bluuebunny/crossref_metadata_2025 huggingface dataset:
Myocardial ischemia during the weaning period
Authors: Abalos A , Leibowitz AB , Distefano D , Halpern N , Iberti TJ
Published: November 2019

OBJECTIVES: To estimate the incidence of silent myocardial ischemia, its pattern over time and its relationship to the time and mode of weaning high-risk cardiac patients after noncardiac surgery. DESIGN: Prospective study with random assignment to one of three weaning modes. SETTING: A surgical intensive care unit in a university hospital and a Veterans Administration hospital. PATIENTS: Sixty-two patients meeting standard criteria for extubation were randomized to one of three modes of weaning: synchronized intermittent mandatory ventilation (n = 19), T-Bar (n = 21) or continuous positive airway pressure (n = 22). METHODS: Ischemia was monitored with a continuous two-lead (V5, III) ST segment analyzer. Tracings were reviewed by a cardiologist. Ischemia was defined as greater than 1 mm ST segment depression 60 milliseconds after the J point. The monitoring period included a prewean (mean 654.0 minutes), wean (mean 46.5 minutes) and postwean (mean 1223.4 minutes) period. RESULTS: Of 62 patients, 12 (19.3%) experienced ischemia at some time during the monitoring period, most often during the weaning period. Ischemia during weaning was detected in 3 of 21 (14.3%) T-Bar patients and 2 of 22 (9.1%) continuous positive airway pressure patients but in no synchronized intermittent mandatory ventilation patients. CONCLUSION: This study demonstrates that silent myocardial ischemia occurs frequently in high-risk postoperative patients, with the highest incidence during weaning.
Clinical management of supraventricular tachycardia with adenosine
Authors: Chronister C
Published: November 2019

Adenosine is a reliable agent to convert supraventricular tachycardia to regular sinus rhythm with few complications. Also, adenosine may be useful in the diagnosis of narrow and wide QRS complex tachycardias. Original research articles published predominantly in the last 10 years were reviewed. These articles examined the therapeutic and electrophysiologic effects of adenosine compounds and compared their actions to other antiarrhythmics.
Room-temperature thermodilution cardiac output: proximal injectate lumen vs proximal infusion lumen
Authors: Pesola GR , Ayala B , Plante L
Published: November 2019

OBJECTIVE: To assess the accuracy of room-temperature thermodilution cardiac output measurements from the venous infusion port. DESIGN: Central venous port cardiac output measurements were compared with venous infusion port measurements in 48 right-heart catheters. INTERVENTION: Three 10-mL injections of 5% dextrose in water were made through each port. The order of port injection was random. RESULTS: The cardiac outputs were 5.8 +/- 1.8 L/min from both ports, with no difference between ports (paired t test). CONCLUSION: Room-temperature thermodilution cardiac output determinations from the venous infusion port can be used in place of central venous port cardiac outputs if the central venous port becomes nonfunctional.
Temporal patterns of heart rate and selected arrhythmias for 48 hours after cardiac surgery
Authors: Woods SL , Felver L , Hoeksel R
Published: November 2019

OBJECTIVE: To describe the temporal patterns of heart rate and arrhythmias in the immediate postoperative period following cardiac surgery. Six postoperative cardiac surgical patients with a mean age of 48.3 years were studied. DESIGN: Descriptive longitudinal design. SETTING: Cardiac surgical ICU. METHODS: Heart rate and arrhythmias were recorded continuously for 48 hours from a cardiac monitor using a Holter tape recorder. Environmental and treatment data were noted throughout data collection by trained nonparticipant observers. RESULTS: Mean heart rate and incidence of arrhythmias were different between the 2 study days; therefore, data were divided into two segments (A and B). These differences coincided with extubation in most cases. Individual subject cosinor analysis revealed 24-hour rhythms of heart rate in both segments in all subjects except segment B for one subject. Rhythms of shorter periods were also found. In segment A individual subjects' acrophases (peak times of fitted curves) occurred later than expected for subjects' prehospitalization sleep-wake schedule, whereas in segment B they occurred earlier. Cosinor analysis of arrhythmias revealed significant 24-hour rhythms in both segments in one of the three subjects with premature atrial complexes, two of the four subjects with premature ventricular complexes and both subjects with ventricular couplets. Four-hour rhythms were found in premature atrial complexes (n = 1), atrial tachycardia (n = 1) and premature ventricular complexes (n = 3). Acrophases for arrhythmias varied among patients. During segment B the 4-hour-rhythm acrophases in heart rate and arrhythmias were related to the timing of respiratory therapy. CONCLUSIONS: Temporal variations in heart rate could be identified in these six critically ill adults. Rhythm parameters changed during the first 48 hours after cardiac surgery. In those who had arrhythmias, some patients demonstrated temporal patterns in the incidence of selected arrhythmias. Further study is needed to describe the temporal patterns of heart rate and arrhythmias in varied groups of critically ill persons in a variety of settings.
Drawing coagulation studies from arterial lines: an integrative literature review
Authors: Laxson CJ , Titler MG
Published: November 2019

