bluuebunny/crossref_metadata_2025 huggingface dataset:
Administration of medications through enteral feeding catheters
Authors: Belknap DC , Seifert CF , Petermann M
Published: November 2019

BACKGROUND: Enteral feeding catheters are commonly used to administer both nutritional feedings and oral forms of medications. Obstruction of the catheters is a major concern. OBJECTIVES: To study characteristics of obstruction of enteral feeding catheters in ICU patients and current knowledge and practices of ICU nurses of administering medications through such catheters. METHODS: A postcard invitation to participate in this descriptive survey was mailed to a random sample of 12,069 members of the American Association of Critical-Care Nurses. The 52-item investigator-designed questionnaire was mailed to the 1700 critical care nurses who agreed to participate; 1167 (68.6%) returned completed survey questionnaires. RESULTS: Nurses estimated that 33.8% of their patients received 8.9 doses of medication per day through the enteral feeding catheter. The rate of obstruction of the tube by medications was 15.6%. Crushed medications contributed to obstruction, although liquid forms of the medications often were available. Nurses' primary source of knowledge about administering medications through enteral feeding catheters was clinical practice (56.9%) and consultation with peers (21.7%); only 19% had had inservice training on the topic. Written agency guidelines varied considerably, and 74% of nurses used two or more techniques that were contrary to recommendations. Factors significantly associated with lower rates of obstruction of enteral feeding catheters included (1) assistance from the pharmacy service to ensure liquid forms of medications, (2) nurses' attendance at a relevant seminar or inservice training program, and (3) not routinely crushing and administering enteric-coated or sustained-release medications through the enteral feeding catheter. CONCLUSIONS: Collaboration between nursing and pharmacy services to ensure delivery of liquid medications and avoid use of crushed medications may reduce the high rate of catheter obstruction due to medications. Research-based guidelines and a more formal dissemination of information to nurses are needed.
Analysis of risk factors for omental herniation associated with removal of peritoneal catheters
Authors: Copnell B , Best JD , Capewell B
Published: November 2019

BACKGROUND: Peritoneal catheters may be used routinely in children undergoing cardiac surgery. Removal of the catheter is often complicated by omental herniation, which can cause intraperitoneal bleeding, peritonitis, and bowel obstruction. Instillation of saline into the catheter before removal is used in some institutions as a preventive measure, but the practice has never been investigated. OBJECTIVE: To determine the effectiveness of instilling saline into peritoneal catheters before their removal in reducing the occurrence of omental herniation and to determine risk factors for omental herniation. METHODS: A total of 404 patients with peritoneal catheters in place were randomized to either the control or the study group. The study group (n = 204) had saline (1 mL/kg; maximum, 10 mL) instilled into the catheter before the catheter was removed; the control group (n = 200) did not. Extrusion or no extrusion of omentum was recorded. Other data collected included the child's weight, the length of time the catheter was in place, whether peritoneal dialysis was performed, and whether the child was pharmacologically paralyzed when the catheter was removed. RESULTS: Extrusion of omentum occurred in 39% of the study group and in 33% of the controls. Results of logistic regression analysis suggested that omental herniation was more common in smaller children, children whose catheters remained in place longer, and children who were not pharmacologically paralyzed when the catheter was removed. CONCLUSIONS: Instillation of saline does not appear to reduce the occurrence of omental herniation. Further research into strategies to reduce this complication is recommended.
Sudden cardiac death--preventable--reversible
Authors: Futterman LG , Lemberg L
Published: November 2019

SCD is defined as unexpected death due to cardiac causes that occurs within 1 hour of acute symptoms. SCD can be reversed with the use of an ICD. These devices now can be implanted by catheter techniques, obviating thoracotomy. SCD is preventable. The incidence of SCD can be significantly reduced by addressing the fundamental pathophysiology of SCD, which primarily is CAD. Our combined and aggressive implementation of preventive regimens to reduce the risk of cardiac events will save lives. These measures include diet, weight reduction, smoking cessation, regular exercise, and therapeutic drugs. Amiodarone, although effective in preventing lethal ventricular arrhythmias, has not matched the long-term results of the ICD in the successful management of SCD.
Preoperative and postoperative predictors of early and delayed extubation after coronary artery bypass surgery
Authors: Doering LV , Imperial-Perez F , Monsein S , Esmailian F
Published: November 2019

OBJECTIVE: To identify preoperative, intraoperative, and postoperative predictors of early (6 hours or less after surgery) and delayed (more than 6 hours) extubation after coronary artery bypass graft surgery. METHODS: The sample for this prospective nonrandomized study consisted of 116 consecutive patients in a 12-bed cardiothoracic ICU who had coronary artery bypass graft surgery in a 6-month period and were followed up prospectively until transfer to an observation unit. RESULTS: Age and the presence of early hemodynamic instability (within the first 3 hours after ICU admission) were independent predictors of intubation times of more than 6 hours when each was considered in separate multivariate models of preoperative, intraoperative, and postoperative variables. In a combined model, when considered with age and ejection fraction, the presence of early hemodynamic instability increased the odds by 4.7 times that extubation would occur more than 6 hours after surgery. For every 1 year increase in age, the odds of extubation occurring more than 6 hours after surgery increased by 6.5%. CONCLUSIONS: Older age and the presence of early hemodynamic instability are associated with postoperative intubation periods of more than 6 hours after coronary artery bypass graft surgery. Clinicians should evaluate extubation goals in older patients carefully. Clinical management of hemodynamic instability should be aimed at prompt optimization of myocardial oxygen supply to limit ischemia and its sequelae.
Design, testing, and results of an outcomes-managed approach to patients requiring prolonged mechanical ventilation
Authors: Burns SM , Marshall M , Burns JE , Ryan B , Wilmoth D , Carpenter R , Aloi A , Wood M , Truwit JD
Published: November 2019

