bluuebunny/crossref_metadata_2025 huggingface dataset:
In vitro and In vivo Models for Anti-inflammation: An Evaluative Review
Authors: Eze Fabian Ifeanyi , Uzor Philip F. , Ikechukwu Peter , Obi Bonaventure C. , Osadebe Patience O.
Published: November 2019

Anti-inflammatory activity study involves developing a model that mimics, or provokes the production or release of, the biochemical mediators of inflammation, and monitoring the response of these biochemicals to the test drugs. This report constitutes an updated review of the in vitro and in vivo study models for assessing anti-inflammatory activity in plant extracts and synthetic drugs. The materials, instrumentation, and methods involved, as well as the mechanism of anti-inflammatory activity tested in each model, are extensively described. The merits and limitations of each method have also been discussed. A comparative assessment of the in vivo animal models vis-à-vis, the in vitro enzyme models have been made to assist scientists and researchers in the choice of assay method in terms of sensitivity, reliability, duration of test, ethical, and cost considerations.
Franchir et affranchir les langues
Authors: Eymar Marcos
Published: November 2019

La conscience linguistique moderne établit des limites entre les langues aussi nettes qu’entre les États-nations, instaurant une équivalence entre le domaine linguistique et le domaine politique. Si la littérature a souvent contribué à la consolidation de ce paradigme nationaliste, elle peut aussi le remettre en question par le biais du plurilinguisme.
La Mara de Rafael Ramírez Heredia ou la dangereuse frontière des réalités et des représentations
Authors: Ducoux Antoine
Published: November 2019

Centré sur l’activité criminelle du gang de la Mara Salvatrucha à la frontière du Mexique et du Guatemala, La Mara de Rafael Ramírez Heredia se distingue des représentations de la frontière articulant l’idée de transculturalité et d’hybridation. Quels savoirs sur la frontière et la criminalité de gang ce roman articule-t-il ? Cet article définit l’écriture de la frontière chez Ramirez Heredia comme une écriture des limites. Oscillant entre deux régimes de représentation contradictoires, cette écriture restitue une expérience sensible et complexe de la frontière, sans se déprendre d’une vision déterministe de la violence ni de stéréotypes mélodramatiques.
Gastric intramucosal pH: a noninvasive method for the indirect measurement of tissue oxygenation
Authors: Clark CH , Gutierrez G
Published: November 2019

BACKGROUND: Monitoring the adequacy of tissue oxygenation is an important goal in the care of the critically ill patient. Global alterations in tissue oxygenation are inferred from changes in systemic oxygen transport (defined as the product of cardiac output and arterial oxygen content) and total oxygen consumption. These parameters, however, cannot measure the level of oxygenation of specific tissue beds, in particular those that are first affected by hypoxia, such as the gastrointestinal tract and the kidneys. DISCUSSION: Gastrointestinal tonometry is a new method for measuring the partial pressure of carbon dioxide of the gastrointestinal mucosa. This information can be used in conjunction with the arterial blood bicarbonate to calculate the pH of the mucosa. Mucosal acidosis correlates well with the onset of anaerobic metabolism in response to hypoxia or sepsis. This review discusses the basic principles of tonometry, the results of experimental and clinical studies, and the practical aspects related to the implementation and use of tonometers in patients in the critical care unit. CONCLUSION: Gastrointestinal tonometry is a relatively noninvasive device that appears capable of measuring metabolic changes produced by hypoxia. Because of the sensitive nature of the gastrointestinal mucosa, these changes often occur well in advance of other, more common, indices of hypoxia. The use of the tonometer may become a routine procedure in the overall monitoring of critically ill patients.
Pulmonary artery pressure measurement in patients with elevated pressures: effect of backrest elevation and method of measurement
Authors: Dobbin K , Wallace S , Ahlberg J , Chulay M
Published: November 2019

OBJECTIVE: To determine whether pulmonary artery pressure measurement is accurate if the head of the bed is elevated; to compare the end-expiratory graphic recording and digital monitor methods for pulmonary artery pressure measurement; to determine whether either mean arterial pressure or mixed venous oxygen saturation changes during backrest elevation. DESIGN: Nonrandomized clinical trial. SETTING: A six-bed cardiac surgical intensive care unit of a 540-bed federal facility. POPULATION: Twenty-five postoperative cardiac surgical patients with elevated pulmonary artery pressures (systolic higher than 35 mm Hg). INTERVENTIONS: In supine patients pulmonary artery pressures were measured at each of the following backrest elevations: 0, 20, 30, 45 and again at 0 degrees. Measurements were obtained once during mechanical ventilation and once during normal breathing after extubation. MAIN OUTCOME MEASURES: End-expiratory graphic recording of pulmonary artery pressures; digital monitor values of pulmonary artery pressures; mean arterial pressure; and mixed venous oxygen saturation. RESULTS: No statistical difference was found in pulmonary artery pressures measured at each of the backrest elevations during mechanical ventilation or normal breathing after extubation. Pulmonary artery diastolic and pulmonary capillary wedge pressures obtained with the digital monitor method were significantly lower than the end expiratory graphic recording method during normal breathing after extubation but not during mechanical ventilation. No changes in mean arterial pressure or mixed venous oxygen saturation occurred during backrest elevation. CONCLUSIONS: These results show that pulmonary artery pressures can be measured accurately with the head of the bed in an elevated position. The data indicate that obtaining pulmonary artery pressure measurements from the digital display of the bedside monitor is accurate when respiratory wave form fluctuations are minimal but may lead to inaccurate values with prominent respiratory fluctuations. Further research is needed to validate this finding in different patient populations and with other models of monitoring equipment.
Effectiveness of nursing involvement in bedside monitoring and control of coagulation status after cardiac surgery
Authors: Zeler KM , McPharlane TJ , Salamonsen RF
Published: November 2019

