Intensive Care Nurse-Community

Cardiovascular Risk After Ischemic Attack Predicted By Ultrasound

2009-08-15T13:53:00.001+07:00

Ultrasound can be used to determine a patient's heart risk after a transient ischemic attack (TIA). An evaluation of transcranial (TCD) and extracranial (ECD) Doppler ultrasonography, published in the journal BMC Medical Imaging, has shown that both future stroke and future cardiovascular ischemic events can be predicted by abnormal findings.

Cardiovascular disease is the major cause of death on long-term follow-up after a TIA. Dr. Holger Poppert from the Technische Universität München, Germany, worked with a team of researchers to evaluate the ability of ultrasound to predict the likelihood of new vascular events in 176 TIA patients, with a median follow-up of 27 months. He said, "Nearly 40% of the patients with either stenoocclusive disease in ECD or pathological findings in TCD suffered a new ischemic stroke or TIA. Furthermore, detection of reactive collateral flow patterns or intracranial stenosis by TCD predicts new cardiovascular ischemic events on medium to long-term follow-up".

The researchers found that 5 of 18 patients with abnormal TCD findings (27.8%), but only 4 of 134 patients without (3%), developed a subsequent cardiovascular ischemic event. Speaking about these results, Poppert said, "Our findings support the routine use of TCD in addition to ECD in TIA patients. Moreover, routine screening tests for coronary artery disease and aggressive prevention therapies should be considered in TIA patients with pathological TCD findings".

Journal reference:

Katrin Holzer, Suwad Sadikovic, Lorena Esposito, Angelina Bockelbrink, Dirk Sander, Bernhard Hemmer and Holger Poppert. Transcranial Doppler ultrasonography predicts cardiovascular events after TIA. BMC Medical Imaging, (in press) [link]

Source : http://www.sciencedaily.com/releases/2009/07/090729203652.htm

Thalidomide Does Not Improve Survival In Small Cell Lung Cancer, Study Finds

2009-07-23T22:18:00.001+07:00

Treating patients with thalidomide in combination with chemotherapy for small cell lung cancer (SCLC) did not improve their survival but did increase their risk of blood clots, according to a new study published online July 16 in the Journal of the National Cancer Institute.

Siow Ming Lee, M.D., of the Department of Oncology, University Hospital in London, and colleagues randomly assigned 724 SCLC patients to take either a placebo or thalidomide. Used in treating some other cancers, thalidomide is an anti-angiogenic drug, i.e., it targets and suppresses the formation of new blood vessels that tumors need to survive and grow. In this randomized double-blind trial, patients received 100-200 milligrams daily for up to two years.

The researchers found no evidence of a survival difference between the two groups. The median overall survival for patients who received the placebo was 10.5 months. For patients who took thalidomide capsules, it was 10.1 months. Patients treated with thalidomide, however, had higher risk of thrombotic events.

"Together, these results suggest that targeting anti-angiogenesis in SCLC may not work as well as in multiple myeloma or colorectal cancer, perhaps because of differences in the angiogenic pathways involved in SCLC," the authors write.

In an accompanying editorial, Curzio Rüegg, M.D., of the Division of Experimental Oncology at the University of Lausanne in Switzerland, and Solange Peters, M.D., Ph.D., of the Clinical Oncology Service at the University of Lausanne, note that this study's results, as well as similar, negative results from previous studies, should lead to a fresh look at the basic biology of SCLC and of the putative anti-angiogenic activity of thalidomide.

"Rather than running from failure to failure, it may be more reasonable to go back to experimental work, including the development and analysis of transgenic SCLC models, to better understand SCLC biology and identify robust therapeutic targets," the editorialists write.

Source : http://www.sciencedaily.com/releases/2009/07/090716164337.htm

Sleep-Disordered Breathing Linked With Behavior Problems in Asthma

2009-07-19T22:43:00.000+07:00

Sleep-disordered breathing (SDB) is associated with behavior problems in children with asthma, according to a paper in the July issue of Pediatrics.

Dr. Maria Fagnano and colleagues from the University of Rochester School of Medicine, New York, write, "Studies have linked asthma symptoms with both childhood behavior problems and troubled sleep. There is growing, but limited, evidence that children with SDB may have worse behavior."

The investigators' study involved 194 inner-city children with asthma who were between the ages of 4 and 10 years (mean age, 8.2). On the basis of scores on the Sleep-Related Breathing Disorder scale, 33% of the children had SDB, the investigators report. Also, they found, on the basis of caregiver responses on the Behavioral Problem Index (BPI), 32% of children had significant behavioral issues.

Children with SDB had significantly worse behavior scores overall compared to those with no sleep difficulties (p<0.001), p="0.013)," p="0.011)," p="0.014).

On multiple regression analyses, SBD remained significantly associated with total BPI scores and eternalizing, internalizing, anxious/depressed, headstrong, and hyperactive behaviors. Similar significant associations were observed between higher sleep scores and worse behaviors across sleep subscales (snoring and sleepiness).

"Additional investigation is needed to determine if treatment of sleep disorders would help to decrease behavior problems in this population," the authors said.

In the meantime, the researchers conclude, "Clinicians should be particularly diligent about screening all children with asthma for SDB, and consider sleep disorders as a possible risk factor for behavior problems."

Pediatrics 2009;124:218-225.

Source : http://www.medscape.com/viewarticle/705784?sssdmh=dm1.499423&src=nldne

Prasugrel Approved for Use During PCI, FDA Announces

2009-07-18T11:23:00.001+07:00

The US FDA has granted the market go-ahead to prasugrel (Effient, Lilly/Daiichi Sankyo), an antiplatelet agent in the same chemical class as clopidogrel (Plavix, Bristol-Myers Squibb/Sanofi-Aventis), during PCI in the setting of ACS, the agency has announced in a press release [1]. The FDA review of prasugrel's application took about 18 months.

The approval is based primarily on the strength of the TRITON-TIMI 38 trial, which compared prasugrel against clopidogrel in 13 608 patients with moderate- to high-risk unstable angina, ST-segment-elevation MI (STEMI), or non-ST-segment-elevation MI (NSTEMI). Prasugrel was given as a 60-mg loading dose followed by 10-mg/day maintenance, and clopidogrel was given as a 300-mg loading dose plus 75-mg/day maintenance for six to 15 months.

In their announcement of the approval [2], Daiichi Sankyo and Lilly say the drug should be given at the dosage used in the trial. "In addition, for those patients who weigh less than 132 pounds (60 kg), physicians should consider lowering the maintenance dose to 5 mg once daily. Patients taking Effient should also take 75 mg to 325 mg aspirin orally once daily, according to their doctors' instructions."

As reported by heartwire when the TRITON-TIMI 38 was presented at the AHA 2007 Scientific Sessions, patients who received prasugrel showed a significant 19% reduction in the primary composite end point of cardiovascular death, MI, and stroke in the entire ACS population. The benefit was about the same across the three kinds of ACS.

The FDA's Cardiovascular and Renal Drugs Advisory Committee unanimously recommended the drug's approval in February 2009, as reported at the time by heartwire . During the hearing, most panel members said they felt comfortable supporting a superiority claim for prasugrel over clopidogrel in ACS patients, despite an increased risk of clinically significant bleeding observed with the newer drug in TRITON-TIMI 38.

According to the FDA announcement, prasugrel's labeling will include "a boxed warning alerting physicians that the drug can cause significant, sometimes fatal, bleeding. The drug should not be used in patients with active pathological bleeding, a history of ministrokes (transient ischemic attacks) or stroke, or urgent need for surgery, including coronary artery bypass graft surgery."

"Effient offers physicians an alternative treatment for preventing dangerous blood clots from forming and causing a heart attack or stroke during or after an angioplasty procedure," said Dr John Jenkins, director of the Office of New Drugs, in the FDA’s Center for Drug Evaluation and Research, in the agency's announcement. "Physicians must carefully weigh the potential benefits and risks of Effient as they decide which patients should receive the drug."

Source : http://www.medscape.com/viewarticle/705725?sssdmh=dm1.499002&src=nldne

Why H1N1 Flu Spreads Inefficiently

2009-07-16T21:23:00.000+07:00

A team from MIT and the Centers for Disease Control and Prevention has found a genetic explanation for why the new H1N1 "swine flu" virus has spread from person to person less effectively than other flu viruses.

The H1N1 strain, which circled the globe this spring, has a form of surface protein that binds inefficiently to receptors found in the human respiratory tract, the team reports in the July 2 online edition of Science.

"While the virus is able to bind human receptors, it clearly appears to be restricted," says Ram Sasisekharan, the Edward Hood Taplin Professor and director of the Harvard-MIT Division of Health Sciences and Technology (HST) and the lead MIT author of the paper. Sasisekharan and his laboratory co-workers have been actively investigating influenza viruses.

That restricted, or weak, binding, along with a genetic variation in an H1N1 polymerase enzyme, which MIT researchers first reported three weeks ago in Nature Biotechnology, explains why the virus has not spread as efficiently as seasonal flu, says Sasisekharan. However, flu viruses are known to mutate rapidly, so there is cause for concern if H1N1 undergoes mutations that improve its binding affinity.

"We need to pay careful attention to the evolution of this virus," says Sasisekharan.

On June 11, the World Health Organization declared a level 6 pandemic alert for H1N1. More than 300 people have died and more than 70,000 people have been infected, according to the WHO.

Genetic variation

Sasisekharan and CDC senior microbiologist Terrence Tumpey have previously shown that a flu virus's ability to infect humans depends on whether its hemagglutinin protein can bind to a specific type of receptor on the surface of human respiratory cells.

In the new Science paper, Sasisekharan, Tumpey and colleagues compared the new H1N1 strain to several seasonal flu strains, including some milder H1N1 strains, and to the virus that caused the 1918 flu pandemic. They found that the new strain, as expected, is able to bind to the predominant receptors in the human respiratory tract, known as umbrella-shaped alpha 2-6 glycan receptors.

However, binding efficiency varies between flu strains, and that variation is partly determined by the receptor-binding site (RBS) within the hemagglutinin protein. The team found that the new H1N1 strain's RBS binds human receptors much less effectively than other flu viruses that infect humans.

The researchers also found that the new H1N1 strain spreads inefficiently in ferrets, which accurately mimics human influenza disease including how it spreads or transmits in humans. When the ferrets were in close contact with each other, they were exposed to enough virus particles that infection spread easily. However, when ferrets were kept separate and the virus could spread only through airborne respiratory droplets, the illness spread much less effectively.

This is consistent with the transmission of this virus seen in humans so far, says Sasisekharan. Most outbreaks have occurred in limited clusters, sometimes within a family or a school but not spread much further.

"One of the big payoffs of long-term investments in carbohydrate biology and chemistry research is an understanding of the relationships between cell surface carbohydrate structure and viral infectivity," said Jeremy M. Berg, director of the National Institute of General Medical Sciences of the National Institutes of Health, which partly funded the research. "Tools developed in building such understanding help in the response to events like the recent H1N1 outbreak."

Second mutation

The researchers also pinpointed a second mutation that impairs H1N1's ability to spread rapidly.

Recent studies have shown that a viral RNA polymerase known as PB2 is critical for efficient influenza transmissibility. (RNA polymerase controls the viruses' replication once they infect a host.) The new H1N1 strain does not have the version of the PB2 gene necessary for efficient transmission.

MIT researchers led by Sasisekharan first reported the PB2 work in the June 9 online issue of Nature Biotechnology. That study also found that the new H1N1 strain has substantial genetic variability in the proteins targeted by current vaccines, making it likely that existing seasonal vaccines will be ineffective against the new strain.

Moreover, the researchers discovered that the new strain might just need a single change or mutation that could lead to inefficient interaction with the influenza drug oseltamivir, commonly known as Tamiflu, raising the possibility that strains resistant to Tamiflu could emerge easily.

The research done at MIT was funded by the Singapore-MIT Alliance for Research and Technology and the National Institutes of General Medical Sciences.

Source : http://www.sciencedaily.com/releases/2009/07/090702140849.htm

Chronic Kidney Disease and its Management

2009-07-12T22:13:00.000+07:00

Chronic kidney disease represents the gradual, substantial, and irreversible reduction in the excretory and homeostatic functions of the kidneys. It is characterised by progressive destruction of renal tissue over a period of at least months to many years, depending on the underlying aetiology. Glomerular filtration rate (GFR) progressively decreases with loss of functioning nephrons.

Until recently, the emphasis has been on patients needing dialysis or transplantation. It is now realised that less severe CKD is quite common, and monitoring in primary care will enable the minority of patients who go on to develop a more severe form to be detected at any earlier stage.¹ This important because the earlier the intervention, the greater the impact. Patients with chronic conditions such as heart disease and diabetes may already undergo structured review in primary care but the full extent of reduced kidney function may not be recognised.²

Classification of chronic kidney disease³

Kidney function should be assessed by estimated GFR (eGFR) and chronic kidney disease (CKD) is classified on this basis. The GFR should be estimated from serum creatinine using the 4-variable Modification of Diet in Renal Disease (MDRD) equation (see under investigations below).⁴

Patients with a GFR of >60 ml/min/1.73 m² without evidence of chronic kidney damage should NOT be considered to have CKD and do not necessarily need further investigation.

Stage 1: normal; eGFR >90 ml/min/1.73 m² with other evidence of chronic kidney damage (see below)
Stage 2: mild impairment; eGFR 60-89 ml/min/1.73 m² with other evidence of chronic kidney damage
Stage 3a: moderate impairment; eGFR 45-59 ml/min/1.73 m²
Stage 3b: moderate impairment; eGFR 30-44 ml/min/1.73 m²
Stage 4: severe impairment; eGFR 15-29 ml/min/1.73 m²
Stage 5: established renal failure (ERF); eGFR less than 15 ml/min/1.73 m² or on dialysis

Use the suffix (p) to denote the presence of proteinuria when staging CKD.

The other evidence of chronic kidney damage may be one of the following:

Persistent microalbuminuria
Persistent proteinuria
Persistent haematuria (after exclusion of other causes, e.g. urological disease)
Structural abnormalities of the kidneys demonstrated on ultrasound scanning or other radiological tests, e.g. polycystic kidney disease, reflux nephropathy
Biopsy-proven chronic glomerulonephritis

Epidemiology

The incidence of chronic kidney disease requiring dialysis varies worldwide: the number of patients per million population starting dialysis each year is 110 in the UK.³
The prevalence of end-stage renal failure also varies worldwide: the number of patients per million population in the UK is 498.³

Causes

The most important causes of chronic kidney disease are diabetes, glomerulonephritis, hypertension and other vascular disease.

Arteriopathic renal disease and hypertension
Glomerulonephritis
Diabetes
Infective, obstructive and reflux nephropathies
Familial or hereditary kidney disease, e.g. polycystic kidneys
Hypercalcaemia
Connective tissue diseases
Neoplasms
Myeloma

Risk factors

Factors other than the underlying disease process that may cause progressive renal injury include the following:

Hypertension
Acute insults from nephrotoxins or decreased perfusion
Proteinuria
Increased renal ammonia formation with interstitial injury
Hyperlipidaemia
Hyperphosphataemia with calcium phosphate deposition

Presentation

Symptoms

Usually presents with non-specific symptoms caused by renal failure, complications (e.g. anaemia in chronic renal failure) and the underlying disease.
May be discovered by chance following a routine blood or urine test.
Specific symptoms usually develop only in severe renal failure, and include anorexia, nausea, vomiting, fatigue, weakness, pruritus, lethargy, peripheral oedema, dyspnoea, insomnia, muscle cramps, pulmonary oedema, nocturia, polyuria and headache.
Sexual dysfunction is common.
Hiccups, pericarditis, coma and seizures are only seen in very severe renal failure.

Signs

The physical examination is often not very helpful but may reveal findings characteristic of the underlying cause (e.g. SLE, severe arteriosclerosis, hypertension) or complications of CRF (e.g. anaemia, bleeding diathesis, pericarditis).
Signs of CKD include increased skin pigmentation or excoriation, pallor, hypertension, postural hypotension, peripheral oedema, left ventricular hypertrophy, peripheral vascular disease, pleural effusions, peripheral neuropathy and restless legs syndrome.

Differential diagnosis

Acute renal failure:
- Making the distinction between acute renal failure and chronic renal failure can be very difficult. A history of chronic symptoms of fatigue, weight loss, anorexia, nocturia, and pruritus all suggest chronic kidney disease.
- The history and examination will provide clues, but renal ultrasound will provide the most important information. Renal abnormalities on ultrasound, such as small kidneys in chronic glomerulonephritis or large cystic kidneys in adult polycystic kidney disease, will almost always be present in patients with chronic kidney disease.
Acute on chronic renal failure: may have features indicating chronic kidney disease but also features suggesting a cause of an acute deterioration of renal function, e.g. infection.

Investigations

Investigations are focused on assessment of renal function and therefore stage of CKD, identification of the underlying cause and assessment of complications of CKD.