BACKGROUND: Outcomes management that uses critical pathways may decrease costs while improving outcomes for patients who require prolonged mechanical ventilation. OBJECTIVE: To study the efficacy of an outcomes-managed approach to weaning patients from prolonged (more than 3 days) mechanical ventilation. METHODS: A method of multidisciplinary care delivery was designed that included an outcomes manager, a care pathway for patients receiving mechanical ventilation, and weaning protocols. Data collection consisted of three parts: a retrospective review of 124 patients who required prolonged ventilation during a 1-year period before implementation of the care model, a 6-month prospective study in which 91 patients were alternately assigned by month to an outcomes-managed approach or a non-outcomes-managed approach, and a 6-month prospective study of 90 patients in which an outcomes-managed approach without alternate-month assignment was used. RESULTS: Outcomes management had no significant effect on total duration of mechanical ventilation or length of stay in the hospital, days of mechanical ventilation without tracheostomy, days of mechanical ventilation with tracheostomy, or outcome (weaned, withdrawal from mechanical ventilation, death, or transfer without weaning). However, duration of mechanical ventilation was 1.3 days shorter, length of stay in the hospital was 2.1 days shorter, and the cost per case was $ 3341 less for patients in the outcomes-managed group than for patients in the non-outcomes-managed group. CONCLUSION: Outcomes-managed care did not have a significant effect on duration of ventilation, length of stay in the hospital, or outcome in patients receiving long-term mechanical ventilation.
Changing practice patterns for children with heart disease: a clinical pathway approach
Authors: Uzark K , Frederick C , Lamberti JJ , Worthen HM , Ogino MT , Mainwaring RD , Moore JW
Published: November 2019

BACKGROUND: Pediatric cardiac care is costly and requires extensive resources. We studied the effect of clinical pathways on practice patterns and patient care outcomes in infants and children hospitalized for cardiac surgery. METHODS: In consecutive patients admitted for selected cardiac surgical procedures before (n = 69) and after (n = 173) implementation of clinical pathways, outcomes including hospital length of stay, days in the ICU, time to extubation, ordering of blood studies, costs, and readmissions were compared. Data were analyzed for each of five cardiac surgical procedures: repair of an atrial septal defect, repair of a ventricular septal defect, division of a patent ductus arteriosus, repair of tetralogy of Fallot, and neonatal arterial switch operation to correct transposition of the great arteries. RESULTS: A significant reduction in length of hospital stay, including days in the ICU (decreased 1 to 2 days per admission), was achieved after the clinical pathway was implemented. Reductions in average duration of mechanical ventilation ranged from 28% for repair of a ventricular septal defect to 63% for repair of tetralogy of Fallot. The number of blood studies ordered decreased 20% to 30%. A significant reduction in hospital costs for each procedure, ranging from 16% to 29%, was also achieved with no adverse effects on patients' outcomes. CONCLUSIONS: Use of clinical pathways with children hospitalized for cardiac surgery can shorten length of stay in the hospital, reduce use of resources, and improve cost-effectiveness with beneficial outcomes for patients.
Complications after placement of an intracoronary stent: nursing implications
Authors: Dabbs AD , Chambers CE , Macauley K
Published: November 2019

BACKGROUND: Care of patients after stent placement has evolved with the goal of reducing thrombosis and bleeding. Initially, all patients received full antithrombotic therapy; now most receive antiplatelet therapy only. Despite this evolution, no description of the differences in complications and nursing care with these two treatments has been published. OBJECTIVES: To determine the differences in complications and nursing care for patients receiving different pharmacological therapies after placement of an intracoronary stent. METHODS: A nonrandomized, noncontrolled, retrospective, comparative design was used with 176 sequential patients assigned to treatment groups on the basis of the adjunctive pharmacological therapy the patient received after placement of a stent. The equivalency of baseline characteristics and risk of complications, as well as the differences in length of stay, intensity of nursing care, and frequencies of bleeding and ischemic or thrombotic events were determined for the two groups: 65 patients who received anticoagulant therapy and 111 patients who received antiplatelet therapy. RESULTS: The two groups were equivalent with respect to baseline characteristics of sex, concomitant illness, and cardiac condition before stent placement. The two groups differed with respect to predisposing risks for bleeding and ischemic or thrombotic events. Patients receiving antiplatelet therapy alone had significantly shorter lengths of stay, less use of intensive care, fewer requirements for nursing care, and fewer bleeding complications, with no increase in ischemic or thrombotic events. CONCLUSIONS: Patients receiving anticoagulant therapy had more complications and required a higher intensity of nursing care than did patients who received antiplatelet therapy alone.
Integrating technology with compassionate care: withdrawal of ventilation in a conscious patient with apnea
Authors: Campbell ML , Bizek KS , Stewart R
Published: November 2019