OBJECTIVE: This study explores: (1) the feasibility of involvement of nursing staff in routine bedside testing of activated clotting time and (2) joint implementation with resident medical staff of a preformulated plan for management of mediastinal bleeding after cardiac surgery. DESIGN: Patients were divided randomly into two groups, an experimental group (n = 108) subjected to ACT testing and management by protocol, and a control group (n = 146) treated by independent medical decisions. RESULTS: Bleeding, volume of blood replaced, abnormal coagulation profiles and reoperations to control bleeding and its consequences were all reduced in the study group. CONCLUSION: We concluded that bedside measurement of activated clotting time by nursing staff, associated with therapy based on a flow diagram, enhanced the overall management of early mediastinal bleeding after cardiac surgery as compared with independent management decisions by resident medical staff. In addition, the method provided a sensitive and reliable means of detecting and correcting rebound heparinization in the early postoperative period.
Survey of the degree to which critical care nurses are performing current procedural terminology-coded services
Authors: Griffith HM , Robinson KR
Published: November 2019

PURPOSE: To identify the degree to which current procedural terminology-coded services are provided by critical care nurses. Current procedural terminology codes are used by government and private insurers for reimbursement for office, home, hospital, nursing home and emergency department services. METHOD: Out of 100 randomly selected registered nurses invited to participate in this national survey, 43 completed the survey questionnaire. The majority of respondents were 18 to 40 years old, had a bachelor's degree, had practiced nursing between 5 and 10 years, and were employed as staff or charge nurses in an intensive care or emergency room setting. RESULTS: More than 70% of the group were found to perform 28 codes. The codes performed by the greatest number (42) were blood or blood component transfusion and cardiopulmonary resuscitation. One-way analysis of variance applied to the amount of supervision the nurses received while performing the codes and the educational level of the nurses revealed a significant difference between the groups. Post hoc analysis of all possible group comparisons showed that diploma-prepared nurses reported significantly more supervision than nurses having a bachelor's or master's degree. CONCLUSION: This exploratory study indicates that critical care nurses frequently perform selected codes with little or no supervision by a physician.
Characteristics of a child's critical illness and parents' reactions: preliminary report of a pilot study
Authors: Youngblut JM , Shiao SY
Published: November 2019

OBJECTIVE: To explore the relationships between parents' reactions to the pediatric intensive care unit admission of a child and characteristics of the child's illness. METHOD: A convenience sample, consisting of 16 mothers and 13 fathers of 16 children aged 5 years and younger, was used. The Pediatric Risk of Mortality scale was used to measure severity of illness. Parental reactions were measured at about 24 hours after the child's admission with the Parental Stressor Scale: PICU and the Parental Concerns Scale. RESULTS: Mothers' concerns and stressors were not related to the child's Pediatric Risk of Mortality score. However, fathers reported greater concern about the child's experience and about parenting as the child's Pediatric Risk of Mortality score increased. CONCLUSIONS: Parents' reactions to their child's critical illness and admission to the pediatric intensive care unit were not related to characteristics of the child's condition in this small sample. Future research needs are suggested.
Clinical safety and cost of heparin titration using bedside activated clotting time
Authors: Thomason T , Riegel B , Jessen D , SCJr Smith , Gocka I , Rich M
Published: November 2019

OBJECTIVE: To evaluate the clinical safety of heparin titration and the procedural cost of anticoagulation measurement using bedside low-range activated clotting time. DESIGN: Quasi-experimental study using data gathered through retrospective record review. SETTING: Coronary care, medical intensive care and telemetry units of a community hospital. SUBJECTS: Sample of 102 patients undergoing elective percutaneous transluminal coronary angioplasty. INTERVENTION: Intravenous heparin therapy was titrated using low-range activated clotting time in 51 percutaneous transluminal coronary angioplasty patients. Data from this group were compared to a matched sample of 51 angioplasty patients whose intravenous heparin therapy was titrated using activated partial thromboplastin time. RESULTS: No differences in procedural, early or late complications were found between the groups. The cost of managing heparin therapy with low-range activated clotting time was less than with activated partial thromboplastin time. CONCLUSION: These results suggest that titrating heparin therapy based on bedside low-range activated clotting time for the angioplasty patients in this sample was as safe as with activated partial thromboplastin time. Use of bedside low-range activated clotting time saved money for the hospital.
Effects of lung hyperinflation and presence of positive end-expiratory pressure on arterial and tissue oxygenation during endotracheal suctioning
Authors: McIntosh D , Baun MM , Rogge J
Published: November 2019