How much blood must be discarded from a heparinized arterial line to obtain accurate coagulation studies, specifically activated partial thromboplastin time? The published literature provides insight into the question and guidelines for practice in adult critical care. This article reviews and integrates findings from 14 research studies published from 1971 to 1993 on discarding blood from arterial lines for coagulation studies. Investigators compared activated partial thromboplastin time values from arterial and venous blood samples using various discard volumes, sites and sizes of catheters, and heparin flush concentrations. Similarities and differences in arterial and venous activated partial thromboplastin time were reported. Studies have demonstrated that adequate discard volume for activated partial thromboplastin time is 6 times the catheter dead space. These results should not be generalized to systemically heparinized patients, pediatric patients, or other types of heparinized lines such as pulmonary artery, central venous, or Hickman catheters.
Emotional responses of family members during a critical care hospitalization
Authors: Kleiber C , Halm M , Titler M , Montgomery LA , Johnson SK , Nicholson A , Craft M , Buckwalter K , Megivern K
Published: November 2019

BACKGROUND: The needs and satisfaction levels of family members of critically ill patients have received much attention in the literature. The feelings of family members, however, have not been thoroughly investigated. To develop appropriate nursing interventions to assist family members in coping with a critical care hospitalization, accurate information about their emotional response to the situation is needed. OBJECTIVE: To examine emotional responses of family members and their descriptions of supportive behaviors of others during a critical care hospitalization. METHODS: An exploratory design was used to study 52 subjects with critically ill family members in the pediatric, neonatal, medical, surgical and cardiovascular intensive care units in a large tertiary care hospital. The subjects kept daily logs of their feelings and the supportive behaviors of others. Thematic analysis was used to identify major themes. RESULTS: Analysis revealed a broad range of powerful emotions throughout the intensive care unit stay. Negative and positive emotions such as despair and joy were sometimes identified by subjects within a 24-hour period. Although fear, worry, anger and exhaustion were dominant themes during the first 24 hours and when the family received bad news about the patient, there was no pattern of emotional response evident as the stay progressed. Some differences between subjects drawn from the medical and neonatal intensive care units were evident. CONCLUSIONS: The findings suggest that family members of critically ill patients experience deep emotional turmoil throughout the intensive care unit stay. Specific nursing interventions to promote adaptive coping are needed throughout the experience.
Radiofrequency catheter ablation for supraventricular tachycardias: Part II
Authors: Futterman LG , Lemberg L
Published: November 2019

Use of percutaneous catheter ablation with radiofrequency current for cardiac arrhythmias is expanding rapidly. Technical ease, high success and low complication rates have allowed RFCA to become standard treatment for accessory AV connections and is the therapeutic procedure of choice for patients with atrioventricular node reentry tachycardias. Techniques still being investigated and evaluated for the treatment of supraventricular tachycardias include laser catheter ablation, cryocatheter ablation and microwave catheter ablation. With further clinical experience, the efficacy and safety of these and other procedures can be determined.
Modifiable risk factors for coronary heart disease in women
Authors: Hanson MJ
Published: November 2019

Research in human coronary heart disease has been conducted primarily on males; however, investigators have begun to focus research efforts on female subjects as well. A literature review that identified studies on women and coronary heart disease was done to describe modifiable risk factors for coronary heart disease in women. Several modifiable risk factors such as smoking, hypertension, and disorders of lipid metabolism previously identified for men are also risk factors for women. However, the mechanisms by which some of these risk factors work in women are different from those in men. Moreover, women have additional risk factors related to menopause and, in some cases, the use of oral contraceptives. Significant initial information has been gained concerning women and coronary heart disease risk factors. However, gaps persist in information regarding the individual and synergistic effects of risk factors for CHD in women.
A Delphi study on research priorities for trauma nursing
Authors: Bayley EW , Richmond T , Noroian EL , Allen LR
Published: November 2019

OBJECTIVES. To identify and prioritize research questions of importance to trauma patient care and of interest to trauma nurses. METHOD. A three-round Delphi technique was used to solicit, identify, and prioritize problems for trauma nursing research. In round 1, experienced trauma nurses (N = 208) generated 513 problems, which were analyzed, categorized, and collapsed into 111 items for subsequent rounds. Round 2 participants rated each research question on a 1 to 7 scale on two criteria: impact on patient welfare and value for practicing nurses. Group median scores provided by 166 round 2 respondents and respondents' individual round 2 scores were indicated on the round 3 questionnaire. Subjects rated the questions again on the same criteria and indicated whether nurses, independently or in collaboration with other health professionals, should assume responsibility for that research. Median and mean scores and rank order were determined for each item. RESULTS. Respondents who completed all three rounds (n = 137) had a mean of 8.3 years of trauma experience. Nine research questions ranked within the top 20 on both criteria. The two research questions that ranked highest on both criteria were: What are the most effective nursing interventions in the prevention of pulmonary and circulatory complications in trauma patients? and What are the most effective methods for preventing aspiration in trauma patients during the postoperative phase? The third-ranked question regarding patient welfare was: What psychological and lifestyle changes result from traumatic injury? Regarding value for practicing nurses, What are the most effective educational methods to prepare and maintain proficiency in trauma care providers? ranked third. CONCLUSION. These research priorities provide impetus and direction for nursing and collaborative investigation in trauma care.
Reviews and summaries of research related to AACN 1980 research priorities: contextual topics
Authors: Riegel B , Banasik JL , Barnsteiner J , Beecroft P , Kern L , Lindquist R , Prevost S , Titler M
Published: November 2019