This case was atypical because the patient was conscious and apneic. The usual responses that indicate a patient's distress during terminal weaning would not have been evident in this patient. Introducing noninvasive monitoring of end-tidal CO2 and SpO2 and using BIS allowed the weaning to progress with confidence that the patient was as comfortable as possible. We think we kept our commitment to HD to honor his wishes by using the most humane method we could devise, and to address his family's needs at the same time.
Clinical evaluation of noninvasive monitoring of oxygen saturation in critically ill patients
Authors: Smatlak P , Knebel AR
Published: November 2019

OBJECTIVE: To examine the effect of abnormal cardiac index on the accuracy of measurement of oxygen saturation by pulse oximetry. METHODS: Forty-six patients (mean age, 49 years) in a 9-bed medical ICU were studied. Measurements of oxygen saturation obtained with pulse oximeters and with a functional cooximeter were collected at baseline and 4, 8, 16, 24, 32, 40, and 48 hours later. Hemodynamic and cardiopulmonary parameters were recorded. RESULTS: The Bland-Altman technique yielded upper and lower limits of agreement of 2.53% and -7.11%. Most (95.7%) of the differences between the measurements of oxygen saturation obtained with the 2 methods were within these limits, although some of these differences may be clinically unacceptable. The bias was -2.29%, and the precision was 2.41%. The clinical conditions associated with inaccurate tracking of saturation by pulse oximetry across the range of actual arterial oxygen saturation values were abnormal cardiac index, partial pressure of carbon dioxide, heart rate, and pulmonary capillary wedge pressure. CONCLUSIONS: In patients with abnormal cardiac index, the pulse oximeter measurements exceeded the actual oxygen saturation by up to 7%. Pending prospective studies, clinicians should be aware that when certain cardiopulmonary parameters are abnormal, the margin of error in measurements of oxygen saturation obtained with a pulse oximeter may be greater than when those parameters are normal.
Agreement and clinical utility of 2 techniques for measuring cardiac output in patients with low cardiac output
Authors: Albert NM , Spear BT , Hammel J
Published: November 2019

BACKGROUND: The reliability of cardiac output obtained with the bolus technique is a problem. OBJECTIVES: To compare measurements of cardiac output measured with bolus and continuous techniques in patients with low cardiac output and to determine if measurements obtained with the continuous technique increased the number of subsequent clinical decisions. METHODS: In 60 intensive care patients, a nurse recorded a single continuous cardiac output measurement and then obtained the mean of 3 consecutive bolus determinations. The medical records of these 60 patients (experimental group) for the next 48 hours and of 60 other patients with regular or mixed venous oximetry catheters (control group) were reviewed to assess the occurrence of cardiac output events and the frequency of clinical decisions based on the events. RESULTS: Mean cardiac output was 4.46 L/min by the continuous technique and 5.20 L/min by the bolus technique (P = .011) for the experimental group. Median bias between the 2 types of measurements was -0.10 L/min (P = .79). Twenty-three of the pairs (38%) had an absolute percent difference greater than 15%. Of these, 18 (78%) had a higher bolus reading. Treatment decisions per 48 hours were 9.9 for the experimental group and 8.6 for the control group (P = .014). Median length of stay was 2 days less in the experimental group (P = .02), and mean highest cardiac output was 0.81 L/min higher (P = .009). CONCLUSIONS: Measurements of cardiac output determined with the continuous technique may be more precise than measurements determined with the bolus technique. Continuous cardiac output information increases the number of treatment decisions and actions that may shorten hospital length of stay.
Low-molecular-weight heparin: an antithrombotic agent whose time has come
Authors: Futterman LG , Lemberg L
Published: November 2019

LMWH (enoxaparin) should be used in combination with aspirin in the early phase of non-Q wave MI and in patients with unstable angina. The benefit of LMWH in acute coronary syndromes has been validated in several clinical trials. In addition, the use of LMWH is cost-effective when compared with use of UFH. The incidence of minor bleeding may be greater with LMWH than with UFH, most frequently due to ecchymosis at the injection site. However, the frequency of major bleeding did not differ between the two heparins. LMWH has been used successfully for the past 4 years by orthopedic surgeons in the prevention of pulmonary emboli. LMWH should replace UFH in the management of acute coronary syndromes.
Pain assessment and management in critically ill postoperative and trauma patients: a multisite study
Authors: Carroll KC , Atkins PJ , Herold GR , Mlcek CA , Shively M , Clopton P , Glaser DN
Published: November 2019