PURPOSE: To explore the effects of endotracheal suctioning on mixed venous oxygen tension and other measures of arterial and tissue oxygenation, to determine if these would be clinically useful outcome measures of endotracheal suctioning. BACKGROUND: Measuring arterial oxygenation only as an outcome of endotracheal suctioning can be misleading in that it may appear adequate in the presence of marked decreases in mixed venous oxygen tension, a good indicator of the adequacy of tissue oxygenation. METHODS: Eighteen instrumented and oleic acid-injured animal models of acute respiratory failure undergoing closed-system endotracheal suctioning were studied according to a 2 x 2 factorial design to measure the effects of oxygen inflations at tidal volume or 135% of tidal volume either in the presence or absence of positive end-expiratory pressure. RESULTS: Using multivariate analysis of variance for repeated measures, protocol by time effects for mixed venous oxygen tension, arterial oxygen saturation, arterial oxygen tension, oxygen delivery and oxygen extraction ratio were statistically significant. Changes in mixed venous oxygen tension and arterial oxygen saturation were parallel. CONCLUSIONS: Continuous measurement of mixed venous oxygen tension allows the calculation of oxygen delivery and oxygen extraction ratio, which provide a better estimation of the effects of endotracheal suctioning on tissue oxygenation than arterial oxygen tension alone.
The effect of saline lavage prior to suctioning
Authors: Ackerman MH
Published: November 2019

OBJECTIVE: To determine the effect on oxygen saturation of instilling a saline bolus into artificial airways prior to suctioning, as measured by pulse oximeter. DESIGN: Quasi-experimental, single-case, counterbalanced design. SETTING: The surgical, medical and coronary intensive care units of a federal, teaching medical center. SUBJECTS: Subjects were 40 men, more than 40 years old, in need of intensive care nursing and mechanical ventilation. INTERVENTIONS: Subjects were suctioned as needed for 24 hours. A 5-mL saline bolus was instilled every other time the subject was suctioned. Outcome measurements were done immediately before and after suctioning and at 1-minute intervals for 5 minutes after suctioning. MAIN OUTCOME MEASURES: Noninvasive oxygen saturation values. RESULTS: The instillation of a saline bolus was found to have an adverse effect on oxygen saturation that worsened over time. Significant changes in oxygen saturation as a result of saline bolus instillation were found at 2,3,4 and 5 minutes after instillation. CONCLUSIONS: These results indicate that instilling saline prior to suctioning has an adverse effect on oxygen saturation. These results support the recommendation that the practice of instilling saline prior to suctioning should be abandoned as a routine procedure. More study is needed to investigate whether a specific group of patients may actually benefit from this procedure.
Severe HELLP syndrome presenting with acute gum bleeding following toothbrushing at 38 weeks' gestation
Authors: Jones KA , Abramowicz JS , Anissi D , Mirwald MA , Sherer DM
Published: November 2019

We describe a case of hemolysis, elevated liver enzymes and low platelet count (HELLP syndrome) at 38 weeks' gestation. This condition was diagnosed when the patient presented with acute, persistent gum bleeding after toothbrushing. Her platelet count was 26,000/mm3. Bleeding gums have rarely led to the diagnosis of this syndrome; this case appears to be the most severe description of this clinical presentation following toothbrushing yet presented in the literature. Although the patient had been hospitalized 48 hours earlier with nonspecific viral-like symptoms, she was discharged after being treated with intravenous hydration. Reexamination of laboratory studies obtained at the time of her first presentation revealed thrombocytopenia. The diagnosis of this syndrome could possibly have been made at that time. This case emphasizes the importance of maintaining a low threshold of suspicion for this syndrome.
Critiquing and using nursing research: guidelines for the critical care nurse
Authors: Liehr P , Houston S
Published: November 2019

This article focuses on a concern that practicing nurses are expected to use nursing research but are not thoroughly prepared to meet this expectation. This concern is addressed by proposing: (1) a guideline for research critique that is designed to bridge baccalaureate education and nursing practice and (2) a unique description of research utilization that may be realistically accomplished by practicing nurses.
Nursing care of the patient with an intravascular oxygenator
Authors: Vaca KJ , Reedy JE , Lohmann DP , Moroney DA , Swartz MT
Published: November 2019

Conventional therapy in the management of adult respiratory distress syndrome is often associated with an increased mortality rate. Several methods to improve survival in patients with severe respiratory insufficiency are under evaluation. One recently developed method of treatment is an implantable intravascular oxygenator, which provides supplemental gas exchange for failing lungs. This device can provide temporary ventilatory support in patients with acute, potentially reversible respiratory insufficiency. Reduction in ventilator settings such as airway pressure, oxygen concentration, positive end-expiratory pressure and minute volume can be achieved, decreasing the likelihood of oxygen toxicity and barotrauma. Success of the intravascular oxygenator in adult respiratory distress syndrome is dependent in part on critical care staff expertise. Therefore, a thorough understanding of the operation of this device and its role in acute respiratory failure is necessary for optimal care.
Myocardial infarction mortality in the hospital: an exploration of time of death and age
Authors: Cole FL , Slocumb EM
Published: November 2019

