bluuebunny/crossref_metadata_2025 huggingface dataset:
Tidal Destruction in a Low-mass Galaxy Environment: The Discovery of Tidal Tails around DDO 44*
Authors: Carlin Jeffrey L. , Garling Christopher T. , Peter Annika H. G. , Crnojević Denija , Forbes Duncan A. , Hargis Jonathan R. , Mutlu-Pakdil Burçin , Pucha Ragadeepika , Romanowsky Aaron J. , Sand David J. , Spekkens Kristine , Strader Jay , Willman Beth
Published: November 2019

We report the discovery of a ≳1° (∼50 kpc) long stellar tidal stream emanating from the dwarf galaxy DDO 44, a likely satellite of Local Volume galaxy NGC 2403 located ∼70 kpc in projection from its companion. NGC 2403 is a roughly Large Magellanic Cloud (LMC) stellar-mass galaxy 3 Mpc away, residing at the outer limits of the M81 group. We are mapping a large region around NGC 2403 as part of our Magellanic Analogs’ Dwarf Companions and Stellar Halos survey, reaching point-source depths (90% completeness) of (g, i) = (26.5, 26.2). Density maps of old, metal-poor RGB stars reveal tidal streams extending on two sides of DDO 44, with the streams directed toward NGC 2403. We estimate total luminosities of the original DDO 44 system (dwarf and streams combined) to be M

i,tot = −13.4 and M

g,tot = −12.6, with ∼25%–30% of the luminosity in the streams. Analogs of ∼LMC-mass hosts with massive tidally disrupting satellites are rare in the Illustris simulations, especially at large separations such as that of DDO 44. The few analogs that are present in the models suggest that even low-mass hosts can efficiently quench their massive satellites.
Planet Formation around Supermassive Black Holes in the Active Galactic Nuclei
Authors: Wada Keiichi , Tsukamoto Yusuke , Kokubo Eiichiro
Published: November 2019

As a natural consequence of the elementary processes of dust growth, we discovered that a new class of planets can be formed around supermassive black holes (SMBHs). We investigated a growth path from submicron sized icy dust monomers to Earth-sized bodies outside the “snow line,” located several parsecs from SMBHs in low luminosity active galactic nuclei (AGNs). In contrast to protoplanetary disks, the “radial drift barrier” does not prevent the formation of planetesimals. In the early phase of the evolution, low collision velocity between dust particles promotes sticking; therefore, the internal density of the dust aggregates decreases with growth. When the porous aggregate’s size reaches 0.1–1 cm, the collisional compression becomes effective, and the decrease in internal density stops. Once 10–100 m sized aggregates are formed, they are decoupled from gas turbulence, and the aggregate layer becomes gravitationally unstable, leading to the formation of planets by the fragmentation of the layer, with 10 times the mass of the Earth. The growth timescale depends on the turbulent strength of the circumnuclear disk and the black hole mass M
BH, and it is comparable to the AGN’s lifetime (∼108 yr) for low mass (M
BH ∼ 106
M
⊙) SMBHs.
Radial Variations in Grain Sizes and Dust Scale Heights in the Protoplanetary Disk around HD 163296 Revealed by ALMA Polarization Observations
Authors: Ohashi Satoshi , Kataoka Akimasa
Published: November 2019

The disk of HD 163296 shows ring and gap substructures in observations with the Atacama Large Millimeter/submillimeter Array. In addition, this is the only disk where the rings and gaps are spatially resolved in millimeter-wave polarization measurements. In this paper, we conduct radiative transfer modeling that includes self-scattering polarization to constrain the grain size and its distribution. We found that the grain size and dust scale height are the key parameters for reproducing the radial and azimuthal distributions of the observed polarization signature. Radial variation is mainly determined by grain size. The polarization fraction is high if the particle size is ∼λ/2π; it is low if the particle size is larger or smaller than this. In contrast, azimuthal variation in polarization is enhanced if the dust scale height is increased. Based on detailed modeling of the polarization of HD 163296, we found the following radial variations in the grain size and dust scale height. The maximum grain size was 140 μm in the gaps and significantly larger or smaller in the rings. The dust scale height is less than one-third of the gas scale height inside the 70 au ring, and two-thirds of it outside. Furthermore, we constrained the gas turbulence to be α ≲ 1.5 × 10−3 in the 50 au gap and α ∼ 0.015–0.3 in the 90 au gap. The transition in the turbulence strength at the boundary of the 70 au ring indicates the existence of a dead zone.
The Effect of Noise Exposure on Cognitive Performance and Brain Activity Patterns
Authors: Jafari Mohammad Javad , Khosrowabadi Reza , Khodakarim Soheila , Mohammadian Farough
Published: November 2019

