muscle relaxation, mental imagery, and relaxing background music (n=28); or the usual nursing care (controls, n=17). Polysomnography was used to measure 1 night of sleep for each patients. Sleep efficiency index was the primary variable of interest. One-way analysis of variance was used to test for difference in the index among the 3 groups. RESULTS: Descriptive statistics showed improved quality of sleep among the back-massage group. Initial analysis showed a significant difference among the 3 groups in sleep efficiency index. Post hoc testing with the Duncan procedure indicated a significant difference between the back-massage group and the control group; patients in the back-massage group slept more than 1 hour long than patients in the control group. However, the variance was significantly different among the 3 groups, and reanalysis of data with only 17 subjects in each group revealed no difference among groups (P=.06). CONCLUSIONS: Back massage is useful for promoting sleep in critically ill older men.
12-lead ST-segment monitoring vs single-lead maximum ST-segment monitoring for detecting ongoing ischemia in patients with unstable coronary syndromes
Authors: Drew BJ , Pelter MM , Adams MG , Wung SF , Chou TM , Wolfe CL
Published: November 2019

BACKGROUND: 12-lead ECG monitoring of the ST segment is more sensitive than patients' symptoms for detecting ischemia after thrombolytic therapy or catheter-based interventions, but it is unclear whether monitoring of the single lead showing maximum ST deviation would be as efficacious. OBJECTIVE: To determine whether monitoring all 12 ECG leads for changes in the ST segment is necessary to detect ongoing ischemia in patients with unstable coronary syndromes. METHODS: Continuous 12-lead ST segment monitoring was performed in 422 patients from the onset of myocardial infarction or during balloon inflation in catheter-based interventions until the patient's discharge from the cardiac care unit. Computer-assisted techniques were used to determine (1) which lead showed the maximum ST deviation at the onset of myocardial infarction or during balloon inflation and (2) what proportion of later ischemic events were associated with ST deviation in this lead. RESULTS: The lead with the maximum ST deviation could be determined in 312 patients (74%). The remaining 110 (26%) had non-Q wave infarction without ST deviation or no ST changes during balloon inflation. During 18,394 hours of 12-lead ST monitoring, 118 (28%) of the 312 patients had a total of 463 ischemic events, 80% of which were silent. Of 377 ischemic events in which a maximum ST lead was detected, 159 (42%) did not show ST deviation in this lead (sensitivity, 58%; 95% CI, 53%-63%). Routine monitoring of leads V1 and II showed ST deviation in only 152 of the 463 events (sensitivity, 33%; 95% CI, 29%-37%). CONCLUSIONS: Monitoring of all 12 ECG leads for changes in the ST segment is necessary to detect ongoing ischemia in patients with unstable coronary syndromes.
Training nontraditional responders to use automated external defibrillators
Authors: Riegel B
Published: November 2019

The American Heart Association is championing a national effort to make automated external defibrillators available to the public. Clinicians are beginning to grapple with the complexities involved in training laypersons to use these devices. The article reviews the experience of researchers involved in such training. Suggestions for training of nontraditional responders are derived from a review of the literature and are integrated with suggestions from active field investigators and the participants in a workshop on this topic held during the American Heart Association Public Access Defibrillation II Conference in Washington, DC (April 17-19, 1997). So far, widespread training of traditional first responders such as police and firefighters to use automated external defibrillators appears to be safe and effective. The data from studies in which nontraditional responders were trained are not as convincing. Further research is needed before we can assume that training of the public will be as easy and effective as training of traditional first responders.
Endotracheal tube narrowing after closed-system suctioning: prevalence and risk factors
Authors: Glass C , Grap MJ , Sessler CN
Published: November 2019