BACKGROUND: Pain in critically ill patients is undertreated. OBJECTIVES: To examine patients' perceptions of pain and acute pain management practices in a large metropolitan area to provide direction for improvements in pain relief. METHODS: In a descriptive, correlational study, data were collected from 213 patients in 13 hospitals. Interviews with patients, chart reviews, and interviews with nurse leaders were used to examine institutional and individual approaches to pain management. RESULTS: Twenty-eight percent of patients did not recall an explanation of a pain management plan, and 64% were often in moderate to severe pain while in the intensive care unit. High pain intensity correlated with wait for an analgesic (P < .001), expectations of less pain (P < .001), and longer stay in the intensive care unit (P < .001). Low satisfaction correlated with expectations of less pain (P < .001), often being in moderate to severe pain (P < .001), and long wait for an analgesic (P < .001). In the first 24 hours postoperatively, only 54% of patients had a numerical pain rating documented; 91% had a pain description. The amount of opioid given on postoperative day 1 was influenced by pain intensity (P < .001), the patient's age (P = .03), type of surgery (P = .002), and route of analgesic (P < .001). Only 33% of patients had nonpharmacological pain interventions documented. CONCLUSIONS: Despite moderate to severe pain, patients are generally satisfied with their pain relief. Measuring patients' satisfaction alone is not a reliable outcome for determining the effectiveness of pain management. Realistic expectations of patients about their pain may enhance coping, increase satisfaction, and decrease pain intensity after surgery.
Point-of-care laboratory testing in critical care
Authors: Harvey MA
Published: November 2019

BACKGROUND: Critical care practitioners are searching for ways to improve the quality and outcomes of care while decreasing cost and length of stay. One technological advance that may facilitate meeting these objectives is bedside or point-of-care laboratory equipment. Evaluation of point-of-care testing for application in each institution requires information about the devices available; knowledge of the advantages and disadvantages of the technologies, the clinical impact, and cost of the process change; and strategies for successful implementation. OBJECTIVES: To review the literature on point-of-care testing and the experience of healthcare professionals who have already successfully implemented this type of testing. METHODS: A total of 81 relevant published articles were reviewed, and 21 critical care units in 8 facilities that use point-of-care testing were visited. Open-ended interviews were conducted with 83 subjects: 56 nurses, 14 laboratory personnel, 9 respiratory therapists, and 4 others. CONCLUSIONS: Point-of-care testing is a technological innovation with the potential for improving patients' care without increasing costs. It most likely will soon become part of the standard of care.
Effects of injectate volume on thermodilution measurements of cardiac output in patients with low ventricular ejection fraction
Authors: McCloy K , Leung S , Belden J , Castenada J , Erickson V , Koch K , Livingston N , Moughrabis S , Gawlinski A
Published: November 2019

OBJECTIVE: To determine the effect of 5-mL injectate on cardiac output measurements in critically ill patients with low ventricular ejection fraction (< 35%). METHODS: Thermodilution cardiac output measurements obtained with three 5-mL and three 10-mL (randomly ordered) iced injectates in 50 patients with low ejection fraction were averaged if the measurements were within 10% of the median. If the 3 measurements were not within those limits, additional measurements were obtained. RESULTS: Cardiac output measured with the 5-mL injectate (mean, 4.63 L/min) and cardiac output measured with the 10-mL injectate (mean, 4.52 L/min) were not significantly different (P = .64). Lower and upper limits of agreement were -1.7 L/min to +1.6 L/min. The bias (mean difference between 10- and 5-mL measurements) of all measurements was -0.09, and the precision was 1.43 L/min, with a 95% confidence limit (mean difference +/- 2 SD) of -1.7 to +1.6 L/min. An additional measurement was necessary in 77% of patients in the 5-mL group but in only 48% of the 10-mL group (P = .006). CONCLUSIONS: Cardiac outputs measured with 5- and 10-mL injectates do not differ significantly. The greater variability of measurements obtained with a 5-mL injectate suggests that more measurements, and thus more time, are needed to measure cardiac output accurately. Clinicians must weigh the benefit of minimizing fluid volume used against the potential decreased reliability of cardiac output measurements.
Card sort: an assessment tool for the educational needs of patients with heart failure
Authors: Luniewski M , Reigle J , White B
Published: November 2019

BACKGROUND: Effective education of patients is an integral component in reducing hospital readmissions for patients with heart failure and in improving patients' quality of life. OBJECTIVES: To describe the use of a card sort method for determining the learning needs of patients with heart failure and the ability of nurses and physicians to accurately predict patients' self-determined needs. METHODS: Thirty patients were asked to sort 12 cards with questions related to the content of discharge teaching for patients with heart failure. The nurse and the physician caring for each patient were instructed to sort the cards independently to characterize the learning needs of the patient. RESULTS: Patients most often selected the following as the most important educational topics: What is wrong with my heart? What is the future of my disease? and How will I know if my heart failure is getting worse? Physicians selected the identical top question as their patients did 17% of the time. Physicians matched any of their patients' top 3 choices 34% of the time. Questions selected as most important by patients were chosen by physicians as least important 13% of the time. Nurses chose the same top question as their patients did 23% of the time. Nurses matched any of their patients' top 3 choices 34% of the time. Nurses selected opposite choices from those of their patients 6% of the time. CONCLUSIONS: The card sort method may be an effective tool to ascertain the individual learning needs of patients with heart failure.
Change in quality of life after lung volume reduction surgery
Authors: Anderson KL
Published: November 2019