Background: It seems qualitative measurements of subjective reactions are not appropriate indicators to assess the effect of noise on cognitive performance. In this study, quantitative and combined indicators were applied to study the effect of noise on cognitive performance.
Materials and Methods: A total of 54 young subjects were included in this experimental study. The participants’ mental work load and attention were evaluated under different levels of noise exposure including, background noise, 75, 85 and 95 dBA noise levels. The study subject’s EEG signals were recorded for 10 minutes while they were performing the IVA test. The EEG signals were used to estimate the relative power of their brain frequency bands.
Results: Results revealed that mental work load and visual/auditory attention is significantly reduced when the participants are exposed to noise at 95 dBA level (P<0.05). Results also showed that with the rise in noise levels, the relative power of the Alpha band increases while the relative power of the Beta band decreases as compared to background noise. The most prominent change in the relative power of the Alpha and Beta bands occurs in the occipital and frontal regions of the brain respectively.
Conclusions: The application of new indicators including brain signal analysis and power spectral density analysis is strongly recommended in the assessment of cognitive performance during noise exposure. Further studies are suggested regarding the effects of other psychoacoustic parameters such as tonality, noise pitch (treble or bass) at extended exposure levels.
Alimentação de Auchenipterichthys punctatus (Siluriformes, Auchenipteridae) em lagos do rio Cuiuni, Amazonas, Brasil
Authors: Uchôa Farias Eletuza , Aguiar Santos Jamerson , de Castro Loebens Sara , Daniel Beltrão Hélio , de Carvalho Freitas Carlos Edwar , Yamamoto Kedma Cristine
Published: November 2019

Auchenipterichthys punctatusé uma espécie de peixe muito abundante durante o período de águas baixas no rio Cuiuni, sendo objetivo deste estudo investigar a alimentação deA. punctatusem lagos desse rio. O conteúdo estomacal, o grau de repleção, índice alimentar (IAi), itens preferenciais e amplitude de nicho trófico (BA) de 130 indivíduos foram analisados. Os resultados demonstram que 26,9% dos indivíduos apresentam estômagos com grau de enchimento baixo, 23,0% moderado, 13,0% semicheio e 10,7% completamente cheio. Foi possível identificar três categorias de conteúdo quanto à origem: animal, vegetal e material não identificado. Os itens de maior consumo e diversidade estão dentro da categoria animal, representados por diferentes ordens de insetos de origem autóctone e alóctone. De acordo com os dados da dieta, a composição alimentar deA. punctatusdurante o período da seca nos lagos do rio Cuiuni evidencia o hábito carnívoro com tendência à insetivoria. Os valores de amplitude de nicho trófico foram considerados baixos em todos os lagos. A atividade alimentar evidenciou que durante o período da seca houve restrição devido ao alto consumo de um único item. Ressaltamos a necessidade de mais estudos sobre a espécie, além de outros auchenipterídeos, envolvendo a ecologia trófica durante todas as fases do pulso de inundação em lagos de água preta na Amazônia para completar as lacunas existentes sobre sua ecologia.
Efficacy of Adductor Canal Block With Liposomal Bupivacaine: A Randomized Prospective Clinical Trial
Authors: Meftah Morteza , Boenerjous-Abel Suhas , Siddappa Vinay H. , Kirschenbaum Ira H.
Published: November 2019

This study compared the postoperative analgesic efficacy of liposomal bupivacaine as a single-administration adductor canal block (ACB) vs periarticular injection (PAI) for pain control after total knee arthroplasty (TKA). From May 2016 to June 2017, a total of 70 unilateral TKA patients were randomized into 2 groups: PAI (extended-release bupivacaine 266 mg [20-mL vial] with 20 mL of 0.5% bupivacaine hydrochloride and normal saline to a total volume of 120 mL) and ACB (subsartorial saphenous nerve using extended-release bupivacaine 266 mg [20-mL vial]). All patents underwent spinal anesthesia with comprehensive preemptive and postoperative multi-modal pain protocol. All opioids administered were converted to morphine equivalents. Pain was recorded at 4 to 12 hours on the day of surgery, and on postoperative days 1, 2, and 3. Patients and investigators other than the surgeon and anesthesiologist were blinded to the study. The difference in pain scores between the PAI and ACB groups was not statistically significant during the first 12 hours (day 0) after surgery or on postoperative day 1 (5.31 vs 4.26,
P
=.091). However, on postoperative day 3, the mean pain score increased in the ACB group and decreased in the PAI group (4.8 vs 1.83,
P
=.037). There was no statistically significant difference between the 2 groups regarding the accumulative daily converted morphine equivalent consumption or total consumption. Although the PAI group demonstrated longer lasting pain relief than the ACB group for the duration of the study, other outcomes were similar between the 2 groups. [
Orthopedics
. 2020; 43(1):e47–e53.]
Un faldellín de guerrero hecho de anillas: ¿una evidencia temprana de cota de malla o la visión de un coleccionista?
Authors: Wijnhoven Martijn A.
Published: November 2019

Un cinturón itálico de bronce en la colección del Museo de Louvre muestra una característica única: de él cuelga una malla de anillas formando un faldellín. El cinturón mismo se ha fechado en el siglo IV a. C. En cuanto al faldellín, se ha sugerido que podría ser una de las primeras manifestaciones de cota de malla, o posiblemente un antecesor de este tipo de armadura. No obstante, un análisis detallado ha demostrado que el cinturón y el faldellín no formaban una sola pieza originalmente y que fueron unidos en el siglo XIX. Resulta que el faldellín no tiene que ver con la cota de malla, ni con un antecesor. El análisis de hallazgos similares muestra que es probablemente un adorno de cadera del siglo VIII-VII a. C. que proviene de un entierro femenino del sur de Italia.
La frontera evanescente: horizontes fronterizos en obras de Daniel Sada y de Eduardo Antonio Parra
Authors: Tapia Miguel
Published: November 2019

