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Category: Nursing

Authors: Lamas D

Reference: N Engl J Med. 2018 Jun 21;378(25):2431-2432. doi: 10.1056/NEJMe1804576.

No abstract

Authors: White DB, Angus DC, Shields AM, Buddadhumaruk P, Pidro C, Paner C, Chaitin E, Chang CH, Pike F, Weissfeld L, Kahn JM, Darby JM, Kowinsky A, Martin S, Arnold RM; PARTNER Investigators.

Reference: N Engl J Med. 2018 Jun 21;378(25):2365-2375. doi: 10.1056/NEJMoa1802637

Background Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients’ preferences. Methods We conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates’ mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates’ mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician-family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay. Results A total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates’ mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, -0.34; 95% confidence interval [CI], -1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, -1.66 to 3.47; P=0.49). The surrogates’ mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, -0.15; 95% CI, -0.26 to -0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P

Authors: Redaelli S, Zanella A, Milan M, Isgrò S, Lucchini A, Pesenti A, Patroniti N.

Reference: J Artif Organs. 2016 Dec;19(4):343-349. Epub 2016 Jun 16.

Daily nursing in critical care patients may alter vital parameters, especially in the most critically ill patients. The aim of our study was to evaluate feasibility and safety of daily nursing on patients undergoing venous-venous extracorporeal membrane oxygenation (vv-ECMO) for severe respiratory failure. Daily nursing was performed following defined phases (sponge bath, elevation with scooping stretcher, change position of endotracheal tube, dressing replacement). We recorded physiological and ECMO parameters before and during daily nursing in 5 patients for several days (total: 25 daily nursing) and adverse events: desaturation, hypertension, reduction of mixed venous oxygen saturation, arterial oxygen saturation or ECMO blood flow and elevation in minute ventilation. Sedative drug dosage and additional bolus were recorded. Daily nursing was performed in 92 % of cases (23/25), with a minimum of two adverse events per daily nursing. Hypertension and tachycardia were mostly recorded at the beginning, while desaturation, reduction in mixed venous oxygen saturation and blood flow were recorded during elevation with scooping stretcher. Increase in minute ventilation was frequent in spontaneous breathing patients. Additional bolus of sedation was required before and/or during nursing. Daily nursing significantly alters physiologic parameters; thus, it should be performed only when physicians are readily available to treat adverse events.
ARDS; Daily nursing care; ECMO

The CJC supplement with our content is out.  Link to Jan 2017

Authors: Abawi M, Nijhoff F, Agostoni P, Emmelot-Vonk MH, de Vries R, Doevendans PA, Stella PR.

Reference: JACC Cardiovasc Interv. 2016 Jan 25;9(2):160-8.

The purpose of this study was to investigate the incidence, predictive factors, and effect of post-operative delirium (POD) among patients treated by transcatheter aortic valve replacement (TAVR).
Patients undergoing operations that involve valve replacement appear at higher risk of POD than patients subjected to coronary artery bypass surgery alone. In patients with severe aortic stenosis undergoing TAVR, little is known regarding the potential impact of POD on the clinical outcomes.
A retrospective observational cohort study of 268 consecutive patients who underwent TAVR at our institute was conducted. Delirium was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorder, 4th Edition criteria. The primary outcome of this study was the presence of in-hospital POD after TAVR.
The incidence of POD after TAVR was 13.4% (n = 36). Of these cases, 18 were associated with post-procedural complications, including major vascular complications/bleeding (n = 4), stroke (n = 3), acute kidney injury (n = 3), atrial fibrillation (n = 4), and infectious disease (n = 4). POD was most frequently diagnosed on the second day after TAVR (interquartile range [IQR]: 1 to 5 days) and was associated with prolonged in-hospital stay regardless of complications (in uncomplicated TAVR: 6 days [IQR: 5 to 10 days] vs. 5 days [IQR: 4 to 5 days]; p < 0.001; and in complicated TAVR: 9 days [IQR: 8 to 15 days] vs. 6 days [IQR: 5 to 9 days]; p < 0.001). Predictors of POD were nontransfemoral (transapical/transaortic) access (odds ratio [OR]: 7.74; 95% confidence interval [CI]: 3.26 to 18.1), current smoking (OR: 3.99; 95% CI: 1.25 to 12.8), carotid artery disease (OR: 3.88; 95% CI: 1.50 to 10.1), atrial fibrillation (OR: 2.74; 95% CI: 1.17 to 6.37), and age (OR: 1.08; 95% CI: 1.00 to 1.17, per year increase). After a median follow-up of 16 months (IQR: 6 to 27 months), POD remained an independent predictor of mortality in patients undergoing transfemoral TAVR compared with the nontransfemoral TAVR (hazard ratio: 2.81; 95% CI: 1.16 to 6.83 vs. hazard ratio: 0.43; 95% Cl: 0.10 to 1.76), adjusted for possible confounders in a time-dependent Cox-regression model (i.e., age, sex, Logistic EuroSCORE and the occurrence of complications). CONCLUSIONS: POD after TAVR has an incidence of around 13% and occurs early in the post-operative course. Nontransfemoral access is strongly associated with the occurrence of POD. Patients who develop POD show prolonged in-hospital stay and impaired long-term survival. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved. KEYWORDS: post-operative delirium; transcatheter aortic valve replacement

Authors: Schmidt GA, Girard TD, Kress JP, Morris PE, Ouellette DR, Alhazzani W, Burns SM, Epstein SK, Esteban A, Fan E, Ferrer M, Fraser GL, Gong M, Hough C, Mehta S, Nanchal R, Patel S, Pawlik AJ, Sessler CN, Strøm T, Schweickert W, Wilson KC, Truwit JD.