This article reviews and summarizes the research conducted following publication of the 1980s American Association of Critical-Care Nurses' contextual research priorities. Reports of original research conducted on the contextual priority topics between 1981 and 1991 were included. Review articles, doctoral dissertations, theses, and abstracts were excluded unless judged to provide important information on the topic. Following the statement of each priority, progress in the area is summarized. Limitations and measurement issues are discussed as appropriate. Recommendations for future research are provided, and progress in the area is summarized.
Chylopericardium following aortic valve replacement and coronary artery bypass surgery: a case report and discussion
Authors: Schactman M , Scott C , Glibbery-Fiesel DR , Murello M , Kerr P
Published: November 2019

The incidence of chylopericardium after cardiac surgery is unusual, but there are documented cases. Those caring for these patients need to be aware of the symptoms and management of chylopericardium because, if left untreated, it may cause catastrophic consequences.
Adult respiratory distress syndrome: outcome in a community hospital
Authors: Willms D , Nield M , Gocka I
Published: November 2019

BACKGROUND: Published reports indicate that survival rates of patients with adult respiratory distress syndrome have not improved dramatically since the first report of the condition in 1967. However, changes in ventilator strategies and improved critical care management may result in better survival rates in patients with well-defined, severe adult respiratory distress syndrome. OBJECTIVES: To report the outcomes of patients with adult respiratory distress syndrome treated in a community hospital and compare these findings with those in previously published reports. METHODS: A retrospective study design was used. All patients diagnosed with adult respiratory distress syndrome (N = 47) over a 2-year period were studied. RESULTS: For the study patients, the survival rate was 64%; 29% died from respiratory failure alone. Analysis demonstrated that advanced age was not associated with mortality. Pressure-control ventilation was used for 31 patients and there was no significant difference in the presence of barotrauma in the pressure-control mode vs volume ventilation. CONCLUSION: This survival rate exceeds most recently reported rates and thus supports the idea that improvement in treatment of adult respiratory distress syndrome is occurring.
Comparison of five clinical weaning indices
Authors: Burns SM , Burns JE , Truwit JD
Published: November 2019

BACKGROUND: Despite extensive data acquired in the area of weaning, clinicians still struggle with the questions of how and when to begin the process. Clinical weaning indices, designed to predict weaning potential, are often difficult to use. They provide an answer at a specific time; extrapolation to the weaning process is rarely possible. No single index has proven to be superior. OBJECTIVES: To test the efficacy of five clinical weaning indices (Burns Weaning Assessment Program; Weaning Index; frequency tidal volume ratio; compliance, resistance, oxygenation and pressure index; and negative inspiratory pressure) at regular intervals during withdrawal of ventilatory support and to determine threshold levels for the program. METHODS: A prospective convenience sample consisted of 37 adult critical care patients requiring mechanical ventilation for at least 7 days and identified as stable and ready to wean. Data were collected on all weaning indices every other day until the patient was weaned. RESULTS: With the exception of the Burns Weaning Assessment Program, weaning indices did not change significantly from preweaning scores. Furthermore, the results failed to demonstrate that any of the five clinical weaning indices have strong predictive power related to weaning trial outcomes, although all the indices had negative predictive values that may be helpful in predicting unsuccessful weaning trials. CONCLUSIONS: The results of this study suggest that the process of weaning may be enhanced by comprehensive, systematic approaches and that clinical weaning indices like the Burns Weaning Assessment Program might best serve as tools to track trends in progress, keep care planning on target, and prevent unsuccessful weaning trials.
Perceived quality of life before and after implantation of an internal cardioverter defibrillator
Authors: Bainger EM , Fernsler JI
Published: November 2019

BACKGROUND: Although use of the internal cardioverter defibrillator in selected high-risk patient groups has significantly improved survival, questions have arisen regarding its impact on psychological adjustment and quality of life. OBJECTIVES: To determine whether there was a difference in perceived quality of life of internal cardioverter defibrillator recipients before implantation, reported retrospectively, and after implantation. METHODS: Survey packets containing a demographic data form, a modified version of the Ferrans and Powers Quality of Life Index: Cardiac Version, and a consent form were mailed to internal cardioverter defibrillator recipients accrued from two hospitals; 70 patients comprised the convenience sample. RESULTS: No significant difference in perceived overall quality of life was revealed by before and after implantation scores of t tests or analyses of variance. Young, unemployed patients with multiple health problems were most at risk for quality of life deficits. Overall, recipients in this study appeared to adapt effectively to the stresses associated with the device. CONCLUSIONS: Our results suggest that the internal cardioverter defibrillator did not prolong life at a sacrifice to quality of life. These findings can help identify patients at increased risk for quality of life deficits.
Monitoring neuromuscular blockade in the adult ICU
Authors: Ford EV
Published: November 2019