Este artículo explora la noción de frontera que se desprende de las representaciones del límite entre México y los Estados Unidos en las obras de dos narradores mexicanos indispensables de las últimas décadas: Daniel Sada y Eduardo Antonio Parra. Tomando como punto de partida las reflexiones geopoéticas de Michel Collot, nuestro trabajo busca mostrar cómo la representación mexicana de la frontera entre estos países funciona, más que como una línea fija e inmóvil, como un horizonte fronterizo cuya naturaleza ha sido social e históricamente construida. Este limite difuso e inalcanzable, que nos permite definir a la vez el propio país y la alteridad, se hace omnipresente a lo largo de todo el territorio cultural mexicano con efectos que sobrepasan los provocados por la existencia de la división física en sí misma.
La fin de toutes choses : frontières et apocalypse dans les nouvelles de science-fiction du nord-ouest du Mexique
Authors: Fabriol Anaïs
Published: November 2019

La frontière et l’apocalypse ont ce point commun de symboliser un point de rupture. La fin du monde est souvent mise en perspective dans la narration courte du nord-ouest du Mexique, qui fait également de la frontière un élément quasi omniprésent. Il convient donc de voir de quelle manière s’articulent ces deux figures majeures. Sont-elles complémentaires, et que disent-elles du rapport que la société frontalière et ses imaginaires entretiennent avec la limite géographique ?
Être de frontières et poétique des confins. Une lecture de Lejos de Roma (2008) de Pablo Montoya
Authors: Le Corre Hervé
Published: November 2019

Dans Lejos de Roma (2008) l’écrivain colombien Pablo Montoya imagine, à la première personne, dans un récit apocryphe, ce qui constitue une espèce de journal intime de Publius Ovidius Naso, écrit au cours des années d’exil à Tomes, aux confins d’un empire dont le poète saisit le délitement. Montoya, dans les fragments qui constituent ce texte, élabore une poétique des frontières. Politiques, historiques, culturelles ou linguistiques, les frontières traversent le sujet ovidien, qui peu à peu, dans un itinéraire de régénération, parvient à reconquérir depuis les limites de la condition humaine sa capacité métamorphique, et à faire de la frontière un limes créatif, et de son corps un limen, comme lieu privilégié de subjectivation et d’interaction.
Enquêter sur la frontière mexico-américaine. Ambivalence d’un objet, stratégies de terrain
Authors: Tocilovac Marko
Published: November 2019

Cet article retrace les principales étapes d’un travail de terrain et d’analyse anthropologique mené à la frontière mexico-américaine. Face à l’impression immédiate d’ambivalence de la frontière, à la fois visible et cachée, l’enquête ethnographique m’a permis de repenser mon objet, cerner ses dynamiques, identifier ses acteurs pour finalement opérer trois changements de perspective, et ainsi mieux comprendre comment la frontière produit des images mentales opposées, voire contradictoires.
Nurse/physician collaboration: solving the nursing shortage crisis
Authors: Evans SA , Carlson R
Published: November 2019

This summary article discusses the status of the nursing shortage in the United States, with emphasis on successful strategies to address it. Liaisons between the American Association of Critical-Care Nurses (AACN) and the Society for Critical Care Medicine, as well as with the American College of Cardiology, are highlighted, with primary emphasis on the strategy of nurse-physician collaboration.
Evaluation of a system for intragastric pH monitoring of intensive care unit patients: preliminary report
Authors: Clochesy JM
Published: November 2019

BACKGROUND: A new pH probe-tipped nasogastric sump tube is available to monitor gastric pH conveniently. This study assesses its ability to measure gastric acidity accurately. METHODS: The accuracy of the combined pH probe nasogastric tube (GrapHprobe ST) was determined by comparing it with standard buffer solutions (pH 1.0, 2.0, 4.0 and 7.0) traceable to the National Institute of Standards and Technology. Gastric pH values obtained were compared with values obtained using indicator paper and a calibrated glass electrode on gastric aspirate. RESULTS: Although statistically significant differences were found in vitro between the pH of three of the buffer solutions and the pH values obtained by the nasogastric sump tube, the results were within 0.5 pH unit. When rounded to the nearest pH unit, all values were the same as the buffer solutions. No significant difference was found in the pH values obtained during in vivo testing. CONCLUSIONS: The GrapHprobe ST measured gastric pH within reasonable accuracy in this small series.
Parental coping and activities during pediatric critical care
Authors: LaMontagne LL , Hepworth JT , Pawlak R , Chiafery M
Published: November 2019