Assessment of renal function:
- Serum urea is a poor marker of renal function, because it varies significantly with hydration and diet, is not produced constantly and is reabsorbed by the kidney.
- Serum creatinine also has significant limitations. The level can remain within the normal range despite the loss of over 50% of renal function.
- A gold-standard measurement is an isotopic GFR, but this is expensive and not widely available.
- For most purposes in primary care, the best assessment or screening tool is the estimated glomerular filtration rate (eGFR).⁵ This uses the 4-variable Modification of Diet in Renal Disease (MDRD) equation³ - see the record Assessing Kidney Function and the Estimated Glomerular Filtration Rate Calculator based on this equation. Most laboratories now provide an estimated GFR (eGFR) when requesting serum creatinine which should be used in preference to calculator above.
Biochemistry:
- Plasma glucose: to detect undiagnosed diabetes or assess diabetes control
- Serum sodium: usually normal, but may be low
- Serum potassium: raised
- Serum bicarbonate: low
- Serum albumin: hypoalbuminaemia in patients who are nephrotic and/or malnourished (low levels at the start of dialysis are associated with a poor prognosis)
- Serum calcium: may be normal, low or high
- Serum phosphate: usually high
- Serum alkaline phosphatase: raised when bone disease develops
- Serum parathyroid hormone: rises progressively with declining renal function
- Serum cholesterol and triglycerides: dyslipidaemia is common
Haematology:
- Normochromic normocytic anaemia; haemoglobin falls with progressive renal failure.
- White cells and platelets are usually normal.
Serology:
- Autoantibodies, particularly antinuclear antibodies, C-ANCA, P-ANCA, anti-glomerular basement membrane antibodies (very suggestive of underlying Goodpasture's syndrome) and serum complement.
- Hepatitis serology: ensure not infected and vaccinate against hepatitis B.
- HIV serology: performed before dialysis or transplantation.
Urine:
- Urinalysis: dipstick proteinuria may suggest glomerular or tubulointerstitial disease. Urine sediment with red blood cells and red blood cell casts suggests proliferative glomerulonephritis.
- Pyuria and/or white cell casts suggest interstitial nephritis (especially if eosinophils are present in the urine) or urinary tract infection.
- Spot urine collection for total protein:creatinine ratio allows reliable estimation of total 24-hour urinary protein excretion. The degree of proteinuria correlates with the rate of progression of the underlying kidney disease and is the most reliable prognostic factor in chronic renal failure.
- Twenty-four-hour urine collection for total protein and creatinine clearance.
- Serum and urine protein electrophoresis: to screen for a monoclonal protein possibly representing multiple myeloma.
ECG and echocardiography: to detect left ventricular hypertrophy and ischaemia, and to assess cardiac function.
Imaging of the renal tract:
- Plain abdominal x-ray: may show radio-opaque stones or nephrocalcinosis.
- Intravenous pyelogram: not often used because of potential for contrast nephropathy.
- Renal ultrasound:
  - Small echogenic kidneys are seen in advanced renal failure.
  - Kidneys are usually initially large and then become normal in size in advanced diabetic nephropathy.
  - Structural abnormalities may be seen, e.g. polycystic kidneys.
  - Also used to screen for hydronephrosis caused by urinary tract obstruction, or involvement of the retroperitoneum with fibrosis, tumour or diffuse adenopathy.
- Retrograde pyelogram: may be indicated if clinical suspicion of obstruction despite a negative ultrasound study finding.
- Renal radionuclide scan:
  - Useful to screen for renal artery stenosis when performed with captopril administration but is unreliable for GFR of less than 30 ml/minute.
  - Also quantifies differential renal contribution to total glomerular filtration rate.
- CT scan: to better define renal masses and cysts seen on ultrasound; is the most sensitive test for identifying renal stones.
- MRI:
  - For patients who require a CT scan but who cannot receive intravenous contrast.
  - Like CT scan and renal venography, it is reliable in the diagnosis of renal vein thrombosis.
  - Magnetic resonance angiography is also useful for diagnosis of renal artery stenosis, although renal arteriography remains the investigation of choice.
- Micturating cystourethrogram: for diagnosis of vesicoureteric reflux.
Renal biopsy

Criteria for referral to specialist services³

Estimated GFR less than 15 ml/min/1.73 m²: immediate referral
Estimated GFR 15-29 ml/min/1.73 m²: urgent referral (routine referral if known to be stable)
Estimated GFR 30-59 ml/min/1.73 m²: routine referral if:
- Progressive fall in GFR/increase in serum creatinine
- Microscopic haematuria present
- Urinary protein to creatinine ratio greater than 45 mg/mmol
- Unexplained anaemia (Hb below 11 g/dl); abnormal potassium, calcium or phosphate
- Suspected systemic illness, eg SLE
- Uncontrolled BP (above 150/90 mmHg on 3 antihypertensive medications)
Estimated GFR 60-89 ml/min/1.73 m²: referral not required unless other problems present
Renal problems irrespective of GFR
- Immediate referral for:
  - Malignant hypertension
  - Hyperkalaemia (potassium >7.0 mmol/l)
- Urgent referral for:
  - Proteinuria with oedema and low serum albumin (nephrotic syndrome)
- Routine referral for:
  - Dipstick proteinuria present and urine protein:creatinine ratio above 100 mg/mmol
  - Dipstick proteinuria and microscopic haematuria present
  - Macroscopic haematuria but urological tests negative

Management

Issues that should be discussed with the patient⁶

Many patients equate kidney disease with renal dialysis. It is important to explain that CKD a spectrum of disease. Mild CKD is common and rarely progresses to a more severe form later.
Explain eGFR and that this will need to be monitored on a regular basis to ensure that the condition is not deteriorating.
If relevant discuss the link between hypertension and CKD and that maintaining tight blood pressure control can limit the damage to the kidneys.
Discuss the link between CKD and an increased risk of developing cardiovascular disease.

In newly diagnosed with eGFR less than 60 ml/min/1.73 m²

Review all previous measurements of serum creatinine to estimate GFR and assess rate of deterioration.
Review all medication including over the counter drugs; particularly consider recent additions (e.g. diuretics, NSAIDs, or any drug capable of causing interstitial nephritis, such as penicillins, cephalosporins, mesalazine, diuretics).
Urinalysis: haematuria and proteinuria suggest glomerulonephritis, which may progress rapidly.
Clinical assessment: e.g. look for sepsis, heart failure, hypovolaemia, palpable bladder.
Repeat serum creatinine measurement within 5 days to exclude rapid progression.
Check criteria for referral (above). If referral not indicated, ensure entry into a chronic disease management register and programme.

All stages of CKD³

Regular measurements of kidney function and other laboratory tests depending on the severity of kidney impairment.
General health advice: smoking cessation, weight loss, aerobic exercise, limiting alcohol intake, limiting sodium intake.
Avoidance of nephrotoxins, e.g. IV radiocontrast agents, NSAIDs, aminoglycosides.
Cardiovascular prophylaxis:
- For patients with 10 year risk of cardiovascular disease of greater than 20%, consider aspirin treatment (if BP is below 150/90 mmHg) and lipid-lowering drug therapy.
- Blood pressure monitoring: blood pressure should be measured at least annually.
- Control of hypertension: hypertension should be tightly controlled. The threshold for initiation of anti-hypertensive medication:
  - If urine protein/creatinine ratio (PCR) is below 100 mg/mmol: threshold 140/90 mmHg, target 130/80 mmHg.
  - If urine PCR is above 100 mg/mmol: threshold 130/80 mmHg, target 125/75 mmHg.
ACE inhibitor or angiotensin receptor blocker to be started:
- If urine PCR is above 100 mg/mmol.
- In diabetic patients with micro-albuminuria.
- Serum creatinine and potassium should be checked before starting medication, two weeks after starting, and after subsequent increases in dose. If creatinine increases by more than 20% or fall in GFR of more than 15%, repeat creatinine, check potassium and refer for specialist opinion on whether to stop treatment or to investigate for renal artery stenosis.
- If hyperkalaemia is present (serum K above 6 mmol/l): stop relevant drugs, eg. NSAIDs and potassium-retaining diuretics; check diet and proprietary treatments, e.g. LoSalt. If hyperkalaemia persists the ACE or ARB should be stopped.

Additional management for CKD stage 3 includes³

Annual measurement of haemoglobin, potassium, calcium and phosphate.
If Hb below 11 g/dl and other causes excluded, treat with erythropoiesis stimulating agents to maintain Hb 11-12 g/dl depending on the patient's functional needs.
Request renal ultrasound in patients with lower urinary tract symptoms, refractory hypertension, unexpected progressive fall in GFR.
Immunise against influenza and pneumococcus.
Review all prescribed medication regularly to ensure appropriate doses.
Avoid nephrotoxic drugs including NSAIDs wherever possible.
Check parathyroid hormone concentration when Stage 3 is first diagnosed: if raised, check serum 25-hydroxyvitamin D and if low, treat with ergocalciferol or cholecalciferol with calcium supplement (not calcium phosphate). Repeat PTH after 3 months and refer if still raised.

Additional management for CKD Stages 4-5 includes³

Care of all patients with stage 4 or 5 CKD should be discussed formally with a nephrologist even if it is not anticipated that renal replacement therapy will be appropriate. Exceptions may include:
- Patients with another terminal illness.
- Patients with stable function in whom all the appropriate investigations and management interventions have been performed and who have an agreed and understood care pathway.
- Patients in whom further investigation and management is clearly inappropriate.
3-monthly tests: serum creatinine (for eGFR), Hb, calcium, phosphate, bicarbonate, parathyroid hormone.
Dietary assessment.
Immunisation against hepatitis B.
Investigation and treatment of phosphate retention and hyperparathyroidism.
Correction of acidosis.
Timely provision of dialysis access depending on treatment choice.

Renal replacement therapy

Indications for renal replacement therapy (haemodialysis, peritoneal dialysis, chronic ambulatory peritoneal dialysis or renal transplantation) include:

Serum creatinine greater than 500 mmol/l.
Symptoms: pericarditis, encephalopathy, peripheral neuropathy, intractable gastrointestinal symptoms, failure to thrive and malnutrition.
Severe metabolic acidosis: bicarbonate less than 12 mmol/L.

Complications

Anaemia: left ventricular hypertrophy, fatigue, impaired cognitive functioning
Coagulopathy
Hypertension: left ventricular hypertrophy, heart failure, stroke, cardiovascular disease
Calcium phosphate loading: cardiovascular and cerebrovascular disease, arthropathy, soft tissue calcification
Renal osteodystrophy: disorders of calcium, phosphorus and bone, most commonly osteitis fibrosa cystica
Bone changes of secondary hyperparathyroidism: bone pain and fractures
Neurological: uraemic encephalopathy, neuropathy including peripheral neuropathy
Dialysis amyloid: bone pain, arthropathy, carpal tunnel syndrome
Fluid overload: pulmonary oedema, hypertension
Malnutrition: increased morbidity and mortality, infections, poor wound healing
Glucose intolerance due to peripheral insulin resistance

Management of complications

Water and electrolyte balance:
- Patients with chronic kidney disease pass normal volumes of urine. Precise restriction of fluid intake is only required for patients with oliguric end-stage renal failure. The usual recommendation is for a daily intake of daily urinary output plus 500 ml (for insensible losses).
- Patients should avoid binge drinking and be vigilant in replacing extra fluid losses in hot weather and during episodes of diarrhoea or vomiting.
- Severe acute volume overload may require high dose loop diuretics or dialysis.
- Dietary restriction to 60 mmol/day each of sodium and potassium is appropriate but compliance is greatly improved with sensible and flexible dietary advice.
- Loop diuretics (with the addition of a thiazide diuretic if resistant) improve sodium balance and blood pressure.
- Hyperkalaemia is treated with dialysis if the potassium level rises above 7 mmol/L. Otherwise treatment is directed towards the cause, e.g. excess fruit, chocolate or coffee, gastrointestinal haemorrhage, acidosis or tissue necrosis. Hyperkalaemia with the GFR still above 10 ml/min may be due to hyporeninaemic hypoaldosteronism in patients with diabetes, hypoadrenalism or as a result of treatment with ACE inhibitors.
Anaemia:
- Erythropoietin is given with iron. The serum ferritin is monitored throughout treatment and iron is stopped if the ferritin level becomes too high, e.g. above 500 mcg/L.
- Early erythropoietin therapy may prevent left ventricular hypertrophy.
- The timing for initiation of treatment remains uncertain. The haemoglobin level is usually maintained at or above 11 g/dl.
Acidosis:
- Chronic acidosis aggravates hyperkalaemia, inhibits protein synthesis and accelerates calcium loss from bone.
- Treated with sodium bicarbonate as long as the patient can tolerate the increased sodium load as additional sodium may cause fluid overload and worsen hypertension.
Hyperphosphatemia:
- Occurs late in chronic kidney disease.
- Treated with dietary restriction, dietary phosphate binders and calcium carbonate.
Hypocalcaemia:
- Prescribe calcium supplements, with or without calcitriol.
Hyperparathyroidism:
- Reduce hyperphosphataemia by diet and phosphate binders.
- Prescribe 1,25-dihydroxycholecalciferol and maintain a normal calcium level.
- Secondary hyperparathyroidism starts early in chronic renal failure and is difficult to treat when it becomes established.
- Secondary hyperparathyroidism may lead to tertiary hyperparathyroidism if not treated effectively.
Malnutrition:
- Must be avoided, although protein restriction can slow progression of renal failure.
- Restriction of dietary protein slows the progress of glomerulosclerosis in residual nephrons in animal experimental models.
- There remains controversy as to the benefits of protein restriction for treatment. Although patients are advised against high-protein diets, low-protein diets are not usually recommended and the emphasis is to maintain good nutrition.

Prognosis

Much of the damage caused by chronic kidney disease occurs early, when interventions may be much more effective.
Patients with chronic kidney disease usually progress to end-stage renal disease. The rate of progression depends on the underlying diagnosis, on the successful implementation of secondary preventative measures, and on the individual patient.
Patients on chronic dialysis have a high incidence of morbidity and mortality. Patients with ESRD (end-stage renal disease) who undergo renal transplantation survive longer than those on chronic dialysis.
Cardiovascular disease is the most common cause of death in patients with chronic kidney disease. Cardiovascular mortality is doubled in patients with a GFR below 70 ml/minute.

Prevention

Early diagnosis and good control of potential causes, e.g. diabetes, hypertension and urinary tract obstruction.

Quality and Outcome Framework

Chronic kidney disease was included in the Quality and Outcome Framework of the GP Contract in April 2006.
The following indicators were added:

Records
- CKD1: The practice can produce a register of patients aged 18 years and over with CKD (US National Kidney Foundation: Stage 3 to 5 CKD).
Initial Management
- CKD2: The percentage of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months.
Ongoing Management
- CKD3: The percentage of patients on the CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 mmHg or less
- CKD4: The percentage of patients on the CKD register with hypertension who are treated with an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded).

Much of the rational for these indicators is enshrined in Part Two of the National Service Framework for Renal Services - Chronic Kidney Disease, Acute Renal Failure and End of Life Care.²

Document references

Royal College of General Practitioners; Introducing eGFR- Promoting good CKD management
Department of Health Feb 2005; National Service Framework for Renal Services - Part Two: Chronic kidney disease, acute renal failure and end of life care
The Renal Association; UK Guidelines for the management of Chronic Kidney Disease. June 2005.
Levey AS, Bosch JP, Lewis JB, et al; A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999 Mar 16;130(6):461-70. [abstract]
More about eGFR; UK CKD Guide Renal Association 2007
Mitra PK, Tasker PR, Ell MS; Chronic kidney disease. BMJ. 2007 Jun 16;334(7606):1273.

Source : http://www.patient.co.uk/showdoc/40025274/

WHO Issues Patient Care Checklist for Influenza A (H1N1)

2009-07-11T14:37:00.000+07:00

The World Health Organization (WHO) has developed a new patient care checklist for hospital staff worldwide to use when treating suspected or confirmed cases of influenza A (H1N1). It is not intended to be comprehensive or to replace routine care or clinical judgment, but all hospitals are encouraged to use the checklist and to modify it as appropriate for their local practice setting.

"The WHO Patient Care Checklist: new influenza A (H1N1) is intended for use by hospital staff treating a patient with a medically suspected or confirmed case of new influenza A (H1N1)," the checklist document states. "This checklist combines two aspects of care: i) clinical management of the individual patient and ii) infection control measures to limit the spread of new influenza A (H1N1)."