Although neuromuscular blocking agents are now administered in intensive care units for extended periods, no standard has been established for their use in critically ill patients. Also, despite wide variations in individual response to neuromuscular blockade, the level of paralysis is not monitored consistently. Paralytic agents are associated with numerous side effects such as prolonged weakness, which is gaining widespread attention. Side effects may be minimized or prevented by consistent and precise monitoring of the degree of blockade. Monitoring is best accomplished by the expert use of the peripheral nerve stimulator. The evoked responses must be correlated with clinical signs of muscle movement. Furthermore, staff education regarding the pharmacology of these agents and the proper operation of the peripheral nerve stimulator must be ongoing.
Acute care nurse practitioner curriculum: content and development process
Authors: Hravnak M , Kobert SN , Risco KG , Baldisseri M , Hoffman LA , Clochesy JM , Rudy EB , Snyder JV
Published: November 2019

Curriculum development for preparation of acute care nurse practitioners requires a comprehensive process. To develop a program for their preparation at a large university, the faculty examined needs of the target patient population and care delivery system; scope of acute care nurse practitioner practice; current guidelines for the education of primary care nurse practitioners; evolving guidelines for the didactic and clinical education of acute care nurse practitioners; educational requirements of governing or licensing and certifying bodies; and placement of this new role within the existing healthcare team structure. A curriculum was then developed using a collaborative, multidisciplinary approach.
The unconscious experience
Authors: Lawrence M
Published: November 2019

BACKGROUND: Although considerable research has been done on pathophysiology, metabolic and physical causes, and prognostic indicators, little is known about unconsciousness or coma from the perspective of the patient. OBJECTIVE: To describe the experiences of patients who were once documented as being unconscious. METHODS: Phenomenologic interviews were conducted with 100 patients whose records indicated that they had been unconscious during hospitalization. Interviews were also attempted with primary family members, significant others, or other external observers. Chart audits documenting the unconscious episode, medications, and diagnoses were also carried out. Data were compared, using van Kaam's method, and contrasted. RESULTS: Patients experienced one or more of five states: unconsciousness, inner consciousness, perceived unconsciousness, distorted consciousness, and paranormal experiences. They described hearing, understanding, and responding emotionally to what was being said when it was assumed they were not aware. In addition, 23 subjects reported near-death experiences or visits, out-of-body experiences, or some other paranormal experience. CONCLUSION: Patients' unconscious experiences can cause long-term effects. Patients often need reassurance that other patients subjected to similar conditions also have these experiences.
Assessing patient comfort: local infiltration of lidocaine during femoral sheath removal
Authors: Bowden SM , Worrey JA
Published: November 2019

BACKGROUND: Patient comfort is a primary nursing concern when removing femoral sheaths. The use of lidocaine infiltration, a common practice at our facility, was not addressed in the reviewed literature. OBJECTIVE: To assess and evaluate the level of patient comfort and efficacy of lidocaine hydrochloride as a local anesthetic during femoral sheath removal and application of a compression device. METHODS: A literature search and telephone interviews were conducted with nurses and technicians who removed or assisted with the removal of femoral sheaths in 13 hospitals in the United States. Three patient comfort indicators were then developed and used for data collection. Over a 12-month period, nurses in the cardiology interventional unit removed the femoral sheaths without the use of lidocaine from 111 angioplasty/arthrectomy patients and evaluated the level of patient comfort. RESULTS: A literature search provided no information that supported the use of lidocaine hydrochloride infiltration during sheath removal. Telephone interviews showed that six of the hospitals used lidocaine as standard procedure and seven did not use lidocaine at all. Of the evaluated patients, 105 (94.59%) reported comfort during sheath removal without local infiltration of lidocaine. CONCLUSION: Our results supported the premise that patients do not require lidocaine before sheath removal to maintain an acceptable level of comfort.
Current nursing practice of point-of-care laboratory diagnostic testing in critical care units
Authors: LSJr Lamb , Parrish RS , Goran SF , Biel MH
Published: November 2019

BACKGROUND: The development of user-friendly laboratory analyzers, combined with the need for rapid assessment of critically ill patients, has led to the performance of in vitro diagnostic testing at the point of care by personnel without formal laboratory training. OBJECTIVES: To determine the range of laboratory testing performed by critical care nurses and their attitudes toward this role. METHODS: A survey of critical care nursing consultants was conducted, using a modified Likert scale, to assess objective measures of point-of-care testing practice in critical care units and to determine nurses' attitudes toward the practice of point-of-care testing. Statistical analysis was performed to determine significant trends in responses. RESULTS: Of the units responding to the survey, 35% used critical care nurses exclusively to perform point-of-care testing, 32.5% used laboratory technicians and critical care nurses, and 25% used other personnel. Of critical care nurses performing laboratory testing, 95.5% performed blood glucose analysis; 18.7%, arterial blood gas analysis; 4.5%, electrolyte analysis; 4.5%, hematology profiles; and 22.7%, other testing. Most agreed that stat tests were not reported promptly, thereby necessitating bedside testing. Respondents indicated that they would prefer that laboratory personnel operate in vitro diagnostic equipment and that requirements for critical care nurses to perform laboratory testing detracted from other patient care duties. CONCLUSIONS: Most nurses who perform point-of-care testing responded that it was necessary and helpful in patient management. However, they would prefer, because of their other patient care responsibilities, that laboratory personnel take this responsibility.
Nitric oxide inhalation in infants and children: physiologic and clinical implications
Authors: Craig J , Mullins D
Published: November 2019