BACKGROUND: Few data exist about buildup of secretions within endotracheal tubes of patients treated with closed-system suctioning in the intensive care unit. OBJECTIVES: To describe the extent, prevalence, and distribution of narrowing of endotracheal tubes related to buildup of secretions and to determine contributing factors. METHODS: Forty endotracheal tubes were examined within 4 hours of extubation, after at least 72 hours of use. Data on patients' daily weight and fluid balance, ventilator humidification temperatures, and nurses' descriptions of secretions during the 3 days preceding extubation were recorded. Any secretion debris in the endotracheal tubes was weighed. At 1-cm intervals along the tube, the debris was described and the depth of the debris was measured to the nearest 0.5 mm. RESULTS: Mean duration of intubation was 6.6 days. Two tubes had no debris. Mean overall depth of debris was 0.64 mm, mean greatest depth was 2.0 mm (range, 0-5 mm), and mean weight was 1.16 g. The entire tube was affected, with the greatest depth of debris at the 6- to 9-cm and 13- to 14-cm markings. Duration of intubation correlated with mean greatest depth of debris (r = 0.37, P = .02), mean overall depth of debris (r = 0.48, P = .002), and mean weight of debris (r = 0.38, P = .02). CONCLUSIONS: Endotracheal tubes are markedly narrowed by the buildup of secretions after closed-system suctioning. Duration of intubation, but not endotracheal tube size or amount of secretions, was associated with the degree of narrowing.
Cardiovascular risk factors and cardiac surgery outcomes in a multiethnic sample of men and women
Authors: Verderber A , Castelfranco AM , Nishioka D , Johnson KG
Published: November 2019

BACKGROUND: Cardiovascular disease is more prevalent in some ethnic groups than in others, as are risk factors stemming from cultural practices and values. Data on the health status of Asians and Pacific Islanders are scarce and sporadic, and data on the 2 groups are usually combined for analysis. OBJECTIVE: To determine ethnic and sex-related differences among white, Japanese, and Pacific Island subjects in cardiovascular risk factors and outcomes after coronary artery bypass graft surgery. METHODS: Data were collected from a random sample of 41 men and 19 women scheduled for nonemergent coronary artery bypass graft surgery: 19 white, 18 Japanese, and 23 Pacific Island/Hawaiian subjects. Subjects were interviewed about risk factors before surgery and were followed up for the first 20 hours after surgery. Problems that occurred during the remainder of the hospital stay were assessed by chart review. Instruments used included the Charlson Comorbidity Index, Acute Physiology and Chronic Health Evaluation II, and the Therapeutic Intervention Scoring System. RESULTS: Pacific Island and Japanese subjects differed significantly in their demographic and clinical characteristics. Pacific Islanders tended to have a more difficult postoperative course than did white subjects, whereas Japanese patients tended to have fewer problems and an easier postoperative course than other subjects. CONCLUSIONS: Further study of ethnic variations in risk factors and surgical outcomes, especially variations in comorbidities, age at the onset of signs and symptoms, and postoperative complications, is needed. Combining data obtained from Japanese and Pacific Island subjects for data analysis most likely will result in a loss of important information.
Prevalence of leg wound complications after coronary artery bypass grafting: determination of risk factors
Authors: Goldsborough MA , Miller MH , Gibson J , Creighton-Kelly S , Custer CA , Wallop JM , Greene PS
Published: November 2019

BACKGROUND: The reported prevalence of leg wound complications after coronary artery bypass grafting is 2% to 24%. Decreased length of hospital stay for patients who have this surgical procedure poses new care requirements in both acute care and community settings. OBJECTIVE: To determine the prevalence of postoperative leg wound complications in patients undergoing coronary artery bypass grafting and the risk factors associated with these complications. METHOD: In this prospective, observational study, 547 consecutive patients who had coronary artery bypass grafting alone or in combination with other cardiac surgical procedures were examined for evidence of leg wound complications each day after surgery during hospitalization. After discharge, problems were detected by home care nurses. RESULTS: The prevalence of leg wound complications was 6.8%. Factors significant by multiple logistic regression included preoperative hospitalization, use of an Ace elastic bandage in the operating room, the length of time the leg incision remained open in the operating room, and administration of nicardipine intravenously in the intensive care unit. Odds ratios were calculated for each variable. Premorbid factors such as diabetes or peripheral vascular disease were not predictive of complications. On average, most problems occurred on postoperative day 10, when many patients were at home. CONCLUSIONS: The results highlight the need to detect complications early, in both the hospital and the community settings. The determination of factors related to poor outcomes may assist clinicians in improving healthcare delivery.
Case report: reversal of an evolving myocardial infarction with intravenous thrombolysis
Authors: Comeau-Luis OY , Corbett SW , Wittlake WA , Jutzy KR , Huiskes BL
Published: November 2019