Reference: Am J Respir Crit Care Med. 2016 Oct 20

This clinical practice guideline addresses six questions related to liberation from mechanical ventilation in critically ill adults. It is the result of a collaborative effort between the American Thoracic Society (ATS) and American College of Chest Physicians (CHEST).
A multi-disciplinary panel posed six clinical questions in a Population, Intervention, Comparator and Outcomes (PICO) format. A comprehensive literature search and evidence synthesis was performed for each question, which included appraising the certainty in the evidence (i.e., the quality of evidence) using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. The Evidence-to-Decision Framework was applied to each question, requiring the panel to evaluate and weigh the: importance of the problem, confidence in the evidence, certainty about how much the public value the main outcomes, magnitude and balance of desirable and undesirable outcomes, resources and costs associated with the intervention, impact on health disparities, and acceptability and feasibility of the intervention.
Evidence-based recommendations were formulated and graded, initially by subcommittees and then modified following full panel discussions. The recommendations were confirmed by confidential electronic voting; approval required that at least 80% of the panel members agree with the recommendation.
The panel provides recommendations regarding liberation from mechanical ventilation. The details regarding the evidence and rationale for each recommendation are presented in the American Journal of Respiratory and Critical Care Medicine and CHEST.

Authors: Vincent JL, Pelosi P, Pearse R, Payen D, Perel A, Hoeft A, Romagnoli S, Ranieri VM, Ichai C, Forget P, Della Rocca G, Rhodes A.

Reference: Crit Care. 2015 May 8;19:224.

A significant number of surgical patients are at risk of intra- or post-operative complications or both, which are associated with increased lengths of stay, costs, and mortality. Reducing these risks is important for the individual patient but also for health-care planners and managers. Insufficient tissue perfusion and cellular oxygenation due to hypovolemia, heart dysfunction or both is one of the leading causes of perioperative complications. Adequate perioperative management guided by effective and timely hemodynamic monitoring can help reduce the risk of complications and thus potentially improve outcomes. In this review, we describe the various available hemodynamic monitoring systems and how they can best be used to guide cardiovascular and fluid management in the perioperative period in high-risk surgical patients.

Authors: Cropsey C, Kennedy J, Han J, Pandharipande P.

Reference: Semin Cardiothorac Vasc Anesth. 2015 Dec;19(4):309-17

Neurologic injury in the form of cognitive decline, delirium, and stroke are common phenomena in patients undergoing cardiac surgery and continues to be one of the most common complication after cardiac surgery, in spite of improvements in mortality and and improved surgical and anesthetic techniques. These complications lead to a significant increase in length of stay in the intensive care unit, increased length of hospital admission, and functional impairment, resulting in not only profound negative effects on patients who experience these complications, but also to increased costs of medical care and delivery. We discuss each of these complications in regard to their risks factors, incidence, potential therapeutic modalities, and relevant intraoperative and postoperative considerations.

Authors: Iwashyna TJ, Hodgson CL,

Reference: Volume 388, No. 10052, p1351–1352, 1 October 2016

It is easy to consider early mobilisation in the intensive care unit (ICU) solely as an exercise intervention. However, it has become increasingly clear that such a simplification is wrong. Instead, early mobilisation in the ICU is a complex intervention demanding interdisciplinary coordination and communication.

Authors: Shaw R.

Reference: Am J Crit Care. 2016 Mar;25(2):181-4.

Adequate sleep is a critical component of illness recovery. Inadequate sleep contributes to a myriad of physiological problems, including impaired immune response, decline in wound healing, greater insulin resistance, increased perceptions of pain, and an increase in mortality. Sleep problems exacerbate the healing process during hospitalization and can endure beyond hospitalization.13 Researchers in one study4 documented that sleep difficulties may endure beyond hospitalization: 50% of respondents reported moderate to severe sleep problems 1 week after discharge. Other studies have offered evidence that sleep problems experienced during hospitalization increase the risk for development of chronic insomnia.3

Acutely ill patients experience difficulty falling asleep, sleep fragmentation, decreased rapid-eye-movement (REM) sleep, and sleep perceived as poor quality.2,5 In hospitals, many factors can interfere with patients’ sleep. Environmental noise (eg, noisy equipment, alarms, staff interaction) is a pervasive problem. The Environmental Protection Agency recommends that noise levels not exceed 45 decibels during the day and 35 decibels at night. Numerous studies in acute and intensive care settings have documented noise levels regularly exceeding the recommendations.6,7 Other sleep disruption factors include lighting that interferes with sleep-wake cycles, pain, anxiety, and symptoms related to patients’ underlying illness.4 Many of these sleep-disrupting factors are amplified in intensive care units.

Pharmacological interventions, such as sedatives, are often the first response to promoting sleep in hospitalized patients. However, use of sedatives has been linked to such adverse effects as memory loss, disorientation, increased fall risk, and daytime fatigue.3 In recent years, growing emphasis has been placed on exploring the effectiveness of non-pharmacological interventions to promote sleep, such as minimizing nighttime disruptions, decreasing noise and light, increasing meaningful daytime activity, and using relaxation techniques (eg, aromatherapy, massage, guided imagery, ear plugs, and eye masks).3Music is another previously studied technique for promoting sleep. Music is hypothesized to have psychological and physiological effects on the body, including potentially sleep-promoting influences.8 The PICO (patient/problem, intervention, comparison, outcomes) question that this review addresses is, What effect do interventions using music, compared with other methods, or usual care, have on promoting sleep in hospitalized adults?

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