Nitric oxide is a significant biologic mediator in a number of physiologic processes. Clinical and laboratory studies in both human and animal models have uncovered a number of conditions responsive to nitric oxide therapy. The use of inhaled nitric oxide is rapidly expanding into neonatal and pediatric critical care. Presently, the primary clinical indication for nitric oxide is pulmonary hypertension of either a primary or secondary etiology. Some patient populations that are refractory to conventional management demonstrate significant improvement when receiving nitric oxide therapy. This article discusses the physiologic properties of nitric oxide, as well as its diagnostic and therapeutic indications. Specific issues regarding nitric oxide delivery, monitoring, safety standards, and nursing care are also addressed.
Endovascular stented graft repair of a pseudoaneurysm of the subclavian artery caused by percutaneous internal jugular vein cannulation: case report
Authors: Pastores SM , Marin ML , Veith FJ , Bakal CW , Kvetan V
Published: November 2019

In high-risk patients endovascular repair of a pseudoaneurysm with a stented graft is a safe and reasonable treatment option that can preclude significant morbidity and shorten hospital stay. We report a case of pseudoaneurysm of the subclavian artery after internal jugular vein cannulation that was treated successfully with an endovascularly inserted, stented graft. The case report highlights the importance of recognizing this unusual but serious complication of percutaneous internal jugular vein catheterization through careful clinical examination, prompt duplex scanning, and arteriography.
Cardiac dysrhythmia during sleep in the critically ill: a pilot study
Authors: Richards KC , Curry N , Lyons W , Todd B
Published: November 2019

BACKGROUND: Few investigators have examined the hemodynamic status related to circadian and sleep-related cardiovascular events in critically ill patients. OBJECTIVE: To describe the relationships among nocturnal angina, myocardial infarction, and sleep, and to describe the cardiac rhythm, heart rate, and frequency of premature supraventricular and ventricular contractions during the sleep of critical care patients with cardiovascular disease. METHODS: A descriptive survey was done on nine patients in the medical intensive care unit of a large medical center. All subjects had cardiovascular disease and were studied during one night of sleep. RESULTS: There were no incidences of chest pain during the study and no changes in baseline cardiac rhythm associated with sleep staging. There was a significant statistical difference in mean heart rate among waking, stage 1 nonrapid-eye-movement sleep, and stage 2 nonrapid-eye-movement sleep; a lower heart rate was observed in stage 2 nonrapid-eye-movement sleep. The mean heart rate decreased by 3% to 4% from the waking state to sleep. No clinical or statistically significant differences in the frequency of premature supraventricular and ventricular contractions between sleep stages or sleeping and waking were found. CONCLUSIONS: The results of this pilot investigation do not suggest that dysrhythmia occurs more frequently during certain sleep stages or during the sleep state in critical care unit patients with cardiovascular disease. The mean heart rate slowed by 3% to 4% during rapid-eye-movement and nonrapid-eye-movement sleep, but decreases in heart rate were not as great as those noted in normal, healthy subjects.
Development of a model of advanced practice
Authors: Ackerman MH , Norsen L , Martin B , Wiedrich J , Kitzman HJ
Published: November 2019

BACKGROUND: The acute care nurse practitioner role is relatively new and not yet clearly defined. Our institution is in the first phase of a role delineation study that includes model development, validity testing, model revision, and dissemination. OBJECTIVES: To identify domains of practice, activities within each domain of practice, and common conceptual strands that cut across each domain, and to synthesize this information into a usable format to guide practice and role development. METHODS: A nonexperimental study design was used, including review of literature, expert consultation, brainstorming, and review of practice. RESULTS: The patient is central to the model. The identified domains of practice include direct comprehensive care, support of systems, education, research, and publication, and professional leadership. The conceptual strands include empowerment, collaboration, and scholarship. A continuum of experience from novice to expert was also identified within each domain. CONCLUSIONS: The development of the model is the first and most important phase in the role-delineation process. We believe that the model is accurate but still in need of testing. Nevertheless, our model can be used to guide institutions and individual practitioners.
A rapid recovery program for cardiac surgery patients
Authors: Riddle MM , Dunstan JL , Castanis JL
Published: November 2019