BACKGROUND: Death is a common complication from myocardial infarction, although little information exists about the pattern of mortality from myocardial infarction and factors associated with this pattern. OBJECTIVES: To identify the periods of greater-than-expected mortality from myocardial infarction in hospitalized patients and to determine whether an association exists between time of death and age of the patient. METHODS: A convenience sample of 1045 death certificates that met selection criteria was reviewed. Time of death and age were documented as they appeared on the death certificate. Data were analyzed by log-linear analysis. RESULTS: Frequency of mortality was determined to be greater than expected between 6 and 6:59 AM, 9 and 9:59 AM and 7 and 7:59 PM. The interaction between time of death and age was statistically significant. DISCUSSION: The periods of greater-than-expected mortality coincide with periods when nurses are occupied with other functions and also coincide with temporal patterns of physiologic events. CONCLUSIONS: A temporal pattern of mortality from myocardial infarction existed for this study. Age was found to be associated with time of death.
Effect of body position on spontaneous respiratory rate and tidal volume in patients with obesity, abdominal distension and ascites
Authors: Burns SM , Egloff MB , Ryan B , Carpenter R , Burns JE
Published: November 2019

BACKGROUND: Nursing textbooks and tradition suggest that the high-Fowler's position is best to optimize diaphragmatic excursion and effective breathing pattern. The optimal position for intubated patients with obesity, ascites or abdominal distention has yet to be determined but is important because weaning trial outcomes may reflect the effect of position rather than weaning trial tolerance. OBJECTIVE: To determine the body position that optimizes breathing pattern (tidal volume and respiratory rate) in spontaneously breathing, intubated patients with a large abdomen. METHODS: Nineteen intubated patients with abdominal distention, ascites or obesity who were on continuous positive airway pressure or the pressure support ventilation mode were studied in the 0 degrees, 45 degrees, 90 degrees and reverse Trendelenburg's at 45 degrees positions for 5 minutes prior to data collection. RESULTS: The RT at 45 degrees position resulted in a significantly larger tidal volume and lower respiratory rate than the 90 degrees position in intubated, spontaneously breathing patients with a large abdomen. The 45 degrees position resulted in a significantly lower respiratory rate than at 90 degrees; however, no difference in tidal volume was demonstrated. DISCUSSION: A high respiratory rate and low tidal volume potentiates atelectasis and ultimately failure to wean. It is important that the effect of positioning on breathing pattern in intubated patients be determined so that care planning results in optimal outcomes. CONCLUSIONS: The results of this study have implications for the selection of chair and bed positioning during weaning trials.
Critical care nursing research: opportunities and resources
Authors: Redeker NS
Published: November 2019

BACKGROUND: As patient needs become more complex in the critical care setting, nurses with increased clinical expertise are needed to expand the research knowledge base and apply existing knowledge in practice settings. PURPOSE: To review opportunities and resources that are available to facilitate nurses' involvement in critical care research: opportunities for participation in research, sources of ideas, human and financial resources, and ideas for the dissemination of research findings. CONCLUSIONS: Opportunities and resources available for critical care research are numerous, varied, and widely available. They should be used to advance the scientific bases for critical care practice.
Q and non-Q wave myocardial infarctions
Authors: Keller KB , Lemberg L
Published: November 2019

Previously, the classification of MI into transmural and subendocardial types has been based on the presence or absence of abnormal Q waves. The pathologic anatomy of necrosis in MI does not necessarily correspond to these ECG criteria. Thus, it is more appropriate to describe myocardial infarcts as Q wave or non-Q wave infarcts. The importance of this classification is underscored by their clinical and pathologic differences and the tendency for more serious prognosis in the non-Q wave infarcts. It should be noted that in Q wave infarcts the volume of necrosis is usually greater than that in non-Q wave infarcts.
Controversial decisions regarding treatment and DNR: an algorithmic Guide for the Uncertain in Decision-Making Ethics (GUIDE)
Authors: Levenson JL , Pettrey L
Published: November 2019

We describe an algorithm to aid clinicians in making ethical decisions regarding interventions. Logically sequenced questions about competency, advance directives, treatment benefit, and patient and family preferences guide the decision maker to nine specific scenarios. Each scenario includes guidelines for action based on legal and ethical consensus.
Effects of two dosing regimens of intravenous ranitidine on gastric pH in critically ill children
Authors: Osteyee JL , Banner W
Published: November 2019