Some specific recommendations:

When the patient arrives at triage, those with flu-like symptoms should be directed to a designated waiting area and given instruction and educational materials regarding respiratory hygiene and cough etiquette (cover mouth and nose with a tissue when coughing or sneezing, discard tissue in a bin with a lid, and then clean hands). Patients who can tolerate it should wear a medical or surgical mask, which should also be worn during patient transport and transfer.
When the patient is first evaluated, respiratory rate should be recorded for 1 full minute, as well as oxygen saturation when available. Senior care staff should be notified and consulted if respiratory rate is high or oxygen saturation is under 90%. History should document flu-like symptoms, date of onset, travel, exposure to persons with flu-like symptoms, and comorbid conditions, and alternative or additional diagnoses should be considered.
Specialized diagnostic tests, such as reverse transcriptase polymerase chain reaction, may be indicated. When taking respiratory samples, healthcare personnel should wear a medical or surgical mask, eye protection, and gloves. Specimens should be correctly labeled and sent with biohazard precautions in compliance with local regulations. Suspected cases of H1N1 infection should be reported to the local authorities.
Before the patient arrives at the isolation room or cohort, restricted entry and infection control signs should be posted. When available, dedicated patient equipment should be provided. Patients in the cohort area should be separated by at least 1 meter (3.3 feet). The local hospital protocol should be implemented for frequent linen and surface cleaning.
Before a healthcare staff member or visitor enters an isolation room or cohort, they should put on a medical or surgical mask and clean their hands by hand rubbing with an alcohol-based hand rub formulation (preferred unless hands are visibly soiled) or by hand washing with soap and water.
Before any exposure to a patient with known or suspected H1N1 influenza infection, healthcare staff should don a medical or surgical mask and clean their hands. When there is risk for exposure to body fluids or splashes, eye protection, gown, and gloves should also be worn. Personal or dedicated patient equipment should be cleaned and disinfected. Between patients, staff should change their gloves and clean their hands.
When aerosol-generating procedures, such as intubation, bronchoscopy, cardiopulmonary resuscitation, or suctioning are being performed, only those staff essential to the procedure should be allowed access. The procedure should be done in an adequately ventilated room. A gown, particulate respirator (if available; eg, EU FFP2, US NIOSH-certified N95), eye protection, and gloves should be worn.
Before a healthcare staff member or visitor leaves an isolation room or cohort, they should remove their gloves, gown, mask, eye protection, and any other personal protective equipment and discard disposable supplies according to hospital protocol. Hands should be cleaned, and dedicated patient equipment and personal equipment used by the patient should be cleaned and disinfected. Viral-contaminated waste should be disposed of as clinical waste.
Alternative or additional diagnoses should be considered in patients with known or suspected H1N1 infection.
Supportive treatment for patients with H1N1 infection should be similar to that for any influenza patient. Supplemental oxygen should be given as needed to maintain oxygen saturation above 90%, as well as to patients with increased respiratory rate if monitoring oxygen saturation is not feasible. For patients younger than 18 years, paracetamol or acetaminophen is recommended as an antipyretic. Patients with evidence of pneumonia or secondary bacterial infection should receive appropriate antibiotics. Use of the antiviral drugs oseltamivir or zanamivir should be considered after weighing contraindications and potential drug interactions.
Before a patient with a confirmed or suspected case of H1N1 influenza infection is discharged from hospital, the patient and/or caregiver should be educated and given materials regarding respiratory hygiene and cough etiquette and counseled regarding home isolation, infection control, and limiting social contact. Patient contact information should be recorded.
After discharge, dedicated patient equipment should be discarded or cleaned and disinfected according to the hospital protocol, linen should be changed and laundered without shaking, surfaces should be cleaned according to the hospital per local protocol, and viral-contaminated waste should be disposed of as clinical waste.

"Staff can use this checklist in a variety of ways — ticking the boxes is optional," the WHO document states. "The objective is to ensure that no critical patient care items are missed during or immediately following care. The checklist can be used as part of the patient's clinical record; reproduced as wall posters for hospitals or clinics; or printed up as cards for staff members to carry around with them."

The checklist is currently being assessed and updated to improve usability, and WHO plans to post the updated version on its Web site.

Source : http://www.medscape.com/viewarticle/705527?src=mpnews&spon=34&uac=133298AG

High-Dose Intravenous Esomeprazole May Reduce Recurrent Peptic Ulcer Bleeding

2009-07-07T03:07:00.000+07:00

High-dose intravenous esomeprazole given after successful endoscopic therapy may reduce recurrent bleeding in high-risk patients with peptic ulcer, according to the results of a randomized controlled trial reported in the February 17 Online First issue of the Annals of Internal Medicine.

"Use of proton-pump inhibitors in the management of peptic ulcer bleeding is controversial because of discrepant results reported in different ethnic groups," write Joseph J.Y. Sung, MD, from the Chinese University of Hong Kong in China, and colleagues from the Peptic Ulcer Bleed Study Group. "Profound and sustained acid suppression, as achieved with high-dose intravenous proton-pump inhibitors (PPIs), is thought to improve outcomes by clot stabilization at higher gastric pH."

The goal of this study was to determine whether intravenous esomeprazole was more effective than placebo at preventing recurrent peptic ulcer bleeding in a multiethnic patient sample.

Between October 2005 and December 2007, patients 18 years or older with peptic ulcer bleeding were enrolled from 91 hospital emergency departments in 16 countries. Participants had bleeding from a single gastric or duodenal ulcer with high-risk stigmata, and all had successful endoscopic hemostasis before randomization. Participants, clinicians, and investigators were blinded as to group assignment.

Through computer-generated randomization, participants were assigned to receive either esomeprazole, 80-mg intravenous bolus followed by 8-mg/hour infusion for 72 hours, or matching placebo. After infusion, patients in both groups were given oral esomeprazole, 40 mg/day, for 27 days. The main outcome of the study was rate of clinically significant recurrent bleeding within 72 hours, and other outcomes were recurrent bleeding within 7 and 30 days, death, surgery, endoscopic re-treatment, blood transfusions, hospitalization, and safety.

Of 767 participants who were randomly assigned, data were available for an intent-to-treat analysis in 764, of whom 375 were in the esomeprazole group and 389 in the placebo group.

Recurrent bleeding within 72 hours occurred in 22 of 375 patients receiving intravenous esomeprazole vs 40 of 389 receiving placebo (5.9% vs 10.3%; 95% confidence interval [CI] of difference, 0.6% - 8.3%; P = .026). At 7 days and 30 days, the difference in bleeding recurrence was still significant (P = .010).

Endoscopic re-treatment was significantly less in the esomeprazole group (6.4% vs 11.6%; 95% CI of difference, 1.1% - 9.2%; P = .012). Compared with placebo, there was also a nonsignificant trend for lower rates of surgery (2.7% vs 5.4%) and all-cause mortality (0.8% vs 2.1%).

In both groups, serious adverse events (AEs) were reported in approximately 10% and nonserious AEs in approximately 40% of patients.

"High-dose intravenous esomeprazole given after successful endoscopic therapy to patients with high-risk peptic ulcer bleeding reduced recurrent bleeding at 72 hours and had sustained clinical benefits for up to 30 days," the study authors write. "This was accompanied by a reduction in endoscopic re-treatment, blood transfusions, and hospital stays because of recurrent bleeding in the esomeprazole group compared with the placebo group."

Limitations of this study include endoscopic therapy not completely standardized; some patients receiving epinephrine injection, thermal coagulation, or hemoclips alone, whereas others receiving combination therapy; slight baseline imbalance with fewer Forrest class Ia ulcers in the esomeprazole group; and insufficient power to detect differences in low mortality rates.

"We believe that this is the first international trial to provide high-quality evidence supporting the use of high-dose intravenous esomeprazole as adjuvant therapy to endoscopic therapy for patients with high-risk endoscopic lesions and peptic ulcer bleeding in a predominantly Caucasian population," the study authors conclude. "In our view, the data indicate that the efficacy of PPIs [proton pump inhibitors] in preventing recurrent peptic ulcer bleeding is not race-specific and should be universally applied."

Medscape obtained independent commentary on this study from Akihiro Tajima, MD, PhD (assistant professor), Tadahito Shimada, MD, PhD (associate professor), and Hideyuki Hiraishi, MD,, PhD (chief and professor), all from the Department of Gastroenterology, Dokkyo Medical University in Mibu, Tochigi, Japan.

They told Medscape that the results suggest that early treatment within the first 3 days is important for ulcer cure but that various methods for endoscopic hemostasis might have some different effects on ulcer healing in the esomeprazole and placebo groups.

"Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding would reduce unnecessary repeated endoscopy," they said. "Infusion-site reactions were more common in the esomeprazole group. Dose reduction might be considered in the continuous infusion phase."

Regarding future research, they suggest that regular-dose esomeprazole, instead of placebo, should be used as a control therapy to show the actual effect of high-dose esomeprazole on the reduction of recurrent bleeding.

"The effect of esomeprazole upon peptic ulcer may be different among several races," they said. "Fibrosis around ulcer scars might be obvious in repeated peptic ulcers, suggesting some difficulties in endoscopic hemostasis. From at least these two viewpoints, tailor made therapy, such as a different dose of esomeprazole, for peptic ulcers needs to be [tested with] additional research."

Source : http://www.medscape.com/viewarticle/588961

ASMBS 2009: Elderly Obese Patients Benefit From Weight Loss Surgery

2009-07-05T00:28:00.000+07:00

Patients who are older than 65 years fare no differently from their younger counterparts after weight loss surgery, suggesting older age is not a risk factor for complications or mortality in bariatric surgery, a study presented here at the American Society for Metabolic and Bariatric Surgery 26th Annual Meeting shows.

The findings refute previous data that indicated mortality was greater in the elderly after gastric bypass surgery, according to Joseph Kuhn, MD, director of clinical research, Department of Surgery, Baylor University Medical Center, Dallas, Texas.

"A few reports that were released years ago had shown a higher mortality rate occurring with this surgery in patients over 65 [years old]," explained Dr. Kuhn, the study's principal investigator. "Most of those procedures were open gastric bypass surgeries...only a smattering of them were laparoscop[ic], and most of those were in the learning curve. Modern programs in laparoscopic surgery mean most patients go home the very next day, even with patients who are older than 65."

Dr. Kuhn and coinvestigators prospectively followed 1753 patients who underwent bariatric surgery between January 2005 and July 2008 at their center and who had at least 6 weeks of postoperative follow-up data.

There were 153 patients who were older than 65 years. They had a less favorable operative risk profile compared with 1600 younger patients who also were followed up. Specifically, older patients had an increased incidence of sleep apnea (46% vs 33%), diabetes mellitus (62% vs 31%), and hypertension (83% vs 57%). The older patients ranged in age from 65 to 77 years and had a mean body mass index of 45 kg/m², whereas younger patients ranged in age from 18 to 64 years and had a mean body mass index of 47 kg/m².

Despite their poorer health status, operative outcomes for patients older than 65 years were similar to those for patients younger than 65 years. Operative time was 70 minutes vs 65 minutes, length of stay was 1.6 days vs 1.3 days, and the 30-day readmission rate was 5.2% vs 7.0%.

Furthermore, complication rates did not significantly differ between older and younger patients. Among seniors, there was postoperative bleeding in 0.6% of patients, pulmonary complications in 1.9%, cardiac complications in 1.9%, wound complications in 1.9%, and stricture complications in 1.2%; there were no deaths.

The percentage of excess body weight loss (% EBWL) in patients who had gastric bypass surgery was not significantly different between the older and younger patients at 12 months (60.4% EBWL vs 71.9% EBWL).

Among patients who had undergone gastric banding, there was comparable weight loss in older and younger patients at the 12-month mark (29.9% EBWL vs 35.8% EBWL) and at the 24-month mark (45.3% EBWL vs 33.4% EBWL).

"In contrast to the countless operations that are performed on patients over the age of 65 [years —] like hip replacements, various kinds of cancer surgeries, liver and lung resections — typically as surgeons we don't hesitate for a second in performing those operations," said Dr. Kuhn.

"One of the obstacles is the anxiety of [perceived] risk," said Dr. Kuhn. "The patients are definitely in need of about 100 pounds of weight loss. They are sicker, with more comorbid problems."

Bruce Wolfe, MD, FACS, a member of the executive council of the American Society for Metabolic and Bariatric Surgery and a professor of surgery at Oregon Health and Science University in Portland, concurred that advancing age had been identified as a risk factor for adverse outcomes following gastric bypass surgery and other bariatric procedures in older analyses.

"The notion that the surgery should be performed infrequently, if at all, in progressively older, severely obese patients has had some basis," said Dr. Wolfe. "What is important is that we look at the current status of surgery. There have been a number of improvements reported overall in the outcomes of bariatric surgery in various databases that have not found advancing age [to be a risk factor for adverse outcome after the mid-60s]."

The study's findings show that discouraging the surgery in patients who are not much older than 65 years needs to be reexamined, said Dr. Wolfe, noting that a limitation of the study was that the oldest patient in the study was aged 77 years.

"[Surgery in patients] who are just older than 65 was shown to be safe, but the safety of patients in their late 70s was not addressed," he said.

Dr. Kuhn has disclosed no relevant financial relationships. Dr. Wolfe is a consultant for Ethicon Endo-Surger Inc and Allergan Inc and is an investigator for EnteroMedics Inc.

American Society for Metabolic and Bariatric Surgery (ASMBS) 26th Annual Meeting: Abstract PL-207. Presented June 25, 2009.

Source : http://www.medscape.com/viewarticle/705055?src=mpnews

Vasopressin and Epinephrine vs. Epinephrine Alone in Cardiopulmonary Resuscitation

2009-07-02T01:28:00.000+07:00

Description

The goal of the trial was to evaluate treatment with vasopressin and epinephrine compared with epinephrine alone among patients with an out-of-hospital cardiac arrest.

Hypothesis

Vasopressin and epinephrine will be more effective in improving survival.

Drugs/Procedures Used

Patients with cardiac arrest were randomized to 40 IU vasopressin and 1 mg epinephrine (n =1,442) versus placebo and 1 mg epinephrine (n = 1,452). Study drugs were re-administered if there was no return in spontaneous circulation within 3 minutes. Defibrillation was attempted up to 3 times before randomization among patients who presented with ventricular fibrillation (VF).

Principal Findings

Overall, 2,956 patients underwent randomization. There were 62 patients excluded after randomization: 26 did not provide informed consent, 29 had traumatic cardiac arrest, and 7 did not meet other inclusion criteria. Baseline characteristics were well-matched, except that there were more men in the vasopressin and epinephrine group (75.4% vs. 71.7%, p = 0.03). The initial cardiac rhythm was VF in 9.2% versus 9.3%, pulseless electrical activity in 7.7% versus 8.3%, and asystole in 83.1% versus 82.4%, respectively. The time to arrival of emergency medical technicians was 7.2 minutes versus 6.8 minutes, and the total duration of advanced cardiac life support was 38.0 minutes versus 37.6 minutes, respectively.

The primary outcome, survival to hospital admission, occurred in 20.7% of the combination treatment group compared with 21.3% of the epinephrine alone group (p = 0.69). Return of spontaneous circulation occurred in 28.6% versus 29.5% (p = 0.62), survival to hospital discharge occurred in 1.7% versus 2.3% (p = 0.24), 1-year survival occurred in 1.3% versus 2.1% (p = 0.09), and good neurological recovery at hospital discharge occurred in 37.5% versus 51.5% (p = 0.29), respectively, for combination treatment versus epinephrine alone. Among patients who presented with pulseless electrical activity, survival to hospital discharge was 0% versus 5.8% (p = 0.02), respectively. There was no difference in this outcome among patients with VF or asystole.

Interpretation

The prognosis among patients who suffer an out-of-hospital cardiac arrest, especially asystole, remains grim. The combination of vasopressin and epinephrine is not superior to epinephrine alone in improving clinical outcomes. Specifically, there was no difference in survival to hospital admission or discharge, return in spontaneous circulation, good neurological recovery, or 1-year survival between the treatment groups. The finding of decreased survival to hospital discharge among the combination treatment group should only be considered hypothesis generating.

Conditions

Arrhythmias / Ventricular fibrillation

Therapies

Medical

Study Design

Randomized. Blinded. Parallel. Stratified.

Patients Enrolled: 2,956

Mean Follow-Up: 1 year

Mean Patient Age: 62 years

% Female: 27

Primary Endpoints

Survival to hospital admission. Survival was defined as a palpable pulse and measurable blood pressure upon arrival to an intensive care unit.

Secondary Endpoints

Return of spontaneous circulation

Survival to hospital discharge

Good neurological recovery

Survival at 1 year

Patient Population

Adult patients with a cardiac arrest due to VF, pulseless electrical activity, or asystole

Exclusions:

Age less than 18 years

Successful defibrillation without the need for vasopressor therapy

Traumatic cardiac arrest

Known pregnancy

Documented terminal illness

Do-not-resuscitate order

Sign of an irreversible cardiac arrest

Source : http://www.medscape.com/viewarticle/582270

Recession-Related Surge in Nursing Employment Just a Blip, Study Cautions

2009-06-25T11:18:00.000+07:00

The worst economic recession in the post–World War II era has shed jobs across almost all industrial sectors, pushing the national unemployment rate close to 10%. Yet for one group in the slowing but still robust healthcare sector — hospital-based registered nurses (RNs) — the current economic downturn has led to a record employment spike, according to a study published online June 12 in Health Affairs.

However, this spike is only temporary, warns lead author Peter I. Buerhaus, PhD, RN, the Valere Potter Professor of Nursing at Vanderbilt University School of Nursing, Nashville, Tennessee. "We've eased the nursing shortage, but we haven't permanently ended it," Dr. Buerhaus told Medscape Nursing.

The history of such shortages, Dr. Buerhaus and the study coauthors write, is inversely related to the general health of the economy: RNs are in short supply during boom periods and are available to fill vacancies when the economy is spiraling down.

In 2001, 3 years after hospitals began reporting difficulty filling vacancies, RN shortages peaked. With vacancy rates reaching a national average of 13%, an estimated 126,000 full-time-equivalent (FTE) RN positions went unfilled, forcing "many hospitals to close nursing units and restrict operations."

The 2001 recession altered this trend. Faced with a bad economy and the prospect of reduced family income, nurses already in the workforce increased their hours, and those who had left it returned, in part to take advantage of the substantially higher RN wages that hospitals began offering in 2002. The exigencies of the recession, coupled with the lure of higher wages, worked like a magnet: During the next 2 years, hospital RN employment surged by 184,000 FTE RNs. "At the time, that was a world record — right off the charts," Dr. Buerhaus said.