Despite a strong national commitment to excellence in healthcare, the available resources are limited. Cardiac surgery consumes more healthcare resources than any other single treatment. It is imperative that healthcare professionals evaluate the traditional methods used to deliver quality care. Rapid recovery programs have been implemented in response to this challenge. The purpose of this article is to discuss development, implementation, and outcome evaluation of a rapid recovery program for cardiac surgery patients in a single health center. A multidisciplinary team examined care before, during, and after surgery, as well as after discharge. The team also evaluated standards of care and CARE Pathways. Changes in protocols were made to prevent the predictable complications of cardiac surgery. A decrease in intubation time, respiratory infections, wound infections, laboratory procedures, length of stay, and costs has been demonstrated. In a follow-up patient and family survey, high satisfaction with nursing care, patient and family education, and length of hospitalization has been voiced. Anticipated goals have been exceeded and improvements in standards continue to be made.
Syndrome X: a discussion of angina and normal coronary arteries
Authors: Zell KA , Reis SE
Published: November 2019

Syndrome X was diagnosed in a female patient who presented with typical angina and a non-Q wave myocardial infarction, yet demonstrated normal coronary arteries. Syndrome X has been described as an impairment in normal endothelial function of the coronary microvasculature, resulting in inappropriate vasoconstriction and inadequate coronary flow reserve. In this article we review pathophysiology, diagnosis, treatment, and prognosis in a single case.
Effect of backrest position on hemodynamic and right ventricular measurements in critically ill adults
Authors: Wilson AE , Bermingham-Mitchell K , Wells N , Zachary K
Published: November 2019

BACKGROUND: Hemodynamic measurements are often obtained with the patient in a flat, supine position. Reports suggest that these measurements can be reliably obtained at backrest elevations from 0 degree to 45 degrees. However, no study has been performed to evaluate the effects of position change on all the measurements that can be obtained via a pulmonary artery catheter. OBJECTIVE: To investigate the effects of backrest elevation of 0 degree, 30 degrees, and 45 degrees on measurements obtained via a pulmonary artery catheter. METHOD: Thirty-nine patients in an ICU at a university-based hospital, who required a pulmonary artery catheter, were studied. A single-group, repeated-measures design was used. Hemodynamic and volumetric measurements were obtained from all subjects. RESULTS: Repeated-measures analysis of variance revealed that differences in cardiac index were statistically significant, and differences in cardiac output approached statistical significance. However, examination of the means of these measurements indicates a clinically nonsignificant difference in these values. No statistically or clinically significant differences were found for the other hemodynamic or volumetric measurements studied related to the order of backrest elevation. CONCLUSION: Findings support the hypothesis that a patient need not be placed flat to obtain accurate hemodynamic and volumetric measurements. Results of this study are consistent with those of previous research and extend previous results to include the volumetric measurements of end-diastolic volume index and right ejection fraction. In addition, the use of mechanical ventilation and vasoactive drugs did not alter the accuracy of the measurements at backrest elevations from 0 degree to 45 degrees.
Quality of life for critical care patients: a concept analysis
Authors: Bond AE
Published: November 2019

Confusion, misunderstanding, and ethical concerns may interfere with patients' choices for appropriate treatment and subsequent quality of life. Such concerns did not originate from recent technological advances but from the ancient Greeks and Romans who honored health more than life, and the early Christians who honored life more than health. These opposing concepts reflect differing notions of quality of life. Determining the quality of life involves personal issues--the cognitive ability to evaluate one's own life; the perception of a satisfactory state of social, emotional, physical, and mental health; and an acceptable feeling of well-being despite physical limitations. In contrast, and often conflict, are objective evaluations of treatment outcomes, morbidity/mortality statistics, cost/benefit analyses, and age studies performed in an attempt to determine quality of life by persons other than the patient.
Impact of patient consciousness on the intensity of the do-not-resuscitate therapeutic plan
Authors: Campbell ML , Thill MC
Published: November 2019

BACKGROUND: The nature and intensity of a do-not-resuscitate therapeutic plan varies by patient. Some do-not-resuscitate therapeutic plans may include interventions directed at the withdrawal of life-sustaining therapy. OBJECTIVE: The purpose of this study was to examine the impact of patient consciousness on the nature and intensity of the do-not-resuscitate plan, and on the decision to withdraw life-sustaining therapy. METHODS: This study represents a secondary analysis of data obtained in a previous study to evaluate patient care requirements under varying intensities of do-not-resuscitate plans. Data were collected retrospectively through record review. Patients were grouped as follows, according to the intensity of the do-not-resuscitate plan: (1) all but cardiopulmonary resuscitation, (2) conservative care without cardiopulmonary resuscitation, (3) comfort only, and (4) withdrawal of life-sustaining therapy. In addition to demographic data, consciousness and illness severity were measured. Data were analyzed using descriptive statistics. RESULTS: There was a significant decrease in consciousness from admission in all groups except conservative care. The withdrawal group had the lowest average Glasgow Coma Scale scores at the time of the do-not-resuscitate designation. Multiple regression analysis was used to demonstrate a significant impact of consciousness on type of do-not-resuscitate decision, but no significant impact from age or illness severity. CONCLUSIONS: These results support previous observations that decisions to withdraw life-sustaining therapy are prompted by diminished consciousness. These results may stimulate caregivers to offer withdrawal of life-sustaining therapy as an option in patients with severely decreased consciousness and a poor prognosis for functional recovery.
Effects of inhaled nitric oxide in patients with hypoxemia and pulmonary hypertension after cardiac surgery
Authors: Bender KA , Alexander JA , Enos JM , Skimming JW
Published: November 2019