BACKGROUND: Lung volume reduction surgery has been reintroduced for treatment of severe emphysema. Goals of this surgery are to decrease dyspnea, increase exercise tolerance, and improve quality of life. OBJECTIVES: To describe the effect of lung volume reduction surgery on overall quality of life, disease severity, dyspnea, and functional status during the first 12 months after surgery. METHODS: Data were collected for 20 patients (mean age, 63 years; 15 men) before and 3, 6, and 12 months after lung volume reduction surgery. Disease severity was determined by percentage of forced expiratory volume in 1 second (compared with established norms); functional status, by a 6-minute walk test; dyspnea, by scores on a visual analog scale; and overall quality of life, by scores on the Quality of Life Scale. RESULTS: Scores on the Quality of Life Scale and distance walked increased significantly after surgery, and these increases were maintained at 6 and 12 months, respectively. Percentage of forced expiratory volume in 1 second increased significantly 3 months after surgery, but changes at 6 and 12 months were not significant. Changes in dyspnea ratings were not significant. No pattern of correlations among study variables was significant. CONCLUSIONS: Quality of life and functional status are improved after lung volume reduction surgery. Because none of the physiological variables were related to changes in quality of life, alternative explanations for these improvements must be explored in future studies.
Assessing dopamine concentrations: an evidence-based approach
Authors: Blad KD , Lookinland S , Measom G , Bond AE , Williams M
Published: November 2019

BACKGROUND: Both overmedication and undermedication can be potentially life threatening. If the actual volume of a 100-mL intravenous bag used to mix dopamine solutions is greater than the labeled volume, overdilution of medication can occur, resulting in an ineffective hemodynamic response in patients and thus an unintended adverse drug event. OBJECTIVES: To determine the actual fluid volumes of 100-mL intravenous bags, compare the actual volumes of 100-mL bags from the 3 major manufacturers of intravenous bags, and determine if the excess volume is sufficient to cause a clinically significant overdilution of dopamine. METHODS: A comparative descriptive design was used. The volumes of 162 intravenous bags of 100 mL of 5% dextrose in water (32 lot numbers with various expiration dates) were measured. Visual volume was confirmed by using a 250-mL graduated cylinder. Volume by weight was determined with a calibrated laboratory-quality electronic scale. On the basis of a mathematical model, any overfill greater than 110 mL was considered clinically significant. RESULTS: The difference between actual and labeled volumes was statistically and clinically significant. Mean visual volume was 110.20 mL (range, 107-114 mL). Mean weighed volume was 109.26 mL (range, 106.15-112.09 mL). The fluid volumes among bags from the 3 major IV companies differed significantly (P < .001). CONCLUSIONS: The overfill in sufficient numbers of 100-mL intravenous bags was enough to cause clinically significant overdilution of dopamine. When dopamine or other vasoactive medications are mixed, either an in-line buret or premixed bags of the drugs should be used to prevent an unintended adverse drug event.
Influence of clinicians' values and perceptions on use of clinical practice guidelines for sedation and neuromuscular blockade in patients receiving mechanical ventilation
Authors: Slomka J , Hoffman-Hogg L , Mion LC , Bair N , Bobek MB , Arroliga AC
Published: November 2019

BACKGROUND: Although popular, clinical practice guidelines are not universally accepted by healthcare professionals. OBJECTIVES: To compare nurses' and physicians' actual and perceived rates of adherence to practice guidelines used in sedation of patients receiving mechanical ventilation and to describe nurses' and physicians' perceptions of guideline use. METHODS: Pairs of fellows and nurses caring for 60 eligible patients were asked separately about their rationale for medicating patients, effectiveness of medication, and their perceived adherence to the guidelines. Actual adherence was determined independently by review of medical records. An additional 18 nurses and 11 physicians were interviewed about perceptions of guideline use. RESULTS: Use of mechanical ventilation was the most common reason given by physicians (53%) and nurses (48%) for medicating patients, although reasons for administering medication to a given patient differed in up to 30% of cases. Physicians and nurses disagreed on the effectiveness of medication in 42% (P = .01) of cases. Physicians reported following guidelines in 69% of cases, but their actual adherence rate was only 20%. Clinicians sometimes had difficulty distinguishing among anxiety, pain, and delirium. Clinicians justified variations from guidelines by citing the value of individualized patient care. Nurses and physicians sometimes had different goals in the use of sedation. CONCLUSIONS: Physicians may think they are following sedation guidelines when they are not, and they may prescribe incorrect medications if the cause of agitation is misdiagnosed. Differences between physicians and nurses in values and perceptions may hamper implementation of clinical practice guidelines.
Depressive symptoms and outcome of coronary artery bypass grafting
Authors: Saur CD , Granger BB , Muhlbaier LH , Forman LM , McKenzie RJ , Taylor MC , Smith PK
Published: November 2019