OBJECTIVE: To investigate the relationship of locus of control, parental age, and state anxiety to parental coping and activities performed during hospitalization of a child in a pediatric critical care center. DESIGN: Cross-sectional. SETTING: Pediatric critical care center at a university medical center. PARTICIPANTS: A convenience sample of 47 parents of 47 children hospitalized in a critical care center. MAIN OUTCOME MEASURES: Parental coping strategies and activities performed during hospitalization in a critical care center. RESULTS: Older, more self-directed and less anxious parents were found to use coping strategies focusing on problem solving rather than on their emotional response to a child's hospitalization. Further, those who used the problem-focused coping modes were more likely to be involved in caring for the child, while parents who used emotion-focused coping modes participated less in care activities. CONCLUSIONS: Appropriate strategies to bolster coping and reduce stress of parents need to be constantly reassessed because coping mechanisms vary according to parental age, locus of control, anxiety level, and parental involvement in child-care activities. More research is needed in the changes of parental coping mechanisms with time and child-care activity, to assess the benefits of interventions planned to encourage a problem-focused approach.
Computerized clinical simulations: a strategy for staff development in critical care
Authors: Henry SB , Waltmire D
Published: November 2019

BACKGROUND: Identifying the learning needs of employees and evaluating the results of staff development offerings are essential elements of the responsibilities of the staff development educator. High patient acuity, the shortage of critical care nurses, and rapidly changing technology within the critical care environment demand the provision of staff development offerings that are appropriate for the learning needs of critical care nurses and the evaluation of the effect of programs on critical care nursing practice. OBJECTIVE: The purposes of this descriptive, correlational study were to compare the ability of a knowledge test, a self-evaluation tool, and computerized clinical simulations to discriminate between nurses with varied levels of knowledge and experience, and to compare the learning needs identified from the three types of evaluative instruments. METHODS: Each subject (n = 142) completed the Basic Knowledge Assessment Tool for Critical Care, Cardiovascular Self-Evaluation Tool, and four computerized clinical simulations. RESULTS: Both the Basic Knowledge Assessment Tool and the Cardiovascular Self-Evaluation Tool discriminated between experienced/inexperienced and Advanced Cardiac Life Support-certified/noncertified critical care nurses. The computerized clinical simulations discriminated according to Advanced Cardiac Life Support certification, but not between experienced and inexperienced critical care nurses. The computerized clinical simulations identified more specific learning needs than did the Basic Knowledge Assessment Tool or Cardiovascular Self-Evaluation Tool. CONCLUSIONS: The evidence for discriminant validity, adequate internal consistency reliability, and ease of administration supports the continued use of these two tools as methods for critical care staff development needs assessment and evaluation. In addition, the study findings support the use of computerized clinical simulations as an adjunct to other needs assessment and evaluation methods in nursing staff development.
A protocol for initiation of nasal positive pressure ventilation
Authors: Spessert CK , Weilitz PB , Goodenberger DM
Published: November 2019

BACKGROUND: Respiratory failure related to neuromuscular weakness has commonly been managed with long-term ventilation by tracheostomy. Currently, nasal positive pressure ventilation is being used with success in this patient population. It has been suggested that initiation of nasal positive pressure ventilation is best done in an intensive care setting. METHOD: Nine patients were placed on nasal ventilation during a brief admission to a medical floor staffed by nurses trained in respiratory care. This process was facilitated by use of a standardized protocol for nursing staff that identified treatment objectives. RESULTS: Following the initiation of nasal positive pressure ventilation, this group of patients experienced near normalization of daytime measurements of partial pressure of arterial carbon dioxide, reported increases in daytime energy levels, and relief of nighttime signs and symptoms. These objectives were accomplished with no significant complications. Use of this protocol may also decrease length and cost of hospitalization and improve patient acceptance of noninvasive ventilatory assistance.
Morphine sulfate, transdermal fentanyl citrate and ketorolac tromethamine: effects on postoperative pulmonary function
Authors: Mason HH
Published: November 2019

The physiological effects of morphine sulfate and fentanyl citrate on postoperative pulmonary function demonstrate varying degrees of respiratory depression related to dose, route of administration and pre-existing pathologies. Current postoperative analgesic therapies that include concomitant use of narcotic agonists and nonsteroidal anti-inflammatory drugs require adjustment of drug dosages to provide adequate pain relief while avoiding drug-induced complications. Specific nursing considerations include understanding therapeutic and adverse effects of these agents on pain and ventilation, continuous pain assessment and early recognition and treatment of respiratory depression.
Urinary creatinine excretion in the ICU: low excretion does not mean inadequate collection
Authors: Pesola GR , Akhavan I , Carlon GC
Published: November 2019

BACKGROUND: It has been assumed that a urinary creatinine excretion rate of less than 10 mg/kg per day means an inadequately collected urine sample. OBJECTIVE: To determine the frequency of a urinary creatinine excretion rate of less than 10 mg/kg per day in intensive care unit patients with an adequately collected urine sample. METHOD: In a prospective study of creatinine excretion rates, 24-hour urine samples were evaluated for urinary creatinine in 209 critically ill patients with indwelling Foley catheters. Patients from three adult intensive care units in New York City were divided into two groups. Group 1 patients excreted less than 10 mg/kg per day of urinary creatinine, and group 2 patients excreted at least 10 mg/kg per day. Groups 1 and 2 were first evaluated by dividing the creatinine excretion data by actual body weight. Since actual body weight may overestimate body weight in the critically ill patient, data from groups 1 and 2 were also evaluated using lean body weight. RESULTS: Urinary creatinine excretion was less than 10 mg/kg per day in 36.8% of patients using actual body weight and 29.7% of patients adjusted for lean body weight. The average age of patients in group 1 was 74 +/- 17 years for both actual body weight and lean body weight. The average age of group 2 patients was 60 +/- 19 years for actual body weight and 62 +/- 19 years for lean body weight. There was a significant difference in age between group 1 and group 2 patients for both actual body weight and lean body weight. The proportion of female vs male patients with reduced creatinine excretion was significantly greater, whether the actual body weight or lean body weight adjustment was used. CONCLUSIONS: A urinary creatinine excretion rate of less than 10 mg/kg per day occurs in about one third of critically ill patients, who are more likely to be elderly and female.
Pressure-controlled inverse-ratio ventilation in children with acute respiratory failure
Authors: Goldstein B , Papadakos PJ
Published: November 2019