BACKGROUND: Cardiopulmonary bypass can increase pulmonary vascular tone and decrease ventilation-perfusion matching by impairing the pulmonary endothelial production of nitric oxide. OBJECTIVES: We tested the hypothesis that inhalation of exogenous nitric oxide decreases the ratio of mean pulmonary arterial pressure to mean system arterial pressure and the intrapulmonary shunt fraction and increases the ratio of arterial blood oxygen tension to fraction of inspired oxygen in patients in whom the ratio of mean pulmonary arterial pressure to mean systemic arterial pressure is more than 0.50, and the ratio of arterial blood oxygen tension to fraction of inspired oxygen is less than 300 mm Hg in the first 24 hours after cardiopulmonary bypass surgery. METHODS: Only those patients who had estimates of the ratio of mean pulmonary arterial pressure to mean systemic arterial pressure and the ratio of arterial blood oxygen tension to fraction of inspired oxygen determined preoperatively were enrolled. Hemodynamic variables were recorded, and blood samples were obtained for oximetric analysis 5 minutes before and 30 minutes after inhalation of nitric oxide began. The concentration of nitric oxide inhaled was maintained at 20 parts per million. The data were analyzed by using Friedman's repeated measures analysis of variance. RESULTS: Thirteen patients were enrolled in the study. The mean preoperative ratio of mean pulmonary arterial pressure to mean systemic arterial pressure was 0.63 +/- 0.08 (standard error of the mean), and the mean preoperative ratio of arterial blood oxygen tension to fraction of inspired oxygen was 131 +/- 15 mm Hg. No differences between preoperative and postoperative values were detected. Inhalation of nitric oxide decreased the ratio of mean pulmonary arterial pressure to mean systemic arterial from 0.53 +/- 0.07 to 0.39 +/- 0.5 and increased the ratio of arterial blood oxygen tension to fraction of inspired oxygen from 167 +/- 35 mm Hg to 235 +/- 45 mm Hg. Inhalation of nitric oxide also decreased the intrapulmonary shunt fraction from 0.29 +/- 0.05 to 0.19 +/- 0.04. CONCLUSIONS: Inhalation of nitric oxide selectively decreases pulmonary vascular tone and increases ventilation-perfusion matching in patients with persistent pulmonary hypertension and hypoxemia after surgery requiring cardiopulmonary bypass. Inhalation of nitric oxide may be a valuable adjunctive therapy for these patients.
Outcomes of long-term ventilator patients: a descriptive study
Authors: Douglas SL , Daly BJ , Brennan PF , Harris S , Nochomovitz M , Dyer MA
Published: November 2019

BACKGROUND: Long-term ICU patients who require prolonged mechanical ventilation are a growing segment of the in-hospital population. Despite recognition that this population is costly to care for no systematic research has been done on the characteristics, outcomes, and disposition of these patients after they leave the hospital. OBJECTIVE: To describe clinical and sociodemographic characteristics and outcomes of ICU patients who require long-term (5 days or more) mechanical ventilation while in the hospital. METHODS: A prospective, longitudinal descriptive design was used to study 57 ICU patients who required 5 days or more of continuous mechanical ventilation while in the hospital. Clinical and sociodemographic data were collected at the time of enrollment. Patients were followed up for up to 6 months after discharge from the hospital to ascertain disposition and morality. RESULTS: On average, patients had a hospital stay of almost 6 weeks and required mechanical ventilation for approximately 4 weeks; 43.9% of the patients died in the hospital. None of the patients discharged from the hospital were able to return home initially without assistance. By 6 months after discharge, more than 50% of the original sample and died, 9% resided in an institution, and 33% were living at home. CONCLUSIONS: A large percentage of ICU patients who require 5 days or more of mechanical ventilation die in the hospital, and many of those who live spend considerable time in an extended-care facility before they are discharged to their homes. These likely outcomes of patients who require long-term ventilation should be discussed with patients and their families to assist them in making informed decisions.
Use of the Trendelenburg position by critical care nurses: Trendelenburg survey
Authors: Ostrow CL
Published: November 2019