BACKGROUND: Depressive symptoms are an independent risk factor for outcome in patients with cardiac disease, but their effect on outcome among patients undergoing coronary artery bypass grafting is not well understood. OBJECTIVES: To determine whether or not clinical variables including length of stay, readmission rates, and mortality are related to patients' level of depressive symptoms before and after coronary artery bypass grafting. METHODS: An observational, longitudinal design was used. The Medical Outcomes Study 36-item short-form health survey was used to collect data on depressive symptoms in 416 patients undergoing coronary artery bypass grafting. The distribution of depressive symptoms was correlated with length of stay after the procedure, readmission, and mortality. RESULTS: The level of depressive symptoms before coronary artery bypass grafting correlated with the level of depressive symptoms at 6 weeks follow-up, both for the individual items "feeling down in the dumps" (r = 0.24, P = .009) and "feeling downhearted" (r = 0.36, P < .001) and for the overall score on the Mental Health scale (r = 0.40, P < .001). Feeling down in the dumps (P = .007) and overall scores on the Mental Health scale (P = .02) were significantly related to readmission within 6 months. CONCLUSIONS: Higher levels of depressive symptoms before coronary artery bypass grafting are related to higher hospital readmission rates 6 months after the procedure. Nurses can play a pivotal role in determining which patients require evaluation, educating patients, and initiating effective treatment, which may prevent readmission related to depressive symptoms.
Patency of radial arterial catheters
Authors: Kaye J , Heald GR , Morton J , Weaver T
Published: November 2019

BACKGROUND: Data on the influence of flush methods, blood-sampling methods, and site location on the patency of radial arterial catheters used for pressure monitoring are sparse. OBJECTIVES: To determine the effects of flush and blood-sampling methods, insertion site, and sex of patients on catheter patency. METHODS: In a randomized trial, 174 patients requiring radial arterial pressure monitoring were assigned to 4 groups: fast flush as needed and nonwaste blood sampling; fast flush as needed and waste blood sampling; fast flush every 4 hours and waste blood sampling; and fast flush every 4 hours and nonwaste blood sampling. All site locations were evaluated for patency, and all monitoring systems were maintained with isotonic sodium chloride solution. RESULTS: Nonpatent catheters were 4.23 times more likely in patients with insertion sites 3 cm or higher above the bend of the wrist than in patients with lower sites (P = .01). Duration of patency did not differ between catheters maintained with fast flush every 4 hours and those flushed as needed or between catheters according to the method of blood sampling. Women were 3.05 times more likely than men to have nonpatent catheters (P = .02). With insertion sites 3 cm or higher above the radiocarpal joint, nonpatency was 7.3 times more likely in women than in men (P < .001). CONCLUSIONS: Insertion sites closest to the bend of the wrist increase chances of maintaining patency. Catheters can be maintained with as-needed flushes, and either waste or nonwaste blood sampling can be used.
Risk factors for sternal wound infection in men versus women
Authors: Hussey LC , Hynan L , Leeper B
Published: November 2019

BACKGROUND: Differences between men and women in complication rates after cardiac surgery have been reported. The rate of one of the most severe postoperative complications, sternal wound infection, has not been compared between the sexes. OBJECTIVE: To compare the frequencies of 21 risk factors for sternal wound infection between men and women. METHODS: Records of 306 patients who had cardiac surgery between 1989 and 1999 at 3 different hospitals in the southwestern and southeastern United States were reviewed for 21 risk factors. Of the 306 patients, 115 (25 women and 90 men) had experienced a sternal wound infection and 191 randomly selected patients (52 women and 139 men) had not. RESULTS: Three risk factors occurred at significantly different rates in men and women. Smoking and use of a single internal mammary artery for grafting were more common in men than women. Women were older than men at the time of cardiac surgery. Logistic regression analyses showed that the 3 dichotomous risk factors (use of single internal mammary artery for grafting, smoking, age > 70 years) that univariate analysis indicated were significantly related to sex could also be used to predict infection group. CONCLUSIONS: This study contributes to the awareness of the possible differences between men and women in the risk of sternal wound infection developing after cardiac surgery. Although 3 risk factors occurred at significantly different rates in men and women, further research is needed to determine the effects that these differences in risk factors may have on the occurrence of sternal wound infection in men and women.
Hospital Experiences of Young Adults With Congenital Heart Disease: Divergence in Expectations and Dissonance in Care
Authors: Kools Susan , Tong Elizabeth M. , Hughes Rene , Jayne Rae , Scheibly Kimberly , Laughlin Judith , Gilliss Catherine L.
Published: November 2019

• Background Despite increasing survival for adults with congenital heart disease, little is known about hospitalization for young adult patients with this disease and for their families. Because of the complexity of the disease and its management during the life span, young adults are often hospitalized on both pediatric and adult units during a stay in the hospital.

• Objectives To explore the experience of hospitalization of young adults with congenital heart disease, the experience of their families, and the views of the nurses who cared for these patients and to generate substantive theory on interactions between patients, patients’ families, and nurses.

• Methods Semistructured interviews and naturalistic observations were conducted with young adults with congenital heart disease (mean age, 28.6 years), their family members, and nurses who cared for the patients during hospitalization (N = 34). Dimensional analysis was used to analyze interviews and field notes from observations.