We report the use of pressure-controlled inverse-ratio ventilation in two children with acute respiratory failure who were failing conventional mechanical ventilation. The children had subsequent improvement in oxygenation and ventilation without hemodynamic compromise. Pressure-controlled inverse-ratio ventilation was well tolerated by one patient who had increased intracranial pressure secondary to head injury. We were able to successfully hyperventilate, improve oxygenation and control intracranial pressure in this patient while using pressure-controlled inverse-ratio ventilation, which may prove to be an alternative method of ventilation for children with severe lung disease.
Analgesics for cardiac surgery patients in critical care: describing current practice
Authors: Maxam-Moore VA , Wilkie DJ , Woods SL
Published: November 2019

BACKGROUND: In the last 10 years, the American Association of Critical-Care Nurses has twice ranked pain management as a priority issue for research and practice. Recent research findings suggest that undermedication of patients continues both in and out of critical care. Postoperative cardiac surgery patients have reported detailed recollections of pain experiences while in critical care, yet little is known about management of postoperative cardiac surgery pain. OBJECTIVE: The purpose of this study was to describe current practice related to analgesic prescription and administration for postoperative cardiac surgery patients in critical care. METHODS: Medical records of 80 adults undergoing cardiac surgery in two hospitals were randomly selected for review. Data pertaining to pain medications prescribed and doses administered for the day of surgery, first and second postoperative days were recorded for 66 eligible subjects. RESULTS: All but one patient had a prescription for intravenous morphine, hourly as needed. In addition, all patients had prescriptions for one or more oral analgesics as needed. Gender and age effects were noted for analgesic prescriptions. The average total amount of intravenous morphine given over the 3 days was 13.9 +/- 13.5 mg in an average of 4 +/- 3.7 doses. The average total number of acetaminophen with oxycodone tablets given over the 3 days was 5.8 +/- 5.4 tablets in an average of 3.6 +/- 3.0 doses. Age and hospital effects were noted in the administration of analgesics. CONCLUSIONS: The finding of small and infrequent analgesic doses is consistent with other studies conducted in and out of critical care. Important inconsistencies, or variations in practice, exist in both the prescription and administration of analgesics for postoperative cardiac surgery patients in the critical care setting.
Use of a mechanical pressure device for hemostasis following cardiac catheterization
Authors: Simon AW
Published: November 2019

BACKGROUND: Peripheral vascular complications that can occur after cardiac catheterization are costly and cause patient discomfort. OBJECTIVES: To determine the difference in frequency of vascular complications in a convenience sample of cardiac catheterization patients who had mechanical pressure vs digital pressure for postprocedural hemostasis. METHODS: A quasi-experimental design was used. The study group consisted of 100 patients on whom a mechanical clamp was used to effect hemostasis; the control group consisted of 100 patients who received digital pressure for hemostasis. Data from the control group were obtained retrospectively through review of cardiac catheterization charts. RESULTS: The two groups showed statistically significant differences for the number of catheters used, mean time elapsed between arterial entry and catheter removal, and compression time. There was no significant difference in complication rate between the groups. DISCUSSION: Complications including hematoma formation, arterial occlusion, ischemia and traumatic neuropathy were monitored. CONCLUSIONS: The mechanical pressure device is a safe, cost-effective alternative to digital pressure for hemostasis following cardiac catheterization. Further studies are needed to verify these results and the effectiveness of the device following other percutaneous intra-arterial procedures.
Continuous venovenous hemodialysis
Authors: Strohschein BL , Caruso DM , Greene KA
Published: November 2019

Hemodialysis and peritoneal dialysis are the main renal replacement therapies for patients with acute renal failure. These patients are often unable to tolerate drastic fluid shifts and other complications of conventional dialysis. Continuous hemodialysis, however, provides protection from the hemodynamic consequences and osmotic stressors of conventional dialysis and is rapidly becoming the treatment of choice for critically ill patients. We present a case in which a patient with a spontaneous cerebellar hemorrhage developed acute renal failure. Surgical evacuation was not an option. Clinical management included the use of continuous venovenous hemodialysis, which is described in the setting of a patient with a posterior fossa mass. The risks of anticoagulation, hemodynamic instability, and development of dialysis disequilibrium syndrome are discussed.
Impact of the DNR therapeutic plan on patient care requirements
Authors: Campbell ML , Thill-Baharozian M
Published: November 2019