BACKGROUND: Gastric bleeding in children is associated with critical illness, shock, and physical trauma. Histamine-2 receptor antagonist therapy is used prophylactically to treat gastric bleeding, but it is not known whether bolus dosing or continuous infusion dosing is more effective. OBJECTIVES: To compare the effects of continuous infusion intravenous ranitidine and intravenous bolus dosing of ranitidine on gastric pH in critically ill children and to look for correlation between illness severity scores and gastric pH. METHODS: Sixteen critically ill children were randomized into two groups. Children in group 1 received bolus dosing on day 1 and continuous infusion of ranitidine on day 2. Group 2 received the continuous infusion on day 1 and bolus dosing on day 2. Equivalent doses of ranitidine were based on weight. Continuous infusion regimen: ranitidine bolus of 0.15 mg/kg followed by continuous infusion at 0.15 mg/kg per hour for 12 hours. Bolus regimen: 1 mg/kg, two doses 6 hours apart. Pediatric risk of mortality scores were recorded upon admission to the study. RESULTS: There was no statistically significant difference between regimens. Both raised gastric pH values above 4.0 during the treatment phase. There was no correlation between illness severity scores and gastric pH values. CONCLUSIONS: Both bolus dosing and continuous infusion dosing of 4 mg/kg per day of intravenous ranitidine were effective at raising and maintaining gastric pH in critically ill children.
Weaning from long-term mechanical ventilation
Authors: Burns SM , Clochesy JM , Hanneman SK , Ingersoll GE , Knebel AR , Shekleton ME
Published: November 2019

Although many investigators have attempted to identify weaning predictors and weaning modes for use in long-term mechanically ventilated patients, none has emerged as superior. Furthermore, few investigators have viewed the process of weaning as a dynamic continuum; thus, guidelines for care of these patients have yet to be developed. Facilitative methods and therapies to enhance weaning potential, although attractive, have little scientific basis for application. Care delivery systems, which focus on systematic, comprehensive and coordinated care, are promising because outcomes demonstrate that they are economical, safe, and effective. This article reviews the research on weaning adult, long-term mechanically ventilated patients, suggests future research directions, and highlights the scientific basis for practice guidelines.
A comparison of five methods of temperature measurement in febrile intensive care patients
Authors: Schmitz T , Bair N , Falk M , Levine C
Published: November 2019

BACKGROUND: A clinically useful temperature measurement method should correlate well with the body's core temperature. Although previous investigators have studied temperature readings from different sites in hypothermic and normothermic patients, none have compared methods specifically in febrile patients. OBJECTIVE: To compare temperature measurement methods in febrile intensive care patients. METHODS: Temperature readings were obtained in rapid sequence from an electronic thermometer for oral and axillary temperature, rectal probe, infrared ear thermometer on "core" setting, and pulmonary artery catheter, approximately every hour during the day and every 4 hours at night. The sample consisted of 13 patients with pulmonary artery catheters and with temperatures of at least 37.8 degrees C. RESULTS: Rectal temperature correlated most closely with pulmonary artery temperature. Rectal temperature showed closest agreement with pulmonary artery temperature, followed by oral, ear-based, and axillary temperatures. Rectal and ear-based temperatures were most sensitive in detecting temperatures greater than 38.3 degrees C. Likelihood ratios for detecting hyperthermia were 5.32 for oral, 2.46 for rectal, and 1.97 for ear-based temperature. Rectal and ear-based temperatures had the lowest negative likelihood ratios, indicating the least chance of a false negative reading. Axillary temperature had a negative likelihood ratio of 0.86. CONCLUSIONS: Rectal temperature measurement correlates most closely with core temperature. If the rectal site is contraindicated, oral or ear-based temperatures are acceptable. Axillary temperature does not correlate well with pulmonary artery temperature. These results underscore the importance of consistency in method when establishing temperature trends, and of awareness of method when interpreting clinical data.
Standardized pain flowsheet: impact on patient-reported pain experiences after cardiovascular surgery
Authors: Voigt L , Paice JA , Pouliot J
Published: November 2019

BACKGROUND: Administration of analgesics per patient request or random pain assessments may provide inadequate pain management. OBJECTIVE: To examine the impact of nurses' use of a standardized pain flowsheet to document pain assessment and pharmacologic management on patient-reported pain intensity. METHODS: A pre-post intervention design was used to compare 61 patients. In the preimplementation group, traditional charting of pain presence or absence was documented in the narrative notes and pharmacologic management was recorded on the medication profile. In the postimplementation group, the intensity of pain and pharmacologic management were documented on a pain flowsheet. Within 24 hours after transfer to the step-down unit, patients were interviewed regarding pain intensity experienced in the surgical heart unit and at the time of questioning. The distribution of these pain intensity scores was compared. RESULTS: The postimplementation group reported significantly lower pain intensity ratings for the average amount of pain experienced while in the surgical heart unit, the least amount of pain experienced while in the surgical heart unit, and the pain experienced at the moment of questioning. CONCLUSIONS: Use of a standardized pain flowsheet to assess pain intensity and document pharmacologic intervention may improve pain management in postsurgical cardiovascular patients.
Physiologic response to two endotracheal suctioning techniques in newborn lambs with and without acute pulmonary hypertension
Authors: Daicoff BB , MRJr Langham , Mullet TW , Yarandi HN
Published: November 2019