BACKGROUND: Little evidence indicates that changing a patient's body position to the Trendelenburg (head lower than feet) or the modified Trendelenburg (only the legs elevated) position significantly improves blood pressure or low cardiac output. This intervention is still used and is often the first measure implemented for treatment of hypotension. OBJECTIVES: The purpose of this research was to assess the degree of use of Trendelenburg positions by critical care nurses, the clinical uses of these positions, and the sources of knowledge and beliefs of nurses about the efficacy of the positions. METHOD: A survey was mailed to 1000 nurses whose names were randomly selected from the membership list of the American Association of Critical-Care Nurses. RESULTS: The return rate was 49.4%. Ninety-nine percent of the respondents had used the Trendelenburg position, and 80% had used the modified Trendelenburg position, mostly for treatment of hypotension. Most used this intervention as an independent nursing action, and most learned about these positions from their nursing education, nurse colleagues, supervisors, and physicians. The Trendelenburg position was used for many nonemergent reasons; the most frequent use was for insertion of central IV catheters. Although 80% of the respondents believed that use of the Trendelenburg position improves hypotension almost always or sometimes, many respondents recognized several adverse effects associated with use of this position. DISCUSSION AND CONCLUSIONS: The results provide evidence that tradition-based therapy still underlies some interventions used in the care of critically ill patients and that some nurses may be relying on an outdated knowledge base that is not supported by the current literature.
Dangling practices of 51 nurses: a pilot project
Authors: Lane LD , Winslow EH , Woods RJ , Dixon JF
Published: November 2019

BACKGROUND: Nurses routinely "dangle" patients to evaluate and promote tolerance to changes in body position and to determine whether the level of activity should progress. Although dangling is a widespread nursing intervention, little research has been done on it, and little is known about how nurses dangle patients. OBJECTIVE: To describe dangling practices reported by critical care and acute care nurses. METHODS: A structured interview tool, developed for the study, was used to interview 51 experienced critical care and acute nurses from seven states about dangling practices. RESULTS: Most respondents said dangling was not routinely ordered and did not require a physician's order. The nurses described numerous strategies they used beforehand to promote tolerance to dangling, for example, premedicating for pain, and multiple interventions they used if patients did not seem to do well during dangling, for example, having patients take slow, deep breaths or move the feet and arms. Indicators of intolerance to dangling included marked changes in blood pressure, heart rate, and level of consciousness and patients' comments such as, "I can't stand it." Estimates of the duration of dangling varied widely, from 1 to 10 minutes; most respondents stated that duration varied "by feel" or depended on the patient's response. The most frequently mentioned personal rule about dangling was, "Get help if you're not sure how the patient will do." CONCLUSIONS: Nurses have developed numerous approaches to dangling acutely ill patients. These approaches should be described and tested to improve nursing practice and patient outcomes.
Drugs for amnesia in the ICU
Authors: Wagner BK , O'Hara DA , Hammond JS
Published: November 2019

OBJECTIVE: This review focuses on how patients' recall of their stay in the ICU can be modified pharmacologically. DATA SOURCES: Computerized MEDLINE and PAPERCHASE searches of English- and foreign-language published research from 1966 to 1995, bibliographies, pharmaceutical and personal files, and conference abstract reports. STUDY SELECTION: All abstracts from uncontrolled and controlled clinical trials were reviewed. DATA EXTRACTION: Study design, population, results, and safety information were retained. Efficacy conclusions were drawn from controlled trials. DATA SYNTHESIS: Patients without cerebral injury may recall mental and physical discomfort during their stay in the ICU. All benzodiazepines produce amnestic effects, but the short duration of action, lack of long-acting metabolites, and potent amnestic effects make lorazepam and midazolam preferable in this setting. Infusions of propofol for conscious sedation produce concentrations below those required for consistent amnesia. Opioids generally do not produce amnesia; however, end-organ failure and use of high doses of opioids may increase plasma concentrations to levels that produce impairment of learning and various degrees of amnesia. High infusion rates of ketamine may be required for satisfactory amnesia and pain control (with coadministration of benzodiazepine). Barbiturates and haloperidol do not impair memory in patients who are not critically ill. Antihistamines and anticholinergics that do not penetrate the central nervous system do not produce amnesia. Flumazenil may induce recall. CONCLUSIONS: Patients may remember their stay in the ICU, depending on the type of injury and the drug therapy. Of the drugs presented, benzodiazepines most reliably provide anterograde amnesia, whereas ketamine and propofol exhibit dose-dependent effects on memory.
Factors associated with compliance of critical care nurses with universal precautions: a pilot study
Authors: Roup BJ
Published: November 2019

BACKGROUND: Universal precautions for all healthcare workers have been recommended by the Centers for Disease Control and were mandated by the Occupational Safety and Health Administration in 1991. OBJECTIVES: The purpose of this study was to examine compliance with universal precautions by direct observation and by self-reporting questionnaire in a random sample of critical care nurses, a group with a high daily index of exposure to blood and body fluids. Additionally, knowledge, attitudes, and supply and equipment variables that might affect the rate of compliance were examined. METHODS: Data were collected on a random sample of 25 nurses in two critical care units in a military medical center. The same sample of nurses was then asked to complete an 85-item questionnaire that produced a score for knowledge of universal precautions, attitudes toward universal precautions, and the nurses' opinions of the supplies and equipment. RESULTS: The overall observed compliance score for all nurses was 67%, with a range of 25% to 100%. The observed compliance rates showed no statistically significant correlations with knowledge of universal precautions, attitudes toward universal precautions, or the quality, fit, availability, or accessibility of supplies and equipment. Power analyses showed that the sample size was too small to reveal significant findings. CONCLUSIONS: A larger sample size might show that these factors are indeed associated with use of universal precautions.