But if hospital officials thought their nurse vacancy problems were solved, they were wrong. Once the economy recovered, the shortage problem reasserted itself. In fact, the annual growth in FTE RN employment between the economic boom years of 2004 and 2006 was −0.9%. It has taken this most recent recession, which some argue started as early as the final months of 2007, to reverse the nursing shortage problem yet again.

In 2007 and 2008, according to the study, hospital-based RN employment increased by an estimated 243,000 FTEs. As in the 2001 recession, bad economic times have pushed nurses back into the labor market, and for many of the same reasons as before. But the lure of higher wages is not among them; for the most part, said Dr. Buerhaus, hospitals did not increase RN wages in 2007 and 2008. That fact, he says, makes the dramatic surge in RN employment during this recession all that more surprising. "From our past studies, we knew the effect the recession would have. But we were completely stunned by the size of the increase. Looking back, there's simply no 2-year period of growth in the hospital employment sector that rivals this one."

For nurses fresh out of school, the influx of new hires has not always worked to their benefit. "Their ability to find the job of their dreams in the hospital down the street from where they live has probably changed," Cheryl Peterson, MSN, RN, director of Nursing Practice and Policy at the American Nursing Association, told Medscape Nursing. "We've also found that employers can be a little more selective these days, holding out for someone with more experience rather than hiring a recent graduate or someone with limited experience."

Despite the trend toward older, more experienced hires, however, younger nurses are by no means absent from the workforce. In 2008, for example, the number of FTE RNs aged 23 to 25 years — 130,000 — was the highest it has been in more than 2 decades, according to the study. In addition, in 2008 there was a large jump in the number of younger FTE nurses with children younger than 6 years, compared with in 2007 — a phenomenon the authors say is related to families' efforts to boost their incomes during hard economic times. Overall, in 2008, employment of RNs younger than 35 years increased by a dramatic 74,000, with most ending up in hospital-based jobs.

Getting a Handle on Looming Shortages

Given the oddly cyclical nature of nurse employment, however, few if any in the nursing community are sanguine about the recent employment surge. "We can't be lulled into thinking that the problem of a shortage is over," said Ms. Peterson.

Similar to past shortages, Dr. Buerhaus said, future ones will be driven by the interaction of supply and demand. On the demand side, he and his coauthors lean heavily on projections outlined by the federal Health Resources and Services Administration (HRSA). Noting that "changing demographics constitute a key determinant of projected demand for FTE RNs," HRSA points to the "much greater per capita healthcare needs" of an aging baby boom generation, the leading edge of which will approach age 65 years starting around 2010.

Dr. Buerhaus and coauthors also consider something likely to drive demand that HRSA does not — the prospect that healthcare reform will expand coverage to more citizens, thereby placing even greater pressure on the nursing workforce.

On the supply side of the equation, the authors say, the waves of baby boomer RNs retiring during the next decade will be significant. So too will be the prospective size of the successive cohorts that will replace them. Will these cohorts be large enough to keep the workforce from shrinking, and yet too small "to meet the projected demand"? If so, the authors say, a much older RN workforce than ever before may be left to do the heavy lifting.

Action Plan for Policymakers

The authors conclude by proposing a series of action steps for policymakers. They want to strengthen the current workforce and, in particular, to "improve the ergonomic environment of the clinical workplace" for older nurses. They want to improve communication skills, especially for RNs educated in other countries — a group that has not only helped to fuel the current surge but also is likely to play a significant role in future supply scenarios. Perhaps most notably, they want to see steps taken to expand the numbers of 2 "underrepresented" groups in nursing — men and Hispanics.

Representatives of each group are sympathetic, although they cite challenges.

"We're up against the historical image of men as doctors and women as nurses," Demetrius J. Porsche, DNS, RN, dean of the Louisiana State University Health Center School of Nursing and president of the American Assembly for Men in Nursing, told Medscape Nursing. Among the barriers to full participation that Dr. Porsche sees are unsupportive families, school counselors who "don't understand that nursing is an autonomous profession, not just a handmaiden to doctors," and too few public images of men in the profession. Each year, Dr. Porsche explained, the American Assembly for Men in Nursing presents a series of awards aimed at enhancing the status of men in nursing, including one for the best workplace and another for the best nursing school/college.

"The push for men in nursing is a diversity issue," he said. "The profession should be open and welcoming not only to all races and ethnicities but to both genders."

Anyone recruiting Hispanics to nursing also faces barriers, said Norma Martinez-Rogers, PhD, RN, FAAN, associate clinical professor in the Department of Family Nursing at the University of Texas Health Science Center, San Antonio, and president of the National Association of Hispanic Nurses.

The biggest barrier, Dr. Martinez-Rogers told Medscape Nursing, is money. Despite some funding, she said, "many Hispanic students end up having to pay back big loans." Then there's the work issue, she added. Used to holding down part-time jobs to make ends meet before entering nursing school, too many Hispanic students try, at their peril, to duplicate that work schedule once enrolled. "Nursing school is all about the application of the content that you're learning, which is very time consuming," Dr. Martinez-Rogers said. "Students can hold down part-time jobs, but they risk having to repeat a course."

Hoping for more funding and support for what she characterizes as "not a brand-new problem," Dr. Martinez-Rogers has been talking to the Congressional Hispanic Caucus about renewed efforts to bring more Hispanics into nursing. One step would be to work with universities — her own included — that have the potential, because of their location, to enroll significant numbers of Hispanic nursing students. Once enrolled, she said, such students need to be mentored while in school and encouraged after they graduate. Her own university has what she described as a "student-driven" mentorship program; for its part, the National Association of Hispanic Nurses is working to develop its own national mentorship program.

Dr. Buerhaus thinks that expanding the capacity of educational programs — for Hispanics, men, and anyone else interested in becoming a nurse — is key. So, too, he said, is turning out the "right" nurses: "Beyond all the rhetoric, we need the future nurse to be really, really sharp in the areas of both quality and safety."

The ANA's Cheryl Peterson agrees, but added that nursing education "can't change on a dime" and that employers must also do their part by giving the freshly minted nurse the necessary "space to learn."

Source : http://www.medscape.com/viewarticle/704668?sssdmh=dm1.488649&src=nldne

Administration of PRN Range Opioid Analgesic Orders for Acute Pain

2009-06-20T22:17:00.002+07:00

Abstract

The use of "as needed" or "pro re nata" (PRN) range opioid analgesic orders is a common clinical practice in the management of acute pain, designed to provide flexibility in dosing to meet an individual's unique needs. Range orders enable necessary adjustments in doses based on individual response to treatment. However, PRN range opioid orders have recently come under scrutiny as a source of confusion and as a medication management safety issue. How nurses administer range orders may vary based on their interpretation of the intent of an order, inadequate knowledge of analgesic titration, or exaggerated concerns about opioid safety. The purpose of this study was to investigate nurses' opinions of the appropriate implementation of range orders. Six hundred two nurses from one large academic medical center and one multihospital system completed an online survey using theoretic clinical vignettes to examine their opinions of appropriate analgesic administration practices. The majority of participants chose appropriate responses to the vignettes; however, there was a great deal of variability in responses. Those who had attended pain management courses were more likely to have a higher percentage of appropriate responses than those who had not attended courses. Years in practice and educational level were not significantly related to percentage of appropriate responses; however, there was a trend for nurses with a master's degree to have a higher percentage than nurses with other educational preparation. Consideration of opioid pharmacokinetics can provide logic to develop a new paradigm where range orders are replaced with orders that provide more explicit instructions to titrate an opioid to the most effective dose.

Introduction

Opioids are commonly used to manage moderate to severe acute pain. The amount of opioid required to manage pain is known to vary widely owing to inter- and intraindividual responses to pain and the available opioid analgesics. The use of "as needed" or "pro re nata" (PRN) range opioid analgesic orders is an age-old conventional practice in the management of acute pain, designed to provide flexibility and safety in dosing to meet an individual's unique needs. However, pain is often undertreated because physicians underprescribe opioid analgesics (order inappropriately low doses or prolonged dosing intervals) and nurses administer inadequate doses (give the lowest doses in a provided dose range despite indications that a higher dose is necessary) (Pasero, Portenoy, & McCaffery, 1999).

In 2001, the Joint Commission (JC) incorporated pain management standards into their survey and accreditation process as a means to stimulate improvements in the quality of pain care in the U.S. (Dahl & Gordon, 2002). Simultaneously, a series of national consensus meetings led by the Institute of Medicine fueled the development of a set of national patient safety goals (Chassin, Galvin, & National Roundtable on Healthcare Quality, 1998). Among these goals is a heightened focus on improved communication among caregivers and medication safety, including the use of opioids. The JC Medication Management standard (MM 3.20) states that medication orders are to be written clearly and transcribed accurately and that hospitals are responsible for taking steps to reduce the potential for error or misinterpretation. An important element of compliance with this standard is "there is a documented diagnosis, condition, or indication-for-use for each medication ordered," emphasizing the need for clear understanding and communication between staff (Joint Commission, 2007).

Following the release of the pain management standards and development of national patient safety goals, JC surveyors began inquiring into institutional policy and procedures surrounding the use of PRN range opioid orders. During accreditation reviews, surveyors encouraged detailing in range orders, such as the designation of specific dose or route of analgesia based on pain intensity ratings. The slogan of pain as the "fifth vital sign," originally developed to increase visibility of pain assessment in the clinical arena (APS, 1995), became misconstrued by some as an edict to treat to a target pain rating. With the encouragement of JC surveyors, many institutions developed policies that led to the development of PRN orders based solely on patient report of pain intensity indexed with a numeric scale. An example of this type of order is: "one tablet oxycodone 5 mg orally (PO) for pain less than or equal to 4/10 (scale 0-10); two tablets oxycodone 5 mg PO for pain 5 to 7/10; morphine 2 mg intravenous (IV) for pain 7-8/10; morphine 4 mg IV for pain greater than 8/10." Regrettably, this approach was soon linked to increased rates of significant adverse events (Taylor et al 2003, Vila et al 2005). In one setting (Vila et al., 2005), the incidence of opioid oversedation episodes per 100,000 inpatient hospital days increased from 11 before implementation of a numeric pain rating treatment algorithm to 24.5, a more than twofold increase (p < .001). Although practice guidelines recommend that the choice of analgesic be based on the severity of pain, the route and amount of medication must always be individualized (APS, 2003).

In response to questions and concerns by clinicians about the course of range order policies, the American Society for Pain Management Nursing, in collaboration with the American Pain Society (APS), developed a national consensus statement to support and clarify the use of PRN opioid analgesic range orders (Gordon, et al., 2004). To date, the APS nursing special interest group E-mail listserve, whose members have a special interest or specialize primarily in pain management nursing, (http://mailman.listserve.com/listmanager/listinfo/apsnursingsig) continues to reverberate with ongoing debate and questions about range order competencies and policies. There are at least two sources of common confusion for nurses about a PRN range order. The first is which dose to administer from within a range. The second is the total time interval during which the maximum dose may be administered. In other words, what dose is safe, effective, and within the prescribed parameters? Considerations for dosing have previously been described (Gordon et al., 2004) and include patient and drug characteristics, such as the patient's prior drug exposure, prior responses to analgesics, age, organ function, pain severity, anticipated pain duration, comorbid conditions, and concomitant drug use. The "total time interval" dilemma has also been described (Pasero, Manworren, & McCaffery, 2007). Some nurses may believe the time interval is defined by the time of the first dose, whereas other nurses may interpret the time period as starting from the most recent dose. The latter is referred to as the "rolling-clock" time interval (Pasero, Manworren, & McCaffery, 2007), whereby the time interval ordered serves as the limiting and pivotal guidepost; the maximum cumulative dose should not be exceeded in any block of the ordered time interval.

Management of acute pain, including the administration and titration of range opioid analgesic orders and patient monitoring, is a critical nursing responsibility. Identification of beliefs that result in variable administration of PRN range orders may further facilitate national recommendations about how to construct range orders that will improve patient safety and outcomes in pain management. The purpose of the present study was to document nurses' opinions of the appropriate implementation of a range order. The research questions were:

How much agreement is there among nurses about the administration (timing and dosing) of analgesics ordered with a PRN range order?
Do respondent characteristics (such as education, years of nursing experience, pain course attendance) affect knowledge and/or comfort in titration and vignette responses?
What factors do nurses consider when selecting a dose to administer from a range order?

Methods

The study was conducted at one 471-bed academic medical center in the Midwestern U.S. and a multihospital system with five operating units (2,102 total beds) located in a mid-Atlantic state. The study protocol was reviewed and given exemption status by the Institutional Review Boards at both sites. Data were collected from participants using a self-administered internet-based questionnaire that took approximately 10-15 minutes to complete. Risks were considered to be minimal, because data were aggregated via a security-protected public online survey service (http://www.vovici.com/). The internet protocol (IP) addresses were analyzed only in aggregate for the two participating sites; no connection was made between individuals and a computer's IP address or compliance. Participation in the study was voluntary. Respondent confidentiality was ensured throughout all stages of the study. No identifying information including age or gender was collected. All 611 licensed nurses at one site were individually contacted via e-mail with an invitation to participate in the study and were provided a link to enter the web-based survey. Because the second site did not provide individual nurses with email accounts, all nursing staff, totaling 3,323, were invited to participate via a notice posted on the health system home web page.

The questionnaire was developed by the authors and pretested among five staff nurses who completed the questions and then discussed the clarity of the specific items with the authors. The final 15-item questionnaire included items on the following: level of nursing education and practice experience; usual patient population and practice setting; special training, course, or certification in pain management; knowledge/comfort level of opioid titration; patient vignettes for determining timing and dose titration of IV and PO opioids; and the three most important factors to consider when selecting a dose to administer from within a range order. The vignettes are described in the Results section of this article.

Data Analysis

Descriptive statistics were run for respondent characteristics and answers to the vignettes. Each answer to the vignettes was then coded as appropriate (preferred) (given 1 point) or not appropriate (not preferred) (given 0 points). The majority of vignettes were constructed to elicit a response of the soonest next dose based on peak effect of the route administered or the amount of a next dose based on a percentage upward titration. Answers were deemed to be appropriate or preferred if the choice was a dose administered at the time or just after peak effect of the previous opioid dose or if the answer was a dose that had previously been effective or represented a 50%-100% dose titration of a previously ineffective dose. Because of the difficulty in constructing a brief vignette with one correct answer, all but one question had two to three answers that were scored as appropriate. A total score was calculated for each respondent by totaling the number of appropriate answers. In final analysis, the authors could not agree on the preferred response(s) for the dose question in the second vignette and decided to delete that item from the total score analysis (see Titration discussion). Therefore, total scores could range from 0 to 6. Comparisons of responses were used to determine if there were associations between respondent characteristics and responses to clinical vignettes using chi-squared and t tests.

Results

Respondent Characteristics

A total of 602 participants completed the on-line survey in July and August 2007. Response rate was 222 (36%) for the site with individual E-mails and 378 (11%) for the site with only a web page invitation; two respondents did not identify their site. Table 1 summarizes the respondents' characteristics. The largest number of participants was baccalaureate-prepared RNs (56%). The largest percentage (27%) had more than 25 years of experience in nursing. Most (90%) worked with adult patients, with 22% identifying themselves as working with pediatric patients. Medical, surgical, and intensive care units were the most frequent responses for current practice settings. Forty-three percent had previous special training or had attended a course in pain management; however, only nine (2%) held certification in pain management by the American Nurses Credentialing Center.

Although both sites had a policy or written protocol for PRN opioid range orders, when asked if they were aware of one at their facility, slightly fewer than one-half said "yes." Forty-one percent were unsure of the existence of a policy. Nurses were also asked to rate on a 0-10 scale (0 = extremely uncomfortable; 10 = extremely comfortable) their knowledge/comfort level on how to titrate opioids. Titrate was defined as "to determine the effective dose by giving graduated increases or decreases in the amount of a drug." The mean rating was 5.98 (standard deviation [SD] 2.66); however, there was a large amount of variability in responses.

Timing and Titration

Four vignettes were included in the survey ( Table 2 ) for the administration of IV and PO opioid analgesics regarding timing and/or titration of opioids. The first described a situation in which a patient had a fourfold PRN range order for IV morphine (2 to 8 mg every 2 h). Following a first dose of 2 mg at 14:00, respondents were asked to choose how soon another dose could be given. The appropriate answers were 14:15 or 14:30. Sixty-eight percent of the respondents chose one of these answers ( Table 2 ). Twenty-three percent, however, chose to wait the entire 2-hour time period before giving another dose. Respondents were then asked what dose should be given assuming there was no change in pain rating, pain was still severe, and there were no side effects. Seventy-two percent chose 3 mg or 4 mg, which were the preferred answers ( Table 2 ).