This case, in many ways, represents the ideal: a timely and effective administration of thrombolytic agents. The rarity of this situation reinforces the need for earlier recognition and treatment of infarction. In an analysis of time delays in thrombolytic therapy, 38% were attributed to in-hospital issues, 22% to patients' delays, 21% to problems with transportation, and 19% to reperfusion time. The National Heart Attack Alert Program calls for treatment within 1 hour of the development of signs and symptoms, including administration of thrombolytic agents within 30 minutes of the patient's arrival in the emergency department. That program seeks heightened awareness among hospital and prehospital providers and public education about seeking immediate treatment for chest pain. The prompt acquisition of additional ECGs and the subsequent rapid administration of a thrombolytic agent were the clinical essentials. This fact suggests the need to look for measures of quality other than simple "door to drug" times. "Data to drug" times may be another indicator of quality to address cases in which the initial ECG findings are not diagnostic. Furthermore, emergency departments may see more patients with impending infarction if public education campaigns are successful. This case emphasizes the need to obtain follow-up ECGs in light of the potential benefits from thrombolysis.
Life with a left ventricular assist device: the patient's perspective
Authors: Savage LS , Canody C
Published: November 2019

BACKGROUND: Understanding the psychological experience of living with a life-sustaining device is necessary for developing individualized, supportive interventions for patients with a left ventricular assist device. OBJECTIVES: To describe patients' experiences with left ventricular assist devices, strategies for coping with prolonged hospitalization, and suggestions for individualized nursing interventions. METHODS: The phenomenology method of qualitative research was used. Data collection involved unstructured, open-ended interviews of 6 hospitalized subjects who had a pneumatic left ventricular assist device. RESULTS: Patients described coping strategies for prolonged hospitalization, including family support, religious convictions, and diversional activities. Data analysis suggests that critical care nurses can best support these patients by establishing trusting relationships, fostering independence, and incorporating humor into their care. CONCLUSIONS: Patients awaiting cardiac transplantation coped effectively with prolonged hospitalization with a life-sustaining device in place. Spirituality, humor, and strong family relationships contributed to their positive outlook.
Stroke risk, cholesterol and statins
Authors: Futterman LG , Lemberg L
Published: November 2019

The natural statins should be used as first line agents in the prevention of stroke. The effects of the synthetic statins on the prevention of coronary events and stroke have not been reported at this time. The National Stroke Association's Stroke Prevention Advisory Board has prepared a consensus statement on risk reducing intervention. The Board identified hypertension, MI, atrial fibrillation, hyperlipidemia and asymptomatic carotid artery stenosis (60% to 99% occlusion) as proven stroke risk factors. The Board's recommendations for the prevention of a first stroke are: 1. Hypertension should be treated with lifestyle, pharmacologic and multidisciplinary management strategies. 2. Aspirin post MI and warfarin (international normalized ratio, 2 to 3) for patients with atrial fibrillation, left ventricular thrombus or significant left ventricular dysfunction. Statin agents should be used post MI. 3. Atrial fibrillation patients age 75 or older should be treated with warfarin. Younger patients 65 to 75 with atrial fibrillation and risk factors should be treated with warfarin [corrected]. Younger patients 65 to 75 with atrial fibrillation without risk factors should be treated with warfarin or aspirin [corrected]. 4. Patients with hyperlipidemia and coronary artery disease should be on statin agents. 5. Carotid endarterectomy is recommended for asymptomatic carotid stenosis (60% to 99%) when surgical morbidity and mortality are less than 3%. 6. Adherence to a low-fat diet, smoking avoidance, mild alcohol use, and physical activity should follow published guidelines.