BACKGROUND: Endotracheal suctioning may cause sudden increases in pulmonary arterial pressure, which can result in hypoxia secondary to right ventricular failure and/or increased right-to-left shunting. An adaptor that allows suctioning without disconnecting the ventilator has been proposed to prevent these problems; however, its efficacy has not been rigorously studied. OBJECTIVE: To examine the physiologic responses to two endotracheal suctioning techniques in newborn lambs with and without acute pulmonary hypertension. METHODS: A repeated-measures design was used to compare two endotracheal suctioning techniques in seven newborn lambs with and without acute pulmonary hypertension. An adaptor was used in the ventilator-controlled technique, making disconnection of the ventilator during suctioning unnecessary. In the bag-controlled technique, the ventilator was disconnected and ventilation was done with a manual resuscitation bag. Physiologic variables, pulmonary and mean arterial pressure, peak inspiratory pressure, mixed venous oxygen saturation, cardiac index, and arterial blood gas values were recorded before, during, and after endotracheal suctioning. RESULTS: Endotracheal suctioning caused a statistically significant systemic hypertensive response in lambs with and without acute pulmonary hypertension, regardless of which suctioning technique was used. No statistically significant changes occurred in pulmonary arterial pressure using either technique. CONCLUSIONS: Use of an adaptor resulted in no differences in the physiologic responses to endotracheal suctioning. However, endotracheal suctioning was easier to perform using an adaptor because no extra equipment or person was needed.
Comparison of continuous with intermittent bolus thermodilution cardiac output measurements
Authors: Ditmyer CE , Shively M , Burns DB , Reichman RT
Published: November 2019

BACKGROUND: Few complete studies have been published to validate the agreement between continuous cardiac output and intermittent thermodilution cardiac output. OBJECTIVE: To analyze the agreement between cardiac output measurements by the continuous thermodilution method and the intermittent bolus thermodilution method, using a continuous cardiac output catheter in postoperative cardiothoracic surgery patients. METHODS: A convenience sample of 14 adult cardiothoracic surgical patients with thermodilution pulmonary artery catheters placed preoperatively was used. A total of 214 comparison measurements of cardiac output by both the continuous and intermittent thermodilution methods were taken on patient admission to the critical care unit, every 4 hours, and with any change greater than 10% from baseline readings. RESULTS: The intraclass correlation between continuous cardiac output and intermittent cardiac output was .89. The limits of agreement were -1.34 to 1.18 L/min, indicating that in 95% of readings the difference between continuous cardiac output and intermittent cardiac output were within this range. CONCLUSIONS: The continuous cardiac output monitoring method shows clinically acceptable agreement with the intermittent cardiac output method.
Comparison of four methods of assessing heart rate variability in patients with heart failure
Authors: Woo MA , Stevenson WG , Moser DK
Published: November 2019

BACKGROUND: Heart rate variability reflects autonomic tone and is used to assess progression and prognosis in a variety of illnesses. However, multiple heart rate variability methods exist and are not necessarily equivalent. OBJECTIVES: To compare four methods of heart rate variability in heart failure patients and healthy subjects. METHODS: Twenty-four-hour Holter recordings were obtained in 50 heart failure patients and 50 age- and gender-matched control patients. From these recordings, heart rate variability was assessed by histograms, standard deviation, Poincare plots, and spectral analysis. RESULTS: For R-R interval histograms, standard deviation, and Poincare plots, diminished heart rate variability was identified in 65% to 100% of heart failure patients versus 0% to 8% of controls. Agreement among these tests ranged from 69% to 96%. Spectral values varied greatly over the recording period, even in the same subject, possibly because of variations in activity. Only 16% of heart failure patients had spectral values that were identified as abnormal. Agreement between spectral analysis and the other methods ranged between 58% and 67%. CONCLUSIONS: Heart rate variability assessed over a 24-hour period with different techniques yields similar but not identical results. Heart rate variability assessed from spectral analysis of short periods of data varied markedly in a 24-hour period and should not be compared with measures obtained from 24-hour methods. Standardization of subject activity and recording time is necessary for comparison of spectral analysis of brief periods. Further research is required to determine if differences among methods assessing 24-hour heart rate variability yield complementary information.
Critical care nurses' knowledge of pulmonary artery catheters
Authors: Burns D , Burns D , Shively M
Published: November 2019

BACKGROUND: Earlier studies indicate that nurses and physicians have a knowledge deficit regarding pulmonary artery catheters. OBJECTIVE: To evaluate critical care nurses' knowledge of pulmonary artery catheters. METHODS: A 31-item, multiple-choice questionnaire was administered to 168 critical care nurses from institutions in a southern California metropolitan area. Fourteen demographic questions were included to determine variables such as critical care nursing experience, educational background, work area, and frequency of pulmonary artery catheter use that may have affected participants' scores. The investigators traveled to the institutions to explain and conduct the study. RESULTS: The mean knowledge score was 16.4 of 29 questions (56.8% items correct), with a standard deviation of 3.74. The range of correct scores was 8 to 25. Two questions were not factored into the statistical analysis because they were specific to the physician's role in pulmonary artery catheter insertion. The variables that correlated with higher scores were CCRN certification, attendance at a pulmonary artery catheter class, years of critical care experience, and frequent use of the pulmonary artery catheter. Of the respondents, 39% were unable to identify a pulmonary artery wedge measurement value from a waveform recording. CONCLUSIONS: Critical care nurses' knowledge of pulmonary artery catheters is related directly to the frequency of their exposure to it, critical care nursing experience, attendance at a pulmonary artery catheter class, and CCRN certification. Additional research is needed on a larger scale to validate these findings and determine if critical care nurses' knowledge of pulmonary artery catheters is sufficient to maintain quality standards of safety and optimal patient care.
Emerging technology in critical care: continuous intra-arterial blood gas monitoring
Authors: Szaflarski NL
Published: November 2019