The patient described in the second vignette had the same range order (2 to 8 mg IV morphine every 2 h PRN) and had received 2 mg at 12:00 and 3 mg at 13:30 with no relief from either dose. This was followed by a 6 mg dose at 14:00. Sixty-five percent of the respondents chose to wait until 15:30 or 16:00 (which was the appropriate answers) before giving a next dose ( Table 2 ). Twenty-nine percent would have given a dose as early as 14:15 or 14:30. Although a rolling-clock time interval approach would indicate that there is still another 2 mg available in the range order maximum, a 2 mg dose at 14:15 or 14:30 was not preferred, because it was considered to be a previously ineffective dose. At the time of the next dose the patient was described as having reported satisfactory relief with the previous dose of 6 mg, but the pain has returned. The patient is drowsy and arousable, but drifts off to sleep during conversation. Respondents were asked what dose of morphine they would next administer. Nearly one-half (49%) of the respondents chose 4, 5, or 6 mg ( Table 2 ), however, 25% chose none (see Titration discussion). Of note, this item was not included in the total score, owing to author disagreement regarding interpretation of the meaning of the phrase "drowsy and arousable, but drifts off to sleep during conversation."

The third vignette asked participants what they would do if they thought the next dose given to a patient should be less than what was ordered. The order stated "morphine 4 to 8 mg IV every 2 h PRN." The patient had received several doses of 4 mg 2 h apart with "good" pain relief and "no" side effects. Just over one-half (56%) of the respondents said they would call an MD to get an order change, which was the preferred response; however, 22% said they would increase the time between doses (which was considered to be inappropriate), and 22% would give some amount less than what was ordered (which was considered to be inappropriate) ( Table 2 ).

The final vignette presented an order for an oral opioid (oxycodone 5 to 20 mg every 4 h PRN). The patient received 5 mg at 08:00, 10 mg at 09:00, and 5 mg at 11:00. Nurses' opinions were again elicited for the soonest time the next dose could be given and the amount of the next dose if the patient has no change in pain rating and is still in severe pain with no side effects. Fifty-two percent of the respondents chose to give the next dose at 12:00 (preferred) ( Table 2 ). Many (23%) chose to wait a full 4 hours after the last dose, which was given at 11:00, before giving the next dose. Appropriate doses (15 to 20 mg) were chosen by 54% of respondents ( Table 2 ).

If respondents selected an appropriate answer for all vignettes they were given a total score of 6. The average total score for all respondents was 3.64 (SD 1.11). (As mentioned, the dose question in the second vignette was not scored.)

Relationship of Respondent Characteristics and Comfort in Titration and Vignette Responses

Increased comfort level with titration was associated with increased years of experience in nursing (Figure 1).

Figure 1.

Years of experience and comfort in titrating opioids (0 =extremely uncomfortable to 10 = extremely comfortable). *Nurses with <5>25 years of experience (p < .05).

Those with <5>25. Special training or course attendance was also associated with higher titration comfort levels. Respondents that had special training or attended a pain course had significantly higher confidence levels, (6.71 [SD 2.47]) than those who did not (5.43 [SD 2.68]); t = 5.88; p < .001. Comfort level with titration was not associated with total score for preferred answers.

Interestingly, there were no significant differences in total score of appropriate responses by years of experience or education level (Figure 2).

Figure 2.

Years of experience and total score for preferred answers (6 = maximum score, meaning all vignettes were answered with an appropriate or preferred response).

All groups had similar scores. Although not significant, there was a trend for respondents with a master's degree to score higher than other groups. Associate and baccalaureate degree graduates were very similar, and those with licensed/vocational and doctoral preparation tended to score slightly lower. There were no differences in scores between respondents who had previous special training or attended a course in pain management and those who did not. Only nine people were certified in pain management, so comparisons were not meaningful.

Factors to Consider in Opioid Administration

The four factors that were most often chosen as the most important to consider when selecting an opioid dose to administer from a range order were, in order of frequency: sedation level, pain intensity rating, respiratory rate, and the patient's prior response to dosing (Figure 3).

(Enlarge Image)

Figure 3.

Respondents were asked to mark the three most important factors to consider when selecting a dose to administer from a range order.

Discussion

Timing

A variable pattern of PRN range order administration is often observed in clinical practice. A range order such as "oxycodone 5 to 20 mg as needed every 4 h" might be administered over 24 hours using incremental doses and varying dosing intervals within any defined 4-hour time period. Although acute pain may vary widely between rest and activity, one must question if a patient's analgesic needs and responses to doses vary in a manner that would require two- to fourfold variations in dosages within a short time period of several days, or if variable patterns of administration more accurately reflect nurses wide range of comfort and opinions of order limits and knowledge of opioid titration. The results of the present study would seem to confirm the latter.

It has been suggested (Pasero, Manworren, & McCaffery, 2007) that range orders could be designed similar to IV patient-controlled analgesia (PCA) to afford patients access to rapid administration when needed and minimize delays that can lead to worsened pain. Time to peak effect varies between opioids, ranging from 1 to 5 minutes for IV fentanyl, to 15 to 30 minutes for morphine and hydromorphone. With IV PCA therapy, the time interval or lockout period is set at 5 to 10 minutes for all opioids, allowing rapid maximum, yet safe, usage, because 80% of peak effect characteristically occurs within the first 5 minutes of bolus administration (Upton & Macintyre, 1997). The recommended hourly limit with IV PCA is three to five times the projected hourly requirement (APS, 2003). Thus it would seem rational to construct a PRN range IV opioid analgesic order in a manner that allows a nurse to repeat at least the same bolus dose at least every 15 minutes. Likewise, it would be reasonable to allow PRN doses of short-acting oral opioids as frequently as every hour. Onset of action of a short-acting oral opioid typically occurs within 45 minutes, with peak drug effect in 1 to 2 hours. It is therefore theoretically safe to provide a second dose at peak effect of a first dose of a short-acting opioid, provided the patient has unrelieved moderate to severe pain and there are minimal side effects.

Although the use of a "rolling-clock" time interval approach clarifies the timing of PRN orders and facilitates a more consistent interpretation of cumulative dosing, it may hamper needed titration. For example, given an order of oxycodone 5 to 20 mg every 4 h PRN, a patient who has received a dose of 10 mg that resulted in inadequate pain relief would need to wait a full 4 hours before receiving an appropriate increased dose of 15 mg. Although the rolling-clock method provides nurses with a more literal interpretation than alternative time-interval approaches, it is less focused on the pharmacokinetics and pharmacodynamics of the analgesic being administered.

Titration

Titrate means to determine the effective dose by giving graduated increases or decreases in the amount of the drug. The APS suggests that repeat IV boluses can be used to titrate to a plasma concentration that provides effective pain relief, e.g., morphine 0.03 mg/kg (e.g., approximately 2 mg in a 150-pound individual), or the equivalent dose of a similar opioid every 10 minutes until there is a 50% reduction in pain or the patient reports satisfactory relief (APS, 2003). The total loading dose required can then be considered to be an effective dose for analgesia and made available as a PRN IV bolus dose for subsequent doses (Harris, Kumar, & Rajagopal, 2003). Alternatively, it has been suggested that subsequent doses be increased if at the time of peak effect the patient has minimal pain relief with minimal or no side effects (Mercadante, 2007). Based on pharmacologic observations (Hanks, DeConno, Cherny, Hanna, Kalso, & McQuay, 2001), the next dose can be increased by 50% to 100% for moderate to severe pain and by 25% for more minor adjustments (Pasero et al., 1999). Similarly, oral opioid doses could be titrated as soon as every hour and the total dose required for pain control could then be made available as the PRN dose, or several graduated increased doses could be used to find the most effective dose. This would require a more lengthy order set or use of a pre-established protocol, as described elsewhere (Pasero et al., 2007). For example a one-time order reads: "Give 10 mg PO oxycodone now; if after 1 h pain is unrelieved and there are no side effects give 20 mg PO oxycodone; if 1 hour later pain continues to be unrelieved and there are no side effects give a third dose of 30 mg PO oxycodone." However, multiple orders would be required for slower titration for conditions of unrelieved pain in the presence of side effects and to also stipulate that the dose that was found to be effective is then the only available PRN dose.

Beyond understanding the pharmacokinetics of opioid analgesics, titration and use of range orders requires nurses to properly evaluate patient status before administration of an opioid dose. The second vignette in the present survey demonstrated the complexity of decision making when a nurse implements an opioid range order and the need to understand how to lower a dose or titrate down. Recall that the patient in the vignette was given a 6 mg dose and reported "satisfactory" pain relief with a reduction of severe pain to moderate pain. The decision to administer an equal or larger subsequent dose should be an easy one in patients who experience a return of severe pain, provided there are no or minimal side effects. However, the patient in this vignette was described as being excessively sedated and "drifting off to sleep during conversation" at the time of the subsequent dose (which, as noted, resulted in significant author debate and exclusion from the total score). A reasonable and safe action in such a situation is to hold opioid analgesia and any other sedating agents (chosen by 25% of respondents), promptly inform the physician of the patient's status, request an order for nonsedating analgesia, and investigate the possible cause of the excessive sedation. Reducing the dose by 25% to 50% and waiting to administer it until the patient is less sedated are also appropriate actions. Thirty percent chose to administer a dose in this dose reduction range (3, 4, or 5 mg), whereas 24% chose to repeat the previous dose of 6 mg which, although effective for pain, had resulted in a significant side effect.

Nurse monitoring of sedation level is frequently cited as an essential function when caring for patients receiving opioids (Pasero and McCaffery 2002, Pasero et al 1999). Indeed, sedation level was cited most often by just over one-half (56.6%) of the respondents when they were asked to choose the three most common factors to consider when selecting an opioid dose. However, this means that nearly one-half of the respondents did not appreciate the importance of sedation assessment and underscores the need for reinforcement of this aspect of safe opioid administration.

Relevance of Findings

Although one-half to two-thirds of the nurses chose what we considered to be reasonably appropriate responses, the other one-third to one-half chose answers indicating that they err on the side of conservative administration of PRN opioid orders even in the presence of severe pain and minimal or no side effects. This may be explained by being less knowledgeable or comfortable with how to titrate opioids, or by variability in how nurses interpret the time interval. Nearly one-fourth of all of the nurses consistently chose responses that would delay or underdose a patient. Alarmingly, 21% of nurses indicated they would give a dose less than what was ordered without first calling a physician. These findings are of concern on at least two levels. First, this indicates that some nurses may not always follow the basic nursing principle that requires them to contact the prescriber when, for whatever reason, the nurse is unable to follow an order. Second, the decision to give less than allowed by the range order could result in loss of stabilized pain control; recall that the patient described in the third vignette had good pain relief and no side effects from 4 mg of IV morphine every 2 hours. The present findings are similar to those of another study that showed 38% of the nurse respondents thought patients should experience pain before giving a subsequent dose and should not be maintained in a "pain-free" state (Howell, Butler, Vincent, Watt-Watson, & Stearns, 2000).

We could find nothing in the literature that described nurses' independent decisions to give less opioid than prescribed in a range order; however, research has shown that nurses will often administer less opioid than allowable when the opioid is prescribed as a PRN dose (Pasero et al 2007, Titler et al 2003). Surveys have consistently shown that nurses tend to select lower PRN doses or withhold analgesics even when a patient's condition warrants the need for more analgesia (McCaffery, Pasero, & Ferrell, 2007). In a study of pain assessment and analgesic administration in elders, Titler et al. (2003) found that the patients in their sample received 25% of the minimum parenteral morphine equivalent of opioid prescribed and that eight patients received no analgesic whatsoever despite having PRN orders for analgesics and demonstrating behaviors indicative of moderate to severe pain. Boer et al. (1997) studied the administration of analgesics that were prescribed in scheduled doses to 150 postoperative patients and found that naproxen and acetaminophen plus codeine were often administered as prescribed. However, patients in the study almost never received the total prescription of parenteral morphine. Nurses cited fears of addiction and respiratory depression and a preference for nonopioid analgesics as reasons for failing to administer the scheduled morphine doses.

These findings indicate that nurses should be reminded that the flexibility in dosing made possible by a range order does not include adjusting the dose limits of the order. They should be encouraged to always communicate with other members of the health care team when they think it is necessary to administer more or less opioid than is prescribed.

Limitations

There are a number of limitations to this study. The survey involved a convenience and voluntary sample of nurses who may not be representative of all nurses. Recruitment was different in the two sites based on E-mail availability. Those who have internet access and/or use E-mail may represent a different group from nurses who do not. A major limitation is the difficulty of using simple vignettes to mirror the complex reality of a patient condition and the comprehensive assessment and decision making nurses perform. No psychometrics analysis was performed in the construction of the nurse survey. Finally, although the authors determined appropriate answers based on onset, peak, and duration of IV and PO short-acting opioids, there were no absolute right or wrong answers.

Summary

Although the use of PRN range opioid analgesic orders has long been a familiar strategy in the inpatient setting, the safety of this practice has recently been called into question owing to concerns about the literal clarity of the orders and the competency of both prescribers and nurses who administer the opioids. Policies and practices that construct range orders in a manner that ties a specific dose or route to a pain-intensity rating raise serious concerns about potential harm. This study demonstrates nurses' variable opinions and likely practices related to selecting a dose from within a range and their decisions on how to space doses within a designated time period. For institutions, the findings of this study underscore the importance of conducting a multidisciplinary examination of range order practices and the need to increase efforts to educate prescribers in how to write appropriate range orders and nurses in how to implement them to provide effective and safe analgesia.

A closer examination of opioid pharmacokinetics can provide logic to develop a new paradigm where range orders are replaced with titration orders. Clear understanding and communication between staff involved in the medication administration process is essential. Nurses should work together with colleagues in pharmacy and medicine to develop and study the safety of alternative ways of constructing orders that would more clearly guide titration of an opioid to meet a patient's need.Benedetti et al., 1998, ISMP (2002)

Source : http://www.medscape.com/viewarticle/580915

Pacemaker and Automatic Internal Cardiac Defibrillator

2009-06-19T21:38:00.002+07:00

Basic Concepts

Introduction

Pacemakers and implantable cardioverter defibrillators (ICDs) have been in use for more than 20 years. With expanding indications and an ever-growing elder population, emergency physicians must be familiar with emergent indications for their application, discontinuation, and complications arising from a patients’ existing device. This article introduces the common problems encountered with pacemakers and ICDs, and rescue techniques that may aid in treating such complications.

Pacemaker and ICD basics

Permanent pacemakers are implanted devices that provide electrical stimuli, thereby causing cardiac contraction when intrinsic myocardial electrical activity is inappropriately slow or absent. These devices sense intrinsic cardiac electric potentials and, if too infrequent or absent, they transmit impulses to the heart to stimulate myocardial contraction.

An ICD is a specialized device designed to directly treat a cardiac tachydysrhythmias. If a patient has a ventricular ICD and the device senses a ventricular rate that exceeds the programmed cut threshold, the device performs antitachycardia pacing. With antitachycardia pacing, the device fires a preset number of rapid pulses in succession in an attempt to terminate the ventricular tachycardia. If unsuccessful, the device will perform a cardioversion/defibrillation.

Newer-generation ICDs are also equipped with an intrinsic bradycardia demand pacing system, and some, if required, are a combination of an ICD and a pacemaker. It is important to be aware that some of the older models (more than 10 years old) may lack this function.

Pacemaker and ICD anatomy

Pacing systems consist of a pulse generator and pacing leads. With permanent systems, endocardial leads are inserted transvenously and advanced to the right ventricle and/or atrium where they are implanted into the myocardial tissue. The pulse generator is placed subcutaneously or submuscularly in the chest wall.

Pulse generators contain a battery as well as sensing, timing and output circuits. The battery (most commonly lithium-iodide) typically has a life span of 5-10 years.

During pacemaker placement, signal amplitude and width are set high enough to reliably achieve myocardial capture, yet low enough to maximize battery life.

Temporary systems use an external pulse generator with leads placed either transcutaneously or transvenously. Transcutaneous leads are the easiest and most convenient to use for rapid application of temporary pacing and is the method of choice during ED resuscitation. Once the patient is stabilized or central venous access is gained, transvenous leads provide the most reliable pacing mechanism and are a good transition to permanent systems.

For transvenous temporary pacing, semirigid catheters are inserted through a central venous access. ECG monitoring (specifically V₁) is used to track catheter positioning. For example, P-wave morphology is initially inverted and becomes upright as the catheter is in line with the SA node. QRS morphology is also initially inverted, transitioning to isoelectric and then upright as the tip is placed in the apex. An injury pattern resembling ST elevation ensures that the catheter tip is in proper positioning for pacing. Semifloating or flexible balloon-tipped catheters can be used in emergencies since they can be positioned without such monitoring.

Transcutaneous pacing is discussed in detail in a separate article (see External Pacemakers).

Pulse generators can be set to fixed-rate (asynchronous) or demand (synchronous) modes. In the asynchronous mode, impulses are produced at a set rate independent of intrinsic cardiac activity. This mode carries a small but inherent danger of producing lethal dysrhythmias should the impulse coincide with the vulnerable period of the T wave. In the synchronous mode, the sensing circuit searches for an intrinsic depolarization potential. If this is absent, a pacing response is generated. This mode closely mimics intrinsic myocardial electric activity.

Pacing Codes

The Heart Rhythm Society and the British Pacing and Electrophysiology Group (BPEG) have developed a code to describe various pacing modes.