• Results A grounded theory was derived, explaining how the hospital context and relationships between patients, patients’ families, and nurses affect patients’ hospital experiences. Expectations differed among the groups, leading to dissonance in care, as exemplified by role confusion and power struggles over control of care. This dissonance resulted in interpersonal conflict, distrust, anxiety, and dissatisfaction with the care and caring experiences.

• Conclusions Changes in hospital units, a better understanding of the healthcare needs of young adults with congenital heart disease, and acknowledgment of the expertise of patients and patients’ families are needed to improve nursing care for these patients and their families.
Practices and Predictors of Analgesic Interventions for Adults Undergoing Painful Procedures
Authors: Puntillo Kathleen A. , Wild Lorie Rietman , Morris Ann Bonham , Stanik-Hutt Julie , Thompson Carol Lynn , White Cheri
Published: November 2019

• Background Research is limited on analgesic practices associated with the commonly performed procedures of turning, inserting central venous catheters, removing wound drains, changing dressings on nonburn wounds, suctioning the trachea, and removing femoral sheaths.

• Objective To determine types of analgesics administered for procedures, the prevalence and amounts of drugs given, and factors predictive of analgesic administration.

• Methods Pain was assessed before and immediately after procedures. Analgesic, sedative, and anesthetic agents administered within 1 hour before and/or during each procedure were noted.

• Results A total of 5957 adult patients at 164 national and 5 international sites participated. Pain intensity increased at the time of procedure for all procedures. More than 63% of patients received no analgesics. Less than 20% received opiates; mean total dose of opiate was 6.44 mg (SD, 8.96 mg). Only 10% of patients received combination therapy. Factors associated with the likelihood of receiving opiates were pain intensity before a procedure, femoral sheath removal, being white, and the duration of a procedure. Patients less likely to receive opiates had a medical diagnosis or were having tracheal suctioning. Only 14.5% of the variance in the amount of opiate administered was explained by factors entered into multiple regression models. Type of procedure was the only significant predictor of amount of opiate administered.

• Conclusions Most patients were not intentionally medicated even though pain intensity increased during their procedure. When used, analgesic amounts were low, and combination therapy was infrequent. Clinical trials are needed to evaluate optimal pain management for patients undergoing procedures.
Cardiac Outcomes After Myocardial Infarction in Elderly Patients With Diabetes Mellitus
Authors: Chyun Deborah , Vaccarino Viola , Murillo Jaime , Young Lawrence H. , Krumholz Harlan M.
Published: November 2019

• Objective To examine the association between (1) comorbid conditions related to diabetes mellitus, clinical findings on arrival at the hospital, and characteristics of the myocardial infarction and (2) risk of heart failure, recurrent myocardial infarction, and mortality in the year after myocardial infarction in elderly 30-day survivors of myocardial infarction who had non–insulin- or insulin-treated diabetes.

• Methods Medical records for June 1, 1992, through February 28, 1993, of Medicare beneficiaries (n = 1698), 65 years or older, hospitalized for acute myocardial infarction in Connecticut were reviewed by trained abstractors.

• Results One year after myocardial infarction, elderly patients with non–insulin- and insulin-treated diabetes mellitus had significantly greater risk for readmission for heart failure and recurrent myocardial infarction than did patients without diabetes mellitus, and risk was greater in patients treated with insulin than in patients not treated with insulin. Diabetes mellitus, comorbid conditions related to diabetes mellitus, clinical findings on arrival, and characteristics of the myocardial infarction, specifically measures of ventricular function, were important predictors of these outcomes. Mortality was greater in patients not treated with insulin than in patients treated with insulin; the increased risk was mostly due to comorbid conditions related to diabetes mellitus and poorer ventricular function.

• Conclusions Risk of heart failure, recurrent myocardial infarction, and mortality is elevated in elderly patients who have non–insulin- or insulin-treated diabetes mellitus. Comorbid conditions related to diabetes mellitus and ventricular function at the time of the index myocardial infarction are important contributors to poorer outcomes in patients with diabetes mellitus.
Calcium channel blockers: nursing care for hypertension
Authors: Beare PG
Published: November 2019

Calcium channel blockers are gaining wider use in patients with cardiac disease, particularly hypertension and angina. The nurse must be aware of the actions, side effects, and interactions of these agents if they are to be administered safely.
Reestablishing patency in an occluded central venous access device
Authors: Brown LH , Wantroba I , Simonson G
Published: November 2019

Nurses in a full range of settings from acute to home care are increasingly exposed to the use and maintenance of central VADs. Although the advantages of central VADs are well recognized, the incidence and potential for complications associated with these devices should not be minimized. The major complication of catheter occlusion has the potential of inducing significant morbidity and mortality. The purpose of the following care plan is to familiarize the nurse with the information needed to restore catheter patency efficiently, safely, and effectively, thereby reducing the potential complications and enhancing the quality of patient care.
Emergency catheter ablation of refractory ventricular tachycardia
Authors: Stevens LL , Redd RM , Buckingham TA
Published: November 2019