The blood-conserving technology of continuous intra-arterial blood gas monitoring has recently been introduced into the field of critical care. This type of monitoring is a real-time method for concomitantly assessing oxygenation, ventilation, and acid-base status in pediatric and adult populations through an indwelling (in vivo) sensor residing in a peripheral artery. This article examines the technology underpinning in vivo blood gas monitoring and reviews research documenting clinical performance, as well as benefits and clinical applications of three-analyte systems in critically ill patients. A majority of research has revealed clinically acceptable accuracy and reliability of in vivo blood gas sensors in critically ill adults subjected to a variety of adverse, but common, physiological conditions. Although most clinical research in critically ill adults has revealed good clinical performance of in vivo blood gas sensors, reports of aberrant blood gas values and sensor problems remain; no reports have been published to date evaluating continuous intra-arterial blood gas monitoring in children or infants. Many benefits of this technology have been postulated, and research examining its effect on patient and cost outcomes in critically ill populations is pending. Clinicians in critical care must keep abreast of this emerging technology, because it holds significant potential for improving the quality of care and outcomes of critically ill patients.
Acute gastrointestinal complications after cardiac surgery
Authors: Halm MA
Published: November 2019

Gastrointestinal problems, with an incidence of about 1%, may complicate the postoperative period after cardiovascular surgery, increasing morbidity, length of stay, and mortality. Several risk factors for the development of these complications, including preexisting conditions; advancing age; surgical procedure, especially valve, combined bypass/valve, emergency, reoperative, and aortic dissection repair; iatrogenic conditions; stress; ischemia; and postpump complications, have been identified in multiple research studies. Ischemia is the most significant of these risk factors after cardiovascular surgery. Mechanisms that have been implicated include longer cardiopulmonary bypass and aortic cross-clamp times and hypoperfusion states, especially if inotropic or intra-aortic balloon pump support is required. These risk factors have been linked to upper and lower gastrointestinal bleeding, paralytic ileus, intestinal ischemia, acute diverticulitis, acute cholecystitis, hepatic dysfunction, hyperamylasemia, and acute pancreatitis. Gastrointestinal bleeding accounts for almost half of all complications, followed by hepatic dysfunction, intestinal ischemia, and acute cholecystitis. Identification of these gastrointestinal complications may be difficult because manifestations may be masked by postoperative analgesia or not reported by patients because they are sedated or require prolonged mechanical ventilation. Furthermore, clinical manifestations may be nonspecific and not follow the "classic" clinical picture. Therefore, astute assessment skills are needed to recognize these problems in high-risk patients early in their clinical course. Such early recognition will prompt aggressive medical and/or surgical management and therefore improve patient outcomes for the cardiovascular surgical population.
The influence of illness severity and family resources on maternal uncertainty during critical pediatric hospitalization
Authors: Tomlinson PS , Kirschbaum M , Harbaugh B , Anderson KH
Published: November 2019

BACKGROUND: Psychological management of parents during a child's critical illness is a challenge to intensive care nurses because of the uncertainty that accompanies hospitalization. OBJECTIVE: To explore the relationship among illness severity, family resources, and maternal uncertainty during the initial stage of a child's hospitalization in a pediatric intensive care unit for a life-threatening illness. METHODS: A convenience sample of 40 mothers rated perceptions of uncertainty (using Mishel's Uncertainty of Illness Scale: Parent Child Form), family cohesion (using Olson's Family Adaptability and Cohesion Evaluation Scale), and social support (using Norbeck's Social Support Questionnaire). Illness severity was estimated with the Pediatric Risk of Mortality Scale. RESULTS: inverted question mark Results showed a positive association between illness severity and maternal uncertainty and a negative association between family cohesion and maternal uncertainty. Severity of illness contributed less to maternal uncertainty than did family cohesion. CONCLUSIONS: Family relationship are important factors to consider when clinicians estimated the effect on parents of their child's critical illness, particularly when uncertainty over their child's outcome may lead to parental stress that can interfere with coping and child management. (American Journal of Critical Care.)
Knowing the score: using predictive scoring systems in clinical practice
Authors: Zollo MB , Moskop JC , CEJr Kahn
Published: November 2019