Table 1.Pacemaker Code Used to Describe Various Pacing Modes

Table

1st Letter	2nd Letter	3rd Letter	4th Letter	5th Letter
Chamber Paced	Chamber Sensed	Response to Sensing	Programmability and Rate Modulation	Antitachyarrhythmia Function
A	A	T	P	P (pacing)
V	V	I	M	S (shock)
D	D	D	C	D (dual: pacing + shock)
	O	O	R
			O

1st Letter	2nd Letter	3rd Letter	4th Letter	5th Letter
Chamber Paced	Chamber Sensed	Response to Sensing	Programmability and Rate Modulation	Antitachyarrhythmia Function
A	A	T	P	P (pacing)
V	V	I	M	S (shock)
D	D	D	C	D (dual: pacing + shock)
	O	O	R
			O

Abbreviations: A, atrium; V, ventricle; D, dual (both chambers); O, none; T, triggered; I, inhibited; D, double (atrial triggered and ventricular inhibited); P, simple programmability; M, multiprogrammable; C, communicating (telemetry); R, rate adaptive.

Pacing code explanation:

A typical pacing code consists of 3-5 letters.

The first letter indicates the chamber(s) paced.
- A: Atrial pacing
- V: Ventricular pacing
- D: Dual-chamber (atrial and ventricular) pacing
The second letter indicates the chamber in which electrical activity is sensed.
- A, V, or D
- O is used when pacemaker discharge is not dependent on sensing electrical activity.
The third letter refers to the response to a sensed electric signal.
- T: Triggering of pacing function
- I: Inhibition of pacing function
- D: Dual response (ie, any spontaneous atrial andventricular activity will inhibit atrial and ventricular pacing and lone atrial activity will trigger a paced ventricular response)
- O: No response to an underlying electric signal (usually related to the absence of associated sensing function)
The fourth letter represents programmability and rate modulation.
- P: Simple programmable
- M: Multiprogrammability
- C: Communication
- R: Rate-response ("physiologic") pacing
- O: No programmability or rate modulation
The fifth letter represents presence of antitachyarrhythmia function.
- P: Pacing (antitachyarrhythmia)
- S: Shock
- D: Dual (pacing + shock)

Although the first 3 letters are used most commonly, a 5 position code is currently in use. The first position denotes the chamber(s) paced; the second position denotes the chamber(s) sensed; the third position denotes the action(s) performed; the fourth position denotes rate response; finally, the fifth position denotes antitachyarrhythmia function.

More modern pacemakers have multiple functions. The simplest settings are VVI and AAT. The VVI mode senses and paces the ventricle and is inhibited by a sensed ventricular event. Alternatively, the AAT mode senses and paces in the atrium, and each sensed event triggers the generator to fire within the P wave.

The most common setting, DDD mode denotes that both chambers are capable of being sensed and paced. This requires two functioning leads, one in the atrium and the other in the ventricle. In the ECG, each QRS is preceded by 2 spikes, The first indicating the atrial depolarization and the second indicating the initiation of the QRS complex. Given that one of the leads is in the right ventricle, a left bundle-branch pattern may be evident on ECG. Note that a 2-wired system does not necessarily need to be in DDD mode, since the atrial or ventricular leads can be programmed off. Additionally, single tripolar lead systems are available that can sense atrial impulses and either sense or pace the ventricle. Thus, this system provides for atrial tracking without the capability for atrial pacing and can be used in patients with atrioventricular block and normal sinus node function.

Pacemaker programming can be performed noninvasively by an electrophysiology technician or cardiologist. Because of the myriad of pacemaker types, patients should carry a card with them providing information about their particular model. This information is crucial when communicating with the cardiologist about a pacer problem. However, most pacemaker generators have an x-ray code that can be seen on a standard chest radiograph. The markings, along with the shape of the generator, may assist with deciphering the manufacturer of the generator and pacemaker battery.

For further information or locations of technicians for pacemaker devices, the device company can be contacted at the 24-hour help line telephone numbers below.¹

Guidant (Boston Scientific) - 800-CARDIAC (800-227-3422)
Medtronic - 800-MEDTRONIC (800-633-8766)
St. Jude Medical - 800-722-3774

Pacemaker and ICD Indications

Pacemaker indications

Absolute indications for pacemaker placement include the following:

Sick sinus syndrome
Symptomatic sinus bradycardia
Tachy-brady syndrome
Atrial fibrillation with sinus node dysfunction
Complete atrioventricular block (third-degree block)
Chronotropic incompetence (inability to increase the heart rate to match a level of exercise)
Prolonged QT syndrome
Cardiac resynchronization therapy with biventricular pacing

Relative indications include the following:

Cardiomyopathy (hypertrophic or dilated)
Severe refractory neurocardiogenic syncope

Temporary emergency pacing is indicated for therapy of significant and hemodynamically unstable bradydysrhythmias and for prevention of bradycardia-dependent malignant dysrhythmias. Examples include refractory symptomatic sinus node dysfunction, complete heart block, alternating bundle-branch block, new bi-fascicular block, and bradycardia-dependent ventricular tachycardia. Examples of indications for prophylactic temporary pacing include insertion of a pulmonary artery catheter in a patient with an underlying left bundle-branch block, use of medications that may cause or exacerbate hemodynamically significant bradycardia, prophylaxis during the perioperative period surrounding cardiac valvular surgery, Lyme disease or other infections (Chagas disease) that cause interval changes, and prolonged PR intervals.

ICD indications²

(For further reading and a detailed list of indications, see ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities.³)

Indications for ICDs include the following:

Survivors of cardiac arrest due to ventricular fibrillation (VF) or hemodynamically unstable sustained ventricular tachycardia (VT) after evaluation to define the cause of the event and to exclude any completely reversible causes
Structural heart disease and spontaneous sustained VT (stable or unstable)
Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study
Patients with left ventricular ejection fraction (LVEF) <35%>
Nonischemic dilated cardiomyopathy with LVEF ≤35% and NYHA functional Class II or III
Left ventricular (LV) dysfunction due to prior MI, ≥40 days post-MI, with LVEF <30%,>
Nonsustained VT due to prior MI, LVEF <40%,>
Unexplained syncope, significant LV dysfunction, and nonischemic dilated cardiomyopathy
Sustained VT and normal or near-normal ventricular function
Hypertrophic cardiomyopathy who have 1 or more major risk factors for sudden cardiac death (SCD)

Initially, ICDs were used for secondary prevention in patients who had documented life-threatening ventricular arrhythmias and survivors of cardiac arrest. A meta-analysis of 3 large trials, principally, Antiarrhythmics vs Implantable Defibrillator (AVID) study,⁴ the Cardiac Arrest Study Hamburg (CASH),⁵ and the Canadian Implantable Defibrillator Study (CIDS),⁶ showed patients in the ICD group had significant reduction in all-cause death and death from arrhythmia. Further analysis of the CIDS trial with an 11-year follow-up revealed that the benefit of ICD over amiodarone increased with time.⁷

Recent trials suggest ICDs are beneficial for primary prevention of sudden cardiac death. Multiple trials have demonstrated that primary prevention in post-MI patients with reduced ejection fraction, nonsustained VT, and inducible nonsuppressible VT in electrophysiological testing with ICD over conventional medical therapy saved lives.^8,9 Further studies have shown that primary prevention using ICDs in other patient subset groups is also beneficial.^{10,11,12,13,14}

For further detailed discussion and evidence supporting ICDs, see Implantable Cardioverter-Defibrillators.

Magnet Inhibition

Placing a magnet over a permanent pacemaker closes an internal reed switch to inhibit sensing. This temporarily "reprograms" the pacer into asynchronous mode. It does not turn the pacemaker off. Each pacemaker type has a unique asynchronous rate for beginning-of-life (BOL), elective replacement indicator (ERI), and end-of-life (EOL). Therefore, application of a magnet can determine if the pacer's battery needs to be replaced. Further interrogation or manipulating of the device should be performed by an individual skilled in the technique.

Although many different branded pacemaker/ICD magnets are available, emergency physicians should be aware that in general any pacemaker/ICD magnet can be used to inhibit the device.

It is worth mentioning that, when a magnet is applied to an ICD, it can temporarily turn off defibrillation therapy without altering its backup bradycardia pacing, this is further described later in the article .

Pacemaker Malfunctions and Complications

Major pacemaker malfunctions include the following:

Failure to output
Failure to capture
Failure to sense
Pacemaker-mediated tachycardia
Runaway pacemaker
Pacemaker syndrome
Twiddler's syndrome

Failure to output

Failure to output occurs when no pacing spike is present despite an indication to pace. This may be due to battery failure, lead fracture, fractured lead insulation, oversensing (inhibiting pacer output), poor lead connection at the takeoff from the pacer, and "cross-talk" (ie, a phenomenon occurring when atrial output is sensed by a ventricular lead in a dual-chamber pacer).

Management of pacer output complications includes medications to increase the intrinsic heart rate and placement of a temporary pacer. A chest radiograph is warranted to check pacer leads and to evaluate for possible lead fracture, which occurs most commonly at the clavicle/first rib. The patient's pacer identification card should be obtained and his/her electrophysiologist/cardiologist consulted.

Failure to capture

Failure to capture occurs when a pacing spike is not followed by an atrial or a ventricular complex. This may be due to lead fracture, lead dislodgement, fractured lead insulation, an elevated pacing threshold, myocardial infarction at the lead tip, drugs (eg, flecainide), metabolic abnormalities (eg, hyperkalemia, acidosis, alkalosis), cardiac perforation, poor lead connection at the takeoff from the generator, and improper amplitude or pulse-width settings. Fibrosis at the endocardial surface where leads were implanted may also occur in the weeks following pacemaker implantation. The fibrosis may create an electrical resistance barrier preventing ventricular depolarization.

Managing pacer capture complications is similar to treating output complications, with extra consideration given to treating metabolic abnormalities and potential myocardial infarction. Temporary pacing is used to stabilize the patient until an electrophysiology technician or cardiologist can further evaluate the pacemaker.

Oversensing

Oversensing occurs when a pacer incorrectly senses noncardiac electrical activity and is inhibited from pacing. This may result in a heart rate lower than the preset rate. This form of output failure may be due to muscular activity (particularly the diaphragm or pectoralis muscles), electromagnetic interference (MRIs), or fractured lead insulation. Oversensing is one condition that is diagnosable and treatable with magnet application. As mentioned before, magnet application will convert the pacemaker to asynchronous mode, and it will then operate at the preset rate.

Of note, recently, it has been reported that cellular phones held within 10 cm of the pulse generator may elicit this response.

Individual ICD manufacturers also have recommendations for unsafe devices that may interact with the ICD. (For example, Safe and Unsafe devices - Medtronic Brochure for Patients¹⁵)

Undersensing

Undersensing occurs when a pacer incorrectly misses intrinsic depolarization and paces despite intrinsic activity. The pacemaker is more or less operating in asynchronous mode. This may be due to poor lead positioning, lead dislodgment, magnet application, low battery, or myocardial infarction. Management is similar to that for other types of failures.

Pacemaker-mediated tachycardia

A premature ventricular contraction (PVC) in a dual-chamber pacemaker may precipitate a pacemaker-mediated tachycardia. If a premature ventricular contraction (PVC) is transmitted in a retrograde manner through the AV node, it may, in turn, depolarize the atria. This atrial depolarization is detected by the atrial sensor, which then stimulates the ventricular leads to fire, hence creating an endless loop. Although the maximum rate is limited by the pacemaker’s programmed upper limit, the possibility of developing ischemia exists in susceptible patients. This is another opportunity to use a magnet to diagnose and treat the arrhythmia. The magnet will place the pacemaker into asynchronous mode and sensing will be deactivated, thus preventing continuation of the reentrant dysrhythmia.

Runaway pacemaker

A malfunction of the pacemaker generator resulting in a life-threatening rapid tachycardia (up to 400 bpm) is known as runaway pacemaker. The generator may malfunction from various causes, although most commonly it is a battery failure or external damage. This rare medical emergency requires immediate action. An external magnet may induce slower pacing, but it is possible that the device will not respond to magnet application and more aggressive measures may be necessary. If a patient becomes unstable, treatment involves making an incision in the chest wall over the pacemaker and severing the pacemaker leads from the generator. Note that the patient may require temporary packing as a result.

Pacemaker syndrome

Pacemaker syndrome is a phenomenon where a patient feels symptomatically worse after pacemaker placement and presents with progressively worsening symptoms of congestive heart failure (CHF). This is mainly due to the loss of atrioventricular synchrony whereby the pathway is reversed and now has a ventricular origin. The atrial contribution to the preload is lost and cardiac output as well as blood pressure fall. Immediate treatment is mainly supportive, whereas long-term treatment involves altering the pacemaker to restore atrial-ventricular synchrony. For example, this may require changing the pacemaker from single-chamber to dual-chamber pacing.

For further reading, see Pacemaker Syndrome.

Twiddler's syndrome

Some patients will persistently disturb and manipulate the pacemaker generator resulting in malfunction. A chest radiograph may reveal twisting or coiling, or lead fracture, dislodgement, or migration. This situation will require surgical correction with further patient education and counseling.

Pacemaker complications

Pacemaker complications include malfunction due to mechanical factors such as pneumothorax, pericarditis, infection, skin erosion, hematoma, lead dislodgment, and venous thrombosis (also see Pacemaker Malfunction). Treatment depends on the etiology. Pneumothoraces may require medical observation, needle aspiration, or even chest tube placement. Erosion of the pacer through the skin, while rare, requires device replacement and systemic antibiotics. Hematomas may be treated with direct pressure and observation, rarely requiring surgical drainage. Lead dislodgment generally occurs within 2 days of device implantation pacer and may be seen on chest radiography. Free-floating ventricular leads may trigger malignant arrhythmias. Device-associated venous thrombosis is rare, but generally presents as unilateral arm edema. Treatment includes extremity elevation and anticoagulation.

Advanced life support protocols, including defibrillation may safely be performed for patients with pacemakers in place. Sternal paddles are placed at a safe distance (10 cm) from the pulse generator. Temporary pacing may become necessary in cases of myocardial infarction, as the current pacemaker discharge settings may be insufficient to stimulate ventricular contraction.

ICD Complications

Major implantable cardioverter defibrillator (ICD) complications are similar to those found in pacemakers and include operative failures, sensing and/or pacing failures, inappropriate cardioversion, ineffective cardioversion/defibrillation, and device deactivation.

Operative failures are identical to those found in regular pacemakers.

ICD sensing problems similar to those seen with pacers may also occur. An example of appropriate failure to treat is when a device has a cut-off rate of 180 bpm. If ventricular tachycardia occurs at 160 bpm, the device, appropriately, fails to cardiovert the patient since the rate of the dysrhythmia is below the programmed threshold.

Inappropriate cardioversion is the most frequent ICD-associated complication. This should be considered when a patient presents in atrial fibrillation or reports multiple shocks in rapid succession without preceding symptoms. Other causes include T wave oversensing, lead fracture, lead insulation breakage, electrocautery, MRI, and electromagnetic interference.

Magnet use inhibits further ICD discharge. It does not, however, inhibit bradycardiac pacing. In some devices, application of a magnet produces a soft beep for each QRS complex. If the magnet is left on for approximately 30 seconds, the ICD is disabled and a continuous tone is generated. To reactivate the device, the magnet must be lifted off the area of the generator and then replaced. After 30 seconds, the beep returns for every QRS complex.

Indications for ICD deactivation
- End-of-life care (after a discussion with the patient and family)
- Inappropriate shocks
- During resuscitation
- With transcutaneous pacing (external pacing can cause an ICD to fire)
- During procedures such as central lines or surgery with electrocautery

Failure to deliver a shock may be caused by failure to sense, lead fracture, electromagnetic interference, and inadvertent ICD deactivation. Management includes external defibrillation or cardioversion and antidysrhythmic medications.

Ineffective cardioversion may result from inadequate energy output, rise in defibrillation threshold (possibly due to antiarrhythmic medications such as amiodarone, flecainide, phenytoin), myocardial infarction at the lead site, lead fracture, insulation breakage, and dislodgment of the leads or cardioversion patches. The latter is occasionally still seen in patients with ICDs implanted during open chest surgery prior to 1993.

Many ICDs deliver a programmed set of therapies per dysrhythmic episode. The number of therapies per episode is manufacturer specific. If a delivered therapy does not terminate the arrhythmia, the device proceeds to the next programmed therapy. For example, a total of 6 attempts at defibrillation are attempted per episode of ventricular fibrillation. The device attempts defibrillation and then reevaluates the cardiac rhythm. If the arrhythmia persists, it delivers therapy number two and so on, until all 6 attempts have been delivered. Once this occurs, the device does not deliver therapy until a new episode is declared. Note that as mentioned earlier in this article, initial therapy for ventricular tachycardia may be anti-tachycardia pacing (also known as overdrive pacing) rather than simple cardioversion.

ICDs do not prevent all sudden deaths, and acknowledging that cardiac arrest is not necessarily an ICD malfunction is important. The device may have properly delivered the required shocks for the triggering rhythm but was ineffective in resolving it.

Resuscitation

If a patient enters a life-threatening cardiac arrhythmia, advanced cardiac life support (ACLS) protocols should be initiated immediately. Although an implantable cardiac defibrillator (ICD) will attempt defibrillation, chest compressions should be continued. Note that some of the current may enter the rescuer, and, besides some mild discomfort, there has never been a reported case of rescuer injury from this.¹ Ventricular tachycardia and ventricular fibrillation refractory to ICD defibrillation will require external defibrillation and/or antiarrhythmic medications as dictated by ACLS protocols. If external defibrillation is required, attempt to keep the generator at least 10 cm away and out of the shock wave. Defibrillation that affects the generator may cause total device failure. However, do not withhold therapy for fear of damaging the ICD.