BACKGROUND. The intensity and nature of a patient therapeutic plan should depend upon the specific therapeutic goals. When the therapeutic plan includes a do-not-resuscitate order, the intensity of the plan may be high or low. OBJECTIVE. To examine the differences in patient care requirements and hospital outcomes in patients with a do-not-resuscitate status to determine the most appropriate care setting, eg, intensive vs nonintensive care. METHOD. Data from a prospective sample of 100 patients were analyzed. Patients were grouped according to the intensity of the therapeutic plan: (1) all-but-CPR: all support except cardiopulmonary resuscitation, (2) conservative-care: medical management without the addition of life-sustaining measures, (3) comfort-only, and (4) withdrawal of life-sustaining therapy. RESULTS. Patient mortality was high for all groups except the conservative-care group. Patient care requirements remained high in the all-but-CPR group, necessitating continued intensive care. Patient care requirements decreased significantly in the comfort-only and withdrawal groups, illustrating the ability to manage these patients in a nonintensive care setting.
Factors influencing prehospital delay in patients experiencing chest pain
Authors: Reilly A , Dracup K , Dattolo J
Published: November 2019

BACKGROUND: Patients experiencing chest pain (or other cardiac symptoms) in the community delay hours, even days, in seeking medical care. Given the potential effectiveness of thrombolytic therapy, it is important to determine patterns of patient delay. OBJECTIVES: A descriptive study was conducted to determine the amount of time patients delayed in seeking medical care when experiencing chest pain and the characteristics of patients delaying longer than 3 hours. METHODS: Adult patients (N = 77) admitted to an emergency department with chest pain participated. Data were obtained using the Response to Symptoms Questionnaire and chart review. RESULTS: The mean prehospital delay times (ie, symptom onset to hospital arrival) was 25.4 hours (+/- 46.5), and the median was 5 hours. Delay groups were divided into those arriving less than 3 hours (n = 31 or 40%) and those arriving more than 3 hours (n = 46 or 60%) after symptom onset. Three hours was chosen based on a mean time, taken from the literature, of 84 minutes spent in the emergency department so that patients in the first group would be able to receive thrombolysis within 4 hours. Univariate statistical analyses revealed that advanced age, symptom onset with a family member present, and self-determination of symptoms as not being serious in nature all contributed to a delay of longer than 3 hours. CONCLUSIONS: Critical care nurses and physicians should focus on patients at high risk for prolonged delay and educate the public about action to take if a family member experiences cardiac symptoms.
Postmyocardial infarction patients: experience from the SAVE trial
Authors: Connors KF , Lamas GA
Published: November 2019

Improving patient survival is the ultimate goal after acute myocardial infarction. Although thrombolytics, aspirin, and beta-blockers have greatly decreased mortality, structural changes such as ventricular dilatation evolving within the myocardium during and after acute myocardial infarction indicate a poor prognosis. The Survival and Ventricular Enlargement trial demonstrated that when administered 3 to 16 days after acute myocardial infarction in selected patients, captopril, the angiotensin-converting enzyme inhibitor, reduces ventricular dilatation, prevents the development of congestive heart failure, and reduces morbidity and mortality. This paper reviews results of that trial and presents guidelines for effective captopril dosage after acute myocardial infarction.
Accuracy of fingerstick glucose values in shock patients
Authors: Sylvain HF , Pokorny ME , English SM , Benson NH , Whitley TW , Ferenczy CJ , Harrison JG
Published: November 2019

BACKGROUND: Fingerstick blood glucose measurement has become widespread in both hospital and prehospital settings. OBJECTIVE: To determine the accuracy of fingerstick blood glucose measurement in patients with poor peripheral perfusion (shock). METHOD: Results obtained during three methods of glucose analysis (fingerstick blood glucose measurement; bedside and laboratory glucose analysis) were examined prospectively on 38 patients from inpatient medical and surgical critical care units or the emergency department of a large tertiary care referral center. RESULTS: The means of the three glucose measurements were significantly different. Univariate analysis of the mean laboratory glucose value versus the mean fingerstick glucose value was significantly different. The mean venipuncture glucose measured by the bedside glucose meter versus the mean venous laboratory glucose was not significantly different. CONCLUSION: These results suggest that fingerstick blood samples should not be used for bedside glucose analysis in patients who may have inadequate tissue perfusion.
Preventing pulmonary hypertensive crisis in the pediatric patient after cardiac surgery
Authors: Medicus L , Thompson L
Published: November 2019

Pulmonary hypertension is seen in infants and young children who have congenital heart defects resulting in excess pulmonary blood flow. The critical care nurse can implement several interventions in the immediate postoperative period to help prevent the potentially lethal complication of pulmonary hypertensive crisis in a cardiac surgery patient. Respiratory interventions include hyperventilation, maintaining an alkalotic pH, supplemental oxygen, and low positive end-expiratory pressure. In addition, the nurse must consider the serum potassium, hematocrit, and patient temperature, and administer appropriate medications.
Peer review of nursing research proposals
Authors: Lindquist RD , Tracy MF , Treat-Jacobson D
Published: November 2019