Outcome scores have been promoted as adjuncts to clinical decision making, especially when further care is thought to be futile. The Pediatric Risk of Mortality score is used to calculate the risk of mortality for patients admitted to pediatric intensive care units. In this article the Pediatric Risk of Mortality score in evaluated for its ability to contribute to individual patient care decisions in the context of clinical practice. Through analysis several features of the Pediatric Risk of Mortality score were identified that require discretion if the score is to be used in decisions involving individual patients. These features include variability and bias introduced in data collection and data presentation. Also, outcome scores do not allow for the incorporation of patient and family values into the decision process. Outcome scores can provide some adjunctive information to clinicians, but they should be used with caution when making patient care decisions. Use of Pediatric Risk of Mortality scores in clinical practice must be tempered with a knowledge of the limitations of the scores, individual patient variability, the conditions under which the scores have been validated and collected and, most importantly, an awareness that outcome scores do not take into account the caregiver and patient values that are inherent in any treatment decision.
The validity of a nursing assessment and monitoring of signs and symptoms scale in ICU and non-ICU patients
Authors: Chang BL , Rubenstein LV , Keeler EB , Miura LN , Kahn KL
Published: November 2019

PURPOSE: This study examined the validity of medical-record-based nursing assessment and monitoring of signs and symptoms (nursing surveillance) in predicting patients who were admitted to ICUs and those admitted to non-ICUs. The association of this assessment and monitoring with differences in an intermediate patient outcome, instability at discharge, was also explored. Patients admitted to either setting with a diagnosis of acute myocardial infarction, cerebrovascular accident, congestive heart failure, or pneumonia, were included in the study. METHOD: A secondary analysis was carried out using a subset of data originally collected for a quality-of-care study. Data from the medical records of 11,246 patients (52% female, 48% male) with a mean age of 76.4 years were used in the present study. RESULTS: ICU patients (n = 3969) were found to have a longer length of stay and to be sicker on admission than non-ICU patients (n = 7277). Overall, patients in the ICU received significantly higher nursing assessment and monitoring of signs and symptoms scores than non-ICU patients. Nursing assessment and monitoring of signs and symptoms scores were lower for patients discharged with greater instability for three of the four diseases (cerebrovascular accidents, congestive heart failure, and pneumonia).
Use of flecainide for refractory atrial tachycardia of pregnancy
Authors: Ahmed K , Issawi I , Peddireddy R
Published: November 2019

Sustained arrhythmias during pregnancy are uncommon. However, when they do occur, atrial tachycardias are usually amenable to pharmacological or electrical therapy. We describe a case of sustained atrial tachycardia in a pregnant patient. The tachycardia was resistant to commonly used antiarrhythmic drugs and to cardioversion but rapidly responded to flecainide, with return to sinus rhythm until the patient was delivered of a healthy baby.
Procedures used in withdrawal of mechanical ventilation
Authors: Daly BJ , Thomas D , Dyer MA
Published: November 2019

OBJECTIVE: The purpose of this study was to describe ways in which withdrawal of mechanical ventilation is carried out in one institution, patient responses to the various methods of withdrawal, and nurses' perceptions of the methods and morality of ventilator withdrawal. METHOD: A retrospective descriptive study was used with a convenience sample of adult patients who underwent terminal weaning at University Hospitals of Cleveland. Demographic and clinical data, and descriptions of the exact method of ventilator withdrawal were collected from the medical records of these patients. The nurse caring for the patient was interviewed about his or her perceptions, within 7 days of the withdrawal. RESULTS: Data were obtained on 42 subjects. There were no differences in mental status, ventilatory status, age, or duration of survival between the patients who had support removed gradually and those from whom it was abruptly removed. Morphine was administered to 88% of the sample during withdrawal. Survival duration was unrelated to morphine dosage, but did correlate with ventilatory status at the time of withdrawal. Every nurse interviewed reported that he or she believed the act of withdrawal for that patient was morally correct, although only 85% were completely comfortable with carrying out the procedure. CONCLUSIONS: These results provide a foundation for preliminary recommendations about the most humane form of ventilator withdrawal and the appropriate use of narcotics and sedatives during withdrawal.
Assisted suicide: clinical realities and ethical challenges
Authors: Scanlon C , Rushton CH
Published: November 2019

The increasing attention to assisted suicide, as evidenced by recent legislation, initiatives, court decisions, and research, propels the issue to a new level of importance and urgency within society and the health professions. Nurses cannot help but be confronted by and struggle with the complex moral and professional quandaries related to assisted suicide. Critical care nurses must continue to evaluate the implications of the possible legalization of assisted suicide and to define the boundaries of morally acceptable professional practice. The challenges to the roles and responsibilities of critical care nurses that might occur if assisted suicide were legalized must be thoughtfully and responsibly explored.
Structuring cardiology services for the 21st century
Authors: Mangan B
Published: November 2019

Segregating patients into small coronary care units began in the 1960s. This step was deemed necessary for two reasons: (1) the high mortality and often profound morbidity of patients who had acute myocardial infarction and (2) the boom in treatment technologies, with the introduction of bedside oscilloscopes, defibrillation, and mechanical and pharmacological means of resuscitation and pacing. Another series of technology booms in cardiology has occurred in the 1990s. This new technology and other associated factors may signal the need for reviewing the cardiac care environment. This article presents the evolution of acute care in cardiology from the 1960s to 1996 and questions the continuing need for small, highly staffed cardiac care units. In the current climate of technological refinements, improved nursing education, and a large and diverse population of cardiovascular patients, these units may be redundant.