If rescuers are uncomfortable with ICD discharge during resuscitations, it is indicated to deactivate the ICD with a magnet, as described in Magnet Inhibition.

Central venous catheters

Pacemaker or ICD leads placed in the venous system often have surrounding thrombosis with 20% of patients having complete occlusion at 2 years.¹⁶ If the metal guidewire contacts the lead system during central line placement, there may be enough noisy artifact to trigger an inappropriate shock. Consideration should be given to either avoid a metal guidewire or deactivate the ICD during central line placement. Although the contralateral subclavian or internal jugular vein can be cannulated with care, the femoral vein access is a much safer option.

Admission and Difficulties Surrounding a Safe Discharge

One of the most difficult decisions after a patient presents to the ED complaining of an ICD discharge is to determine if the discharge was appropriate. Whenever possible, the device should be investigated. Unless the shock and rhythm that preceded it was witnessed, it is not possible to determine shock appropriateness without investigation. Reasons for admission may include the following: device investigation to determine whether there is an eminent battery failure (multiple shocks will deplete battery life); addition of antiarrhythmic medications; treatment of myocardial infarction, which may be linked to the initial discharge; treatment of patient discomfort; and to give psychological support (up to 35% of people develop anxiety disorder following ICD placement).¹⁷

Summary

The goal of this article is to orient the reader to the basic function and use of pacemakers/ICDs and important complications of such devices, thus allowing the ED clinician to better understand and troubleshoot the causes of pacemaker/ICD failure and initiate appropriate therapy. The patient's electrophysiologist/cardiologist can also be an invaluable resource in these cases and should be contacted early during the emergency department evaluation.

Multimedia

(Enlarge Image)

Media file 1: Intermittent periods of ventricular capture.

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Media file 2: Complete heart block.

(Enlarge Image)

Media file 3: 100% ventricular paced rhythm.

Keywords

pacemakers, defibrillator, internal defibrillator, automatic internal cardiac defibrillator, cardiac contraction, cardiac tachydysrhythmia, implantable cardioverter-defibrillators, ICD, ICDs, AICD, AICDs.

References

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Source : http://emedicine.medscape.com/article/780825-overview?src=emed_whatnew_nl_0#ICDindication

Serious Parenteral Medication Errors Common in Intensive Care Units

2009-06-18T11:49:00.000+07:00

Parenteral medication errors at the administration stage are common in intensive care units and may result in permanent harm or death, according to a multinational study published online March 12 in the British Medical Journal.

"The combination of complexity and the potential for great harm makes medicine, especially intensive care, even more fraught with risk than other high complexity areas such as aviation," explain Andreas Valentin, MD, from the Department of Emergency Medicine, Medical University of Vienna and the Rudolfstiftung Hospital, Medical Department II in Vienna, Austria, and colleagues. "Although patients' safety is increasingly recognized as an essential component in the practice of intensive care medicine, the complexity of processes and medical conditions dealt with makes the practice of this specialty vulnerable and prone to error."

The frequency of medication errors at the prescription and administration stages was previously reported in the first multinational sentinel events evaluation (SEE 1). Because these errors are associated with a high potential for serious harm, this current study, the second multinational sentinel events evaluation study (SEE 2) was designed to evaluate the frequency, characteristics, and contributing factors of parenteral medication errors at the administration stage in intensive care units. In addition, the effect of parenteral medication errors and the outcome of patients exposed to these errors were assessed.

SEE 2 was a prospective, observational, 24-hour, cross-sectional study involving 113 intensive care units from 27 countries. A total of 1328 adult patients participated in the study, in which hospital staff self-reported medication errors in a single questionnaire for each participant.

"A medication error at the administration stage was defined as an error of omission or commission in the context of parenteral drug administration that harmed or could have harmed a patient," Dr. Valentin and colleagues write. "We exclusively addressed medication errors that were attributable to five types of error during the stage of administration: wrong dose, wrong drug, wrong route, wrong time, missed medication." These errors were further classified according to the method of drug administration and the class of drug administered.

The total prevalence of parenteral medication errors at the administration stage in intensive care units was found to be 74.5 errors per 100 patient days (95% confidence interval [CI], 69.5 – 79.4). In addition, while 71% of errors resulted in no change in the patient's health status, 0.9% of the total study population experienced permanent harm or death as a result of errors in the administration of parenteral drugs in intensive care units.

Overall, 67% of the participants experienced no errors, 19% experienced 1 error, and 14% experienced more than 1 error. Nineteen percent of the intensive care units did not report any medication errors. Errors were most frequently associated with the wrong time of administration (n = 386) followed by missed medication (n = 259), wrong dose (n = 118), wrong drug (n = 61), and wrong route (n = 37). Medication errors at the administration stage were most likely to occur during routine situations (69%) and during intravenous bolus administration (9%). Furthermore, the administration of antimicrobial drugs and those in the class of sedation or analgesia were most frequently associated with errors.

Workload, stress, and fatigue were reported as the most frequent contributing factors to medication errors (32%). Other contributing factors included changes in drug names; written or oral miscommunication; lack of experience, knowledge, or supervision; violation of protocol; shift change; and equipment failure. More than half of the errors (53%) that resulted in permanent harm or death occurred in situations in which trainees were involved.

"One of the most important steps in improving patients' safety is to understand how and why errors occur," the authors emphasize. Several contributing factors to medication errors were identified in this study, but a causal relationship could not be confirmed due to the study's observational design. "Univariate and multivariate analyses showed that more severely ill patients, who receive a higher level of care with the corresponding increased use of parenteral medication, are more likely to experience a medication error. This finding directly reflects the complexity of care and thus the increased opportunity for error," Dr. Valentin and colleagues write.

A limitation of this study was that certain elements that influence the occurrence of errors were unable to be evaluated due to the 24-hour observational study design. These elements include variations in culture, communication, data collection, and organizational structure. Furthermore, because hospital staff members were self-reporting the occurrence of errors, there was a risk of underreporting. The nature of the study design could have also led to overreporting due to possible duplications in the questionnaire.

"Our results suggest that the implementation of several achievable measures might enhance the safe process of parenteral drug administration in intensive care units," the authors conclude. These include the standard verification of perfusors and infusion pumps at every nursing shift change, the use of a critical incident reporting system, a lower ratio of patients to nurses, improved supervision of trainees, as well as enhanced technical measures such as aided recall, clear drug identification, and proper design of infusion pumps.

Source : http://www.medscape.com/viewarticle/589596

Home-Based Care Administered by Skilled Nurses Comparable to Standard Care for Obstructive Sleep Apnea

2009-06-18T11:00:00.001+07:00

Home-based treatment administered by highly skilled nurses is noninferior to and less costly than standard hospital-based, physician-directed care for the management of symptomatic, moderate to severe obstructive sleep apnea (OSA), according to a study published in the March 15 issue of the American Journal of Respiratory and Critical Care Medicine.

In addition, there is no significant difference between both methods of care with regard to objective sleepiness, general and disease-specific quality-of-life measures, neurocognition, patient satisfaction, or adherence to continuous positive airway pressure (CPAP) after 3 months.

With the rise in obesity, the prevalence of OSA has increased throughout developed countries and will likely rise among developing countries as well because of their increasing acceptance of Western lifestyles, according to the study. Furthermore, the number of sleep centers and physician specialists is not adequate to meet the growing need.

"[Thus], more cost-effective clinical pathways of investigation and treatment are required to match the increased demand for services that is resulting from increasing public awareness of OSA," explain Nick A. Antic, PhD, MBBS, FRACP, from the Adelaide Institute for Sleep Health, Repatriation General Hospital in Daw Park, and the Department of Medicine, Flinders University in Bedford Park, South Australia, and colleagues. "The present study was designed as a randomized controlled study in which a package of care incorporating...newer management strategies including simplified home diagnosis, CPAP titration with an autoadjusting positive airway pressure device to set a fixed CPAP pressure, and overall care supervised by a specialist nurse was compared with the more traditional physician-directed, in-laboratory polysomnography (PSG), hospital-based program of care."

A total of 195 symptomatic patients with moderate to severe OSA from 3 Australian sleep medicine service centers were randomly assigned to receive either the simplified, nurse-led model of care or the traditional, physician-directed model of care. The primary endpoint of the study was the change in Epworth Sleepiness Scale (ESS) score after 3 months of CPAP therapy. The ESS score among the patients who received the nurse-led model of care was 4.02, and the ESS score among the patients who received the traditional physician-directed care was 4.15 (difference, −0.13; 95% confidence interval [CI], −1.52 to 1.25).

Nurse-Lead Management Noninferior

"We found that the mean change in ESS score for nurse-led management was not inferior to the mean change in ESS score for specialist-led service because the lower limit of the two-sided 95% confidence interval for the mean difference did not include −2, the margin of noninferiority," state Dr. Antic and colleagues.

In addition, there was no significant difference between the 2 models of care with respect to the other outcomes measured, which include the Short Form 36 Health Survey, Functional Outcomes of Sleep Questionnaire, executive neurocognitive function, objective CPAP adherence, Maintenance of Wakefulness Test after 3 months of therapy, and general patient satisfaction with investigation and treatment.

However, there was a significant decrease in the cost associated with the simplified, nurse-led model of care vs the traditional, physician-directed model of care. Specifically, nurse-led management cost $1111 Australian (A$1111) per patient less than physician-directed care (95% CI, A$1084 – A$1137). "Hence the within-study analysis suggests that a nurse-led model of care saves considerable resources without compromising effects in patients diagnosed by oximetry as having a high likelihood of moderate to severe [OSA,] and consequently is cost-effective in these patients," write the researchers.

One possible limitation of this study is the fact that the results may not be replicated without the specific combination of diagnostic and therapeutic equipment used. Moreover, several conditions contributed to the effectiveness of the simplified model of care in this study. These include awareness of the pretest probability of OSA among the patient referrals, availability of a highly experienced nursing staff in the management of OSA, access to a tertiary sleep laboratory as a back-up for the interpretation and quality control of oximetry data and autoadjusting positive airway pressure (APAP) data, and availability of input from a sleep physician.

Physician Consult Allowed

Twelve percent of the patents in the simplified model of care group received physician consults because of unsatisfactory progress. "We believed it important for the specialist nurse to be able to cross-consult under circumstances in which they were uncertain about the management of the patient," explain Dr. Antic and colleagues. "[Thus, there is] the need for this simplified model of care to be ideally conducted either within a tertiary sleep medicine service or with patient access to same. We do not recommend that the simplified management approach occur autonomously."

Nevertheless, the researchers emphasize that there is the possibility that the use of this simplified model of care could be used in existing sleep medicine clinics to reduce the PSG and physician waiting time by approximately 20% to 25%.

"This overall package of care involving simplified OSA diagnosis, APAP titration in the home, and the expansion of the sleep medicine workforce using skilled CPAP nurses working under protocol (with the backup of sleep medicine services if needed) has the potential to add significantly to the field of sleep medicine and improve access to care for those with OSA," the authors conclude.

This study was supported by the National Health and Medical Research Council of Australia. Dr. Antic has received financial support for research in terms of equipment from Respironics and ResMed and from Masimo. Another author has received grants totaling $2.5 million from the Respironics Sleep and Respiratory Foundation for an investigator-initiated multicenter trial. Equipment grants are also pending for the Respironics Foundation and ResMed for the same trials. The authors also received $20,000 from Fisher and Paykel for the same study in 2008.

Am J Respir Crit Care Med. 2009;179:501–508.

Source : http://www.medscape.com/viewarticle/589440

Proper Oral Hygiene May Cut Risk of Pneumonia in Critically Ill Patients

2009-06-13T11:00:00.001+07:00

New research shows that oropharyngeal cleansing with chlorhexidine solution is no better than a control solution of potassium permanganate in preventing nosocomial pneumonia in critically ill patients. However, the regular maintenance of "meticulous" oral hygiene does provide a benefit, the findings suggest.

There is clear evidence that oral cleansing with chlorhexidine can help stave off nosocomial pneumonia after heart surgery, Dr. Dilip R. Karnad, from Seth GS Medical College, Mumbai, and colleagues note. By contrast, the benefit of this intervention in critically ill patients is unclear.

The current study, reported in the May issue of Chest, featured 512 patients who were randomized to receive twice-daily oropharyngeal cleansing with 0.2% chlorhexidine or with the control solution.

The rate of nosocomial pneumonia during the ICU stay was 7.1% in the chlorhexidine group, not significantly lower than the 7.7% rate seen in the control group.

The median day of development of pneumonia was identical in each group: 5.0 days. Likewise, the chlorhexidine and control groups had similar median ICU stays (5.0 vs. 6.0 days) and mortality rates (34.8% vs. 28.3%).

Despite these null findings, oropharyngeal cleansing did seem to be beneficial. During the study, the nosocomial pneumonia rate was 7.4%, whereas the rate in the 3 months before and following the study it was 21.7% (p < rr =" 0.34).

"Meticulous oral cleansing seems to decrease the risk of the development of pneumonia regardless of the content of the solution used for this purpose," the authors write.

"More studies using a higher concentration of chlorhexidine are required to establish the role of routine antiseptic oral cleansing in ICU patients," they add.

Chest 2009;135:1150-1156.

Source : http://www.medscape.com/viewarticle/704029?src=mpnews&spon=34&uac=133298AG

Evidence-Based Catheter-Care Procedures May Reduce Bloodstream Infection Rate

2009-06-13T10:43:00.002+07:00

Evidence-based catheter-care procedures regarding hand hygiene may significantly reduce the rate of catheter-related bloodstream infections (CRBSIs), according to the results of a prospective before-and-after interventional cohort study reported in the May 29 Online First issue of Critical Care.

"...CRBSI are a well recognized problem in the intensive care unit (ICU)," write Walter Zingg, MD, from the University Hospitals of Geneva in Geneva, Switzerland, and colleagues. "A recent study, in the neonatal setting, found hand hygiene successful as a single intervention measure in reducing CRBSI when its promotion was guided by healthcare workers' perceptions and combined with organization at the workplace. On the basis of high incidence rates of CRBSI in previous surveys of the ICUs in our institution, we decided to conduct an interventional study using an educational campaign focusing on hand hygiene and catheter care."

At 5 adult ICUs of a university hospital, CRBSIs were studied in all patients with a central venous catheter (CVC) from September to December 2003 (baseline period) and from March to July 2004 (intervention period). The intervention consisted of an educational program focusing on hand hygiene, catheter care standards, and intravenous drug preparation. The rate of CRBSIs per 1000 catheter days during the 4-month baseline period and the 5-month intervention period was the main endpoint of the study, and the secondary endpoint was compliance with hand hygiene.

The investigators monitored 499 patients with 6200 catheter days in the baseline period and 500 patients with 7279 catheter days in the intervention period. In the baseline period, there were 3.9 CRBSIs per 1000 catheter days, which decreased to 1.1 per 1000 catheter days in the intervention phase (P < .001). Both univariate and multivariate analysis revealed a significantly higher risk for CRBSIs in the baseline period. Hospitalization in the medical ICU and male sex were also independent risk factors.

During the intervention period, time to CRBSI was significantly longer vs baseline (median, 9 days vs 6.5 days, respectively; P = .02). Although compliance with hand hygiene increased only slightly from 59% in the baseline period to 65% in the intervention period, the rate of correct performance of hand hygiene improved from 22.5% to 42.6% (P = .003).

Limitations of this study include lack of randomization and disparity of the study population, with a higher fatal McCabe score, more trauma patients, longer ICU stay, longer median catheter duration, and more blood culture samples obtained in the intervention period.

"Evidence-based catheter-care procedures, guided by healthcare workers' perceptions and including bedside teaching, reduce significantly the CRBSI rate and demonstrate that improving catheter care has a major impact on its prevention," the study authors write. "Infection control efforts to improve the quality of hand hygiene and catheter care are essential elements for patient safety, not only for the reduction of CRBSI but also for other health care-associated infections."

The study authors have disclosed no relevant financial relationships.

Critical Care. Published online May 29, 2009.

Clinical Context

Risk factors for CRBSIs include long duration of CVC use, insertion site other than subclavian, overmanipulation of the CVC system, and heavy cutaneous colonization, as well as patient factors of illness severity and immunodeficiency. Strategies such as handwashing and the use of CVCs coated with antimicrobials have been examined as methods to reduce CRBSIs.

This is a study of the effect of an educational intervention on hand hygiene practice in ICUs and its impact on CRBSI rates and predictors of CRBSIs among patients in the ICU.