The grant review process that operationalizes peer review for the critique, scoring, approval, and selection of research grants for funding may intimidate a novice reviewer. This article describes the peer review panel and process of grant review, specifies the role and responsibilities of the reviewer in the review session, and presents considerations for the evaluation of proposals and the preparation of a written critique. A sample critique is provided.
Oxygen saturation and hemodynamic response in critically ill, mechanically ventilated adults during intrahospital transport
Authors: Evans A , Winslow EH
Published: November 2019

BACKGROUND: Despite the frequency of intrahospital transport of critically ill patients, little research has been done on this topic and the findings are contradictory. OBJECTIVES: To describe arterial oxygen saturation by pulse oximetry, heart rate, heart rhythm, and systolic blood pressure and equipment problems in critically ill, mechanically ventilated adults during intrahospital transport. METHODS: The sample consisted of 36 critically ill, mechanically ventilated adults who required transport out of the intensive care unit for diagnostic testing or procedures within the hospital. Arterial oxygen saturation, heart rate, heart rhythm, and systolic blood pressure were measured at baseline, at least every 5 minutes during transport to and from the test site and at the test site, and every 5 minutes for 15 minutes after return to the unit. Descriptive statistics were used to analyze the data. RESULTS: Nineteen patients (53%) had clinically important changes in arterial oxygen saturation, heart rate, and/or systolic blood pressure. New cardiac arrhythmias developed in two patients. The clinically important changes occurred most frequently at the test/procedure site. Equipment problems such as monitor power failure and ventilator disconnection occurred during transport of 4 patients (11%). Total time out of ICU averaged 62 +/- 30 (range = 26 to 166) minutes. CONCLUSIONS: Transport outside the intensive care unit places the critically ill patient at additional risk. Although transport is often unavoidable, its risks versus benefits should be carefully and collaboratively evaluated for every patient prior to making the decision for transport.
Weaning chronically critically ill adults from mechanical ventilatory support: a descriptive study
Authors: Clochesy JM , Daly BJ , Montenegro HD
Published: November 2019

BACKGROUND: Ventilator-dependent patients average 11,419 daily in US acute care hospitals. OBJECTIVE: To describe the process of ventilatory weaning among chronically critically ill adults. METHODS A retrospective survey was used to study ventilator-dependent adults enrolled in a larger randomized study. Patients records were used to obtain duration of mechanical ventilatory support, success of weaning, serum albumin level, left ventricular function, number of drugs used to treat heart failure, and 24-hour fluid balance. Data were collected on admission to the intensive care unit; 24 hours after initiation of mechanical ventilation; and 7 days before, and on the day of, weaning status determination. RESULTS: Of 174 subjects, 120 were weaned from mechanical ventilation. There were no differences in maximum inspiratory pressure, minute ventilation, or ventilatory capacity between successful and unsuccessful candidates. There were differences in serum albumin level, rapid shallow breathing index, fraction of inspired oxygen, and 24-hour fluid balance. Among subjects who were weaned, the duration of mechanical ventilation was significantly longer in those with left ventricular dysfunction (n = 53; 29.1 +/- 25.2 days) than in those with normal left ventricular function (n = 67; 21.1 +/- 18.1 days). Subjects who were weaned received a greater number of drugs to treat heart failure (1.46 +/- 1.24) than did those who were not (0.77 +/- 1.04). CONCLUSIONS Many weaning parameters do not differentiate patients able to be weaned from those who are unable. The presence of left ventricular dysfunction, number of drugs used to treat heart failure, serum albumin level, and 24-hour fluid balance were associated with weaning success and/or duration of mechanical ventilation in adults requiring prolonged mechanical ventilation.
Normal saline instillation before suctioning: helpful or harmful? A review of the literature
Authors: Raymond SJ
Published: November 2019

This research utilization paper reviews the body of published literature on the practice of normal saline instillation before endotracheal suctioning of mechanically ventilated adult patients. Although normal saline instillation before suctioning is a common clinical practice, the research literature does not demonstrate any physiologic benefit to this procedure. Moreover, normal saline instillation may decrease oxygen saturation values (via pulse oximetry) after suctioning. The relevant research studies have been inconsistent and inconclusive because of limitations in sample size and research methodology. Further research studies using larger, more diverse samples, adhering strictly to recommended guidelines for endotracheal suctioning, and examining additional physiologic parameters of oxygenation are necessary. In addition, long-term outcomes of normal saline instillation such as respiratory infection and complications, as well as atelectasis, should be evaluated. Until scientific data can be presented to support the physiologic benefit of this practice, normal saline instillation should be discontinued as a routine or standard practice.
Shivering and rewarming after cardiac surgery: comparison of ventilator circuits with humidifier and heated wires to heat and moisture exchangers
Authors: McEvoy MT , Carey TJ
Published: November 2019