Catheter ablation, in extreme cases, can be used successfully as emergency therapy for VT in the CCU. In the hands of a physician experienced in electrophysiologic procedures, catheter ablation may prove to be an alternative to surgical or pharmacologic therapy in acutely ill patients with refractory ventricular arrhythmias.
Maxillofacial trauma: implications for critical care
Authors: Brown-Stewart P
Published: November 2019

Maxillofacial trauma is a complex phenomenon that creates challenges for the critical care nurse. Effective management of maxillofacial trauma requires a comprehensive understanding of facial anatomy and function. Physiologic requirements, such as airway management and hemodynamic monitoring are the focus during the acute care phase. Nutritional and self care needs are also priorities. A collaborative approach across health care disciplines is essential to healing, the prevention of further injury, and the development of adaptive processes.
An unusual neurologic problem: Werdnig-Hoffmann disease
Authors: Barden C , Lee R , Parchment Y , Dempsey RM
Published: November 2019

Werdnig-Hoffmann Disease, its pathophysiology, and the resulting symptoms are described in this article. A case study is presented with treatment goals outlined, and the appropriate nursing interventions are delineated.
Rhabdomyolysis and myoglobinuric renal failure
Authors: Harper J
Published: November 2019

Rhabdomyolysis, a clinical syndrome resulting from the release of skeletal muscle cell contents into the plasma, is causally connected to up to 25 percent of all cases of acute renal failure. Critical care nurses need to be aware of precipitating factors and proper interventions in order to assure optimal function in this patient population.
The effect of two concentrations of heparin on arterial catheter patency
Authors: Bolgiano CS , Subramaniam PT , Montanari JM , Minick L
Published: November 2019

The use of invasive lines with heparinized fluid for hemodynamic monitoring is a routine procedure in critical care areas. The main objective of this study was to compare the duration of patency of indwelling arterial catheter lines and patient coagulation values when the recommended dilution of 1.0 U heparin/mL was used versus the use of only 0.25 U heparin/mL. One hundred four intensive care unit (ICU) patients were studied. There were no significant differences between the two groups in patency or coagulation values. The results of the study demonstrated that 0.25 U heparin/mL was sufficient to maintain arterial line patency for patients with lines in place for up to 3 days.
Determination of electrical axis deviation
Authors: Knapik ML
Published: November 2019

While the determination of an abnormal electrical axis is not considered to be diagnostic, it will lend support to suspicions of abnormalities such as hypertrophy or intraventricular conduction defects. In some instances the recognition of axis deviation may be the first indication of underlying heart disease in an otherwise asymptomatic patient. Axis deviation can be determined easily in the critical care setting and should become as routine to the critical care nurse as the interpretation of a rhythm strip.
Holistic care of the patient receiving pancuronium bromide
Authors: Sohl L
Published: November 2019

Pancuronium bromide therapy can be devastating to patient and family alike. However, with an understanding of the effects of drug administration, and following the holistic care considerations, the critical care nurse can provide a successful outcome for the patient.
Neoplastic cardiac tamponade
Authors: Joiner GA , Kolodychuk GR
Published: November 2019

Once thought to be rare, neoplastic cardiac tamponade is beginning to be recognized more frequently, and is occasionally the presenting symptom of neoplastic disease. This article provides the critical care nurse with the knowledge necessary for care of the patient with neoplastic cardiac tamponade.
Successful methods for arterial blood gas interpretation
Authors: Russell JM
Published: November 2019

Understanding acid-base disturbances is essential in the care of the critically ill patient. Through a systematic evaluation of patient symptoms and arterial blood gas values, patient care can be improved. These formulas can be effective tools for the nurse to use in the care of patients with acid-base imbalances.
Perceptions and significance of patient deaths for pediatric critical care nurses
Authors: Benica SW , Longo CB , Barnsteiner JH
Published: November 2019

This study provides nursing administrators with data regarding stressors of the pediatric critical care nurse in order of priority. Death of patients was the only item isolated and compared to the other stress categories. It is suggested that death of patients be compared to all other items on the audit. The authors recommend expanding this study by asking two additional questions: Does the amount of time spent caring for dying patients correlate with the nurses' estimate of patient deaths and is there a relationship between the time spent caring for patients who die and perception of death as a stressor? This information can be utilized at the unit level in the development of stress management activities. At the hospital administrator level, this information can assist in the expansion of retention and recruitment strategies.
Neurodiagnostic testing in critically injured adults
Authors: Mason PJ
Published: November 2019

The recent expansion of diagnostic technology in healthcare now offers many devices for diagnostic testing. Each has strengths and weaknesses as a neurodiagnostic data source. Understanding these components allows the critical care nurse to prepare the patient and family adequately for tests and then use the results knowledgeably in planning care for the critically ill patient.
Emergency management of drug overdose
Authors: Weinman SA
Published: November 2019

Successful management of patients presenting after intentional, accidental, acute or chronic overdose depends on prompt identification of drugs ingested, an organized approach of care that centers around stabilization, patient assessment, gastric evacuation, GI/systemic elimination, patient education and psychiatric evaluation.