BACKGROUND: Detrimental physiologic effects of shivering in the cardiac surgery patient have been well documented. Rewarming techniques have been compared, with noted differences in the incidence of shivering. Ventilator circuits have not been examined independently from other rewarming variables. OBJECTIVE: To compare heated wire humidification circuits with heat and moisture exchanger circuits on the incidence of shivering and speed and pattern of rewarming in mechanically ventilated patients. METHODS: A prospective, descriptive, correlational study was done on 140 adult cardiac surgery patients in a university teaching medical center. All subjects underwent cardiac surgical procedures with hypothermic cardiopulmonary bypass. Subjects were randomized to humidified, heated wire circuits (n = 70) or heat and moisture exchanger circuits (n = 70). Heated water blankets were used on all patients. RESULTS: Mean intensive care unit admission temperature was 35.28 degrees C. No statistical differences were found in preoperative, demographic, or operative course data between treatment and control groups. Shivering was more common in the heat and moisture exchanger group than in the heated wire group. In our analysis, the only variable associated with shivering was the type of ventilator circuit. Patients using heated wire systems rewarmed more rapidly and had significantly higher temperatures than did patients using heat and moisture exchangers. CONCLUSION: These data suggest that use of heated wire humidified ventilator circuits with heated water blankets in adult cardiac surgery patients significantly reduces the incidence of shivering and results in a more rapid return to normothermia.
Postoperative atelectasis and pneumonia: risk factors
Authors: Brooks-Brunn JA
Published: November 2019

Postoperative pulmonary complications frequently lead to increased patient morbidity and mortality, hospital length of stay, and resource utilization. Atelectasis and infectious complications account for the majority of reported pulmonary complications. Risk factors are thought to exaggerate pulmonary function deterioration, which occurs both during and after surgical procedures. This article reviews the literature and describes risk factors frequently identified in relation to pre-, intra-, and postoperative settings, impact of each risk factor on pulmonary function, and issues related to risk factor evaluation. Eighteen risk factors are reviewed regarding their pathophysiologic impact on pre-, intra-, and postoperative pulmonary function. Key issues related to risk factor evaluation are also discussed. Identification of risk factors and prediction of postoperative pulmonary complications are important. Early identification of patients at risk for postoperative pulmonary complications can guide our respiratory care to prevent or minimize these complications.
Chest tube removal practices in critical care units in the United States
Authors: Kinney MR , Kirchhoff KT , Puntillo KA
Published: November 2019

BACKGROUND: Pain assessment and management are recognized as major problems in critical care settings. However, little is known about pain management practices related to medical procedures performed in the ICU, particularly removal of chest tubes. OBJECTIVES: To describe practices related to chest tube removal in the United States, with an emphasis on pain assessment and management. METHODS: A survey instrument was developed and mailed to 995 members of the American Association of Critical-Care Nurses who cared for patients with chest tubes. They were asked about chest tube removal practices in their institutions. RESULTS: Chest tubes are removed primarily by physicians and house staff, although 11% of respondents reported that specially trained nurses removed the tubes. Only 16% indicated that a prescription for pain medication was routinely available before chest tube removal. The drug administered most frequently was intravenous morphine sulfate, but the dose varied considerably. Nurses were generally satisfied (65.6%) with practices related to chest tube removal in their unit; nurses who were not satisfied (34.4%) wished to see better pain management practices (45%), removal of tubes by the patient's assigned nurse (17.8%), a protocol for tube removal (13.9%), notification of the nurse before removal (12.2%), and other changes (10%). CONCLUSIONS: Practices associated with chest tube removal, especially pharmacologic management of procedure-related pain, vary in critical care units. Caregivers are advised to develop practice policies to guide decisions about management of acute pain in this patient population.
Defining and redefining death
Authors: Ott BB
Published: November 2019

The definition of death, brain death in particular, is increasingly important to critical care professionals. There are essentially three definitions of death from a theoretical perspective: the traditional heart-lung definition, the whole-brain definition, and the higher-brain definition. These definitions use different underlying assumptions within their own theoretical framework. The differing definitions and theoretical frameworks have encouraged physiological, philosophical, spiritual, and ethical analyses, which have led to spirited debate throughout the healthcare community and especially in critical care.
Therapeutic Intervention Scoring System used in the care of patients in pentobarbital-induced coma to determine nurse-patient ratios
Authors: Myles GL , Malkoff MD , Perry AG , Bucholz RD , Gomez CR
Published: November 2019

BACKGROUND: Critical care patients generally require extensive interventions, thereby consuming a large percentage of healthcare resources. Induced pentobarbital coma for the management of increased intracranial pressure is one such intervention, required to maintain patient stability. Quantification of these interventions, as well as the amount of nursing work required, has not been addressed in the literature. OBJECTIVE: To use the Therapeutic Intervention Scoring System to analyze and quantify how interventions affect nurse-patient ratios in the management of patients in pentobarbital coma for refractory increased intracranial pressure. METHODS: The medical records of patients with subarachnoid hemorrhage from aneurysmal rupture and subsequent increased intracranial pressure, in whom pentobarbital coma was salvage therapy, were reviewed retrospectively. The Therapeutic Intervention Scoring System was used to quantify the number of interventions required before, during, and after coma induction. The data were analyzed and daily Therapeutic Intervention Scoring System scores correlated with serum pentobarbital levels. Typically, a critical care nurse can manage a patient caseload of 40 to 50 Therapeutic Intervention Scoring System points. By quantifying the interventions, the score reflected the amount of care required to manage the patient in barbiturate coma. RESULTS: The intensity of interventions correlated with the level of coma, length of time in coma, and associated complications. CONCLUSIONS: The scores indicated the intensity of interventions used in pentobarbital coma and the use of resources. Nursing care and complications involved with this therapy were quantified and nurse-patient ratios were established.