Study Highlights

The study was conducted at 5 ICUs (medical, cardiovascular, trauma, general surgery, and neurosurgery) with a total of 52 beds at 1 hospital.
All adults hospitalized in any of the ICUs with 1 or more CVCs were included, and there were no exclusion criteria.
Surveillance of CVCs was conducted by a trained infection control nurse who visited the ICUs daily and recorded information.
CRBSI was defined by the criteria of the Centers for Disease Control and Prevention and the National Healthcare Safety Network.
Patients were monitored for CRBSI until 48 hours after discharge from the ICU.
CRBSI was considered ICU acquired if diagnosed 48 hours or more after admission or within 48 hours of discharge from the ICU.
Comorbidities were assessed with the Charlson Comorbidity Index, and the McCabe score and severity of illness was assessed with the Simplified Acute Physiology Score during the first 24 hours of ICU stay.
The educational intervention consisted of training of head nurses and instructors, general teaching to all ICU nurses, bedside small group teaching for all nurses, and teaching of medical staff.
Teaching phase 1 consisted of 12 interactive training sessions with use of evidence-based CVC procedures.
Teaching phase 2 consisted of 5 teaching interventions of 45 minutes each in the auditorium.
Teaching phase 3 consisted of 80 practical bedside teaching workshops on hand hygiene, and teaching phase 4 consisted of a physician teaching program.
Primary outcomes were compliance with hand rubbing before and after patient contact with use of surveillance forms and monitoring the volume of alcohol-based hand rub used, and CBSRI rate.
499 and 500 patients were included in the baseline and the intervention period.
A total of 6649 ICU days were observed (2944 for baseline and 3705 for intervention).
The intervention period had more patients with trauma and rapidly fatal McCabe score.
A total of 974 CVCs representing 6200 catheter days were surveyed during baseline, and 1015 CVCs representing 7279 catheter days during the intervention period.
Incidence densities of CRBSI were 3.9 per 1000 catheter days in the baseline and 1.0 per 1000 catheter days in the intervention period (P < .001).
Time to CRBSI was significantly longer in the intervention period (9 days vs 6.5 days; P = .02).
CRBSI rates in medical ICUs were significantly higher vs other ICUs (9.0 vs 3.0 per 1000 catheter days).
Patients with CRBSI had a longer stay in ICU by 10.5 days (15.5 vs 5 days).
The most common pathogens in CRBSI were coagulase-negative staphylococci followed by Escherichia coli, Staphylococcus aureus, and Candida albicans.
Risk factors for CRBSI were baseline vs the intervention period (hazard ratio [HR], 4.47), hospitalization in a medical ICU vs other ICUs (HR, 3.32), and male sex (HR, 2.54).
A higher Simplified Acute Physiology Score and a rapidly fatal McCabe score were not independent predictors.
Patients in medical ICUs had longer stays, more CVCs per patient, and higher Simplified Acute Physiology Score at admission but similar CVC days vs other ICUs.
Male patients had longer ICU stays, more diabetes, and higher Charlson scores.
Correctly performed hand hygiene practices before patient contact improved significantly from 26% to 45% (P = .007) and after patient contact from 21% to 56% (P < .001).
Overall compliance with hand hygiene was improved, but this was not significant.

Clinical Implications

Predictors of risk for CRBSIs in ICUs are hospitalization in a medical ICU, male sex, and baseline period.
An educational intervention for ICU nurses and medical staff is associated with improved hand hygiene and reduced CRBSI rates.

Sedatives and Hypnotics May Increase Risk for Suicide in Elderly Patients

2009-06-12T16:36:00.000+07:00

Sedatives and hypnotics may increase the risk for suicide in elderly patients, according to the results of a case-control study reported online in the June issue of BMC Geriatrics.

"While antidepressant-induced suicidality is a concern in younger age groups, there is mounting evidence that these drugs may reduce suicidality in the elderly," write Anders Carlsten and Margda Waern, from Gothenburg University in Gothenburg, Sweden. "Regarding a possible association between other types of psychoactive drugs and suicide, results are inconclusive. Sedatives and hypnotics are widely prescribed to elderly persons with symptoms of depression, anxiety, and sleep disturbance."

The aim of this study was to evaluate the association of specific types of psychoactive drugs with suicide risk in late life, after controlling for appropriate indications. In Gothenburg and 2 adjacent counties, the investigators performed a case-control study of 85 patients 65 years or older who had committed suicide matched with 153 control subjects from a population-based comparison group.

Of the 85 suicide cases, 46 were men and 39 were women; mean age was 75 years. A psychiatrist interviewed close informants for the patients who had committed suicide, and control subjects were also interviewed face-to-face. Primary care and psychiatric records were also reviewed for case patients and control subjects, and analysis of all available data allowed diagnosis of past-month mental disorders based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.

Unadjusted analysis showed that use of antidepressant, antipsychotic, sedative, and hypnotic drugs were all associated with an increased risk for suicide, but adjusting for affective and anxiety disorders abolished this association for antidepressants in general and for selective serotonin-reuptake inhibitors (SSRIs). Adjustment for psychotic disorders abolished the association of antipsychotic use.

In the unadjusted analyses, use of sedatives was associated with nearly a 14-fold increase of suicide risk, and this persisted as an independent risk factor for suicide even after adjusting for any disorder based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. In the adjusted model, having a current prescription for a hypnotic was associated with a 4-fold increase in suicide risk.

Limitations of this study include inability to determine causality or the contribution of availability of suicide means on suicide risk, small sample size, and diagnoses of the patients who had committed suicide based on data obtained by proxy interviews.

"Sedatives and hypnotics were both associated with increased risk for suicide after adjustment for appropriate indications," the study authors write. "Given the extremely high prescription rates, a careful evaluation of the suicide risk should always precede prescribing a sedative or hypnotic to an elderly individual."

The Swedish Foundation for Health Care Science and Allergy Research, the Swedish Council for Social Research, and the Swedish Research Council supported this study. The study authors have disclosed no relevant financial relationships.

BMC Geriatr. 2009;9:20.

Source : http://www.medscape.com/viewarticle/703908?sssdmh=dm1.481497&src=nldne

World Health Organization Issues Guidelines on Hand Hygiene in Healthcare

2009-05-23T12:34:00.002+07:00

May 6, 2009 — The World Health Organization (WHO) has issued Guidelines on Hand Hygiene in Health Care, offering a thorough review of evidence on hand hygiene in healthcare and specific recommendations to improve hygiene practices and reduce transmission of pathogenic microorganisms to patients and healthcare workers (HCWs).

The guidelines target hospital administrators and public health officials as well as HCWs, and they are designed to be used in any setting in which healthcare is delivered either to a patient or to a specific group, including all settings where healthcare is permanently or occasionally performed, such as home care by birth attendants. Individual adaptation of the recommendations is encouraged, based on local regulations, settings, needs, and resources.

Hand Hygiene Indications

Indications for hand hygiene are as follows:

• Wash hands with soap and water when visibly dirty, when soiled with blood or other body fluids, or after using the toilet.

• Handwashing with soap and water is preferred when exposure to potential spore-forming pathogens, such as Clostridium difficile, is strongly suspected or proven.

• In all other clinical situations, use an alcohol-based handrub as the preferred means for routine hand antisepsis, if hands are not visibly soiled. Wash hands with soap and water if alcohol-based handrub is not available.

• Hand hygiene is needed before and after touching the patient; before touching an invasive device used for patient care, whether gloves are used; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; if moving from a contaminated body site to another body site on the same patient; after touching inanimate surfaces and objects in the immediate vicinity; and after removing gloves.

• Hand hygiene is needed before handling medication or preparing food using an alcohol-based handrub or handwashing with water and either plain or antimicrobial soap.

• Soap and alcohol-based handrub should not be used together.

Hand Hygiene Techniques

Specific recommendations for hand hygiene technique are as follows:

• Rub a palmful of alcohol-based handrub over all hand surfaces until dry.

• When washing hands, wet hands with water and apply enough soap to cover all surfaces; rinse hands with water and dry thoroughly with a single-use towel. Whenever possible, use clean, running water. Avoid hot water, which may increase the risk for dermatitis.

• Use the towel to turn off the tap or faucet, and do not reuse the towel.

• Liquid, bar, leaf, or powdered soap is acceptable; bars should be small and placed in racks that allow drainage.

Surgical Hand Preparation

Specific recommendations for surgical hand preparation are as follows:

• Before beginning surgical hand preparation, remove jewelry. Artificial nails are prohibited.

• Sinks should be designed to reduce the risk for splashes.

• Visibly soiled hands should be washed with plain soap before surgical hand preparation, and a nail cleaner should be used to remove debris from underneath the fingernails, preferably under running water.

• Brushes are not recommended.

• Before donning sterile gloves, surgical hand antisepsis should be performed with a suitable antimicrobial soap or alcohol-based handrub, preferably one that ensures sustained activity. Alcohol-based handrub should be used when quality of water is not assured.

• When using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the maker, usually 2 to 5 minutes.

• When using an alcohol-based surgical handrub, follow the maker's instructions; apply to dry hands only; do not combine with alcohol-based products sequentially; use enough product to keep hands and forearms wet throughout surgical hand preparation; and allow hands and forearms to dry thoroughly before donning sterile gloves.

Selecting Hand Hygiene Agents

Some specific recommendations for selection and handling of hand hygiene agents are as follows:

• Provide effective hand hygiene products with low potential to cause irritation.

• Ask for HCW input regarding skin tolerance, feel, and fragrance of any products being considered.

• Determine any known interaction between products used for cleaning hands, skin care products, and gloves used in the institution.

• Provide appropriate, accessible, well-functioning, clean dispensers at the point of care, and do not add soap or alcohol-based formulations to a partially empty dispenser.

Skin Care Recommendations

Some specific recommendations for skin care are as follows:

• Educate HCWs about hand-care practices designed to reduce the risk for irritant contact dermatitis and other skin damage.

• Provide alternative hand hygiene products for HCWs with confirmed allergies to standard products.

• Provide HCWs with hand lotions or creams to reduce the risk for irritant contact dermatitis.

• Use of antimicrobial soap is not recommended when alcohol-based handrub is available. Soap and alcohol-based handrub should not be used together.

Recommendations for Glove Use

Some specific recommendations for use of gloves are as follows:

• Glove use does not replace the need for hand hygiene.

• Gloves are recommended in situations in which contact with blood or other potentially infectious materials is likely.

• Remove gloves after caring for a patient, and do not reuse.

• Change or remove gloves if moving from a contaminated body site to either another body site within the same patient or the environment.

"In hand hygiene promotion programmes for HCWs, focus specifically on factors currently found to have a significant influence on behaviour, and not solely on the type of hand hygiene products," the guidelines authors write. "The strategy should be multifaceted and multimodal and include education and senior executive support for implementation. Educate HCWs about the type of patient-care activities that can result in hand contamination and about the advantages and disadvantages of various methods used to clean their hands."

Four of the guidelines authors have disclosed various financial relationships with GOJO, Clorox, and GlaxoSmithKline, and other companies and institutions. A complete description of their disclosures is available in the original article. The other guidelines authors have disclosed no relevant financial relationships.

WHO Guidelines on Hand Hygiene in Health Care. May 2009.

Clinical Context

In 2004, WHO convened a group of international experts in infection control to prepare guidelines for hand hygiene in healthcare. In 2002, the Centers for Disease Control and Prevention Guideline for Hand Hygiene in Health-Care Settings was adopted. Following a systematic review of the literature and task force meetings, the Advanced Draft of the WHO Guidelines on Hand Hygiene in Health Care was published in 2006. An Executive Summary of the Advanced Draft of the Guidelines is available separately (http://www.who.int/gpsc/tools/en/). Pilot testing of the advanced draft occurred, with subsequent updating and finalization of the guidelines.

The WHO Guidelines on Hand Hygiene in Health Care includes a review of scientific data, consensus recommendations, process and outcome measurements, proposals for large scale promotion of hand hygiene, patient participation in promotion of hand hygiene, and a review of national and subnational guidelines. The recommendations are expected to be valid until 2011 and will be updated every 2 to 3 years.

Study Highlights

Indications for washing hands with soap and water include visibly dirty hands, hands visibly soiled with body fluids, or after using the toilet.
Handwashing with soap and water is preferred after exposure to potential spore-forming pathogens, including Clostridium difficile outbreaks.
Alcohol-based handrub is preferred in the following situations if hands are not visibly soiled: before and after touching a patient; before handling an invasive device for patient care; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; between contact with a contaminated body site to another site on the same patient; after contact with inanimate surfaces and objects; and after removing sterile or nonsterile gloves.
Handwashing with soap and water is recommended when alcohol-based handrub is unavailable.
Alcohol-based handrub or soap and water can be used before handling medication or preparing food.
Concomitant alcohol-based handrub and soap use is not recommended.
Soap and water hand-washing technique includes using a towel to turn off the faucet, thorough drying of hands, and single towel use.
Acceptable forms of soap are liquid, bar, leaf, or powdered.
Bar soap racks should allow drainage to ensure that the soap dries.
Alcohol-based handrub technique includes applying palmful amount of handrub, covering all surfaces, and rubbing hands until dry.
Surgical hand hygiene recommendations include removal of jewelry, no brushes, and use of either antimicrobial soap or alcohol-based handrub according to the maker's recommendations.
Selection of hand hygiene agents should consider input from HCWs, interaction with other products or gloves, risk for contamination, accessibility and proper functioning of dispensers, approval of dispensers for flammable materials, and cost comparisons.
Soap or alcohol-based handrub should not be added to partially empty soap dispensers.
Skin care irritation in HCWs can be avoided by providing educational programs, alternative hand hygiene products for those with allergies or adverse reactions to standard products, and hand moisturizers to reduce irritant contact dermatitis.
Glove use does not replace the need for handrub or handwashing.
Gloves should be used if contact with potentially infectious body fluids, mucous membranes, or nonintact skin is anticipated.
Gloves should be removed or changed after each patient or after contact with a contaminated body site.
Artificial nails or extenders should not be used, and the length of natural nail tips should be less than 0.5 cm.
Educational and motivational programs for HCWs should focus on behavior; be multimodal; include senior executive support; educate about the advantages and disadvantages of various hand hygiene methods; monitor adherence and provide performance feedback; and encourage partnership between patients, families, and HCWs.
Healthcare administrators should provide and monitor safe, continuous water supply; provide alcohol-based handrub at the point of patient care; prioritize compliance; provide leadership, administrative support, and financial resources; ensure training; implement a multidisciplinary, multifaceted, and multimodal program to improve adherence; and adhere to national safety guidelines and local legal requirements.
National governments should prioritize adherence; consider funded, coordinated implementation and monitoring; support strengthening of infection control in healthcare settings; promote community hand hygiene; and encourage use of hand hygiene as a quality indicator in healthcare settings.

Clinical Implications

The WHO guidelines recommend handwashing with soap and water for visibly dirty hands, hands visibly soiled with body fluids, after toilet use, exposure to potential spore-forming pathogens, and if alcohol-based handrub is not available in other situations.
The WHO guidelines recommend alcohol-based handrub before and after touching patients; before handling invasive devices; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; between touching contaminated body site and another body site; after contact with inanimate surfaces and objects; and after removing gloves.

Source : http://cme.medscape.com/viewarticle/702403?src=cmenews

Nurse Practitioners, HIV/AIDS, and Nursing in Resource-Limited Settings

2009-05-21T11:30:00.003+07:00

Abstract

HIV/AIDS affects the lives of everyone who lives in sub-Saharan Africa. In the past 3.5 years, access to free antiretroviral therapy has increased dramatically as a result of the support of the President's Emergency Plan for AIDS Relief. Health care must now include caring for those who will live with HIV/AIDS as well as those for whom HIV/AIDS is a terminal illness. This article discusses the contribution of nurse practitioners to the redesign of nurses' work with HIV1 patients in sub-Africa, especially Uganda. Strategies currently being implemented and those planned for the future to increase access to care and improve the quality of nursing care that patients receive are discussed.

Introduction

The UNAIDS/World Health Organization states that in 2006 between 21.8 and 27.7 million persons in sub-Saharan Africa were living with HIV/AIDS.^[1] In addition to these staggering numbers, 14 million children younger than 15 years have lost one or both parents to HIV/AIDS.^[2] This is the largest health problem in this area of the world, and large numbers of health care workers are persons infected with and affected by HIV/AIDS. In the United States, exposure of health care workers to HIV is generally through occupational exposure. In sub-Saharan Africa, the main mode of transmission of HIV is heterosexual transmission, and this is the most common exposure for health care workers also. Besides caring for upward of 100 patients per day in many outpatient clinics, nurses are concerned with accessing their own care and treatment. Although treatment is available, many nurses are reluctant to receive care in the institution in which they work because of stigma. Frequently, they are unable to get to another institution for treatment because of transportation problems or requesting released time from work to get care.

Impact of HIV/AIDS in sub-Saharan Africa

Without access to adequate care and treatment, life expectancy has decreased significantly. For example, in Botswana in 2010, the average life expectancy without AIDS was projected to be 73.2 years. Instead, with AIDS, life expectancy has decreased to 29.0 years; a loss of 44.2 years.^[3] The disease trajectory in sub-Saharan Africa is also different from that in the rest of the world. In the developed world, the course of the disease in persons who do not receive treatment is 12 years from infection to death. In sub-Saharan Africa, the time frame is 5 years. Some of the difference can be explained by the virulence of the different clades (differences in genetic structure of the virus) found in sub-Saharan Africa compared with the virus clades found in the United States. The presence of comorbidities, especially tuberculosis (TB) and malaria and inadequate nutrition, also contribute to the difference in the disease trajectory. Orphaned children are also at higher risk. The usual safety net of families providing care for orphaned children has been decimated because of the high death rates of adults and the ongoing civil wars in many of the countries. The orphaned children younger than 15 years are now frequently the head of the household. They face stigma, extreme poverty, mal nutrition, impaired social and cognitive development, illiteracy, and sexual abuse.

Before the influx of monies for HIV care that began in 2003, poverty prevented most HIV-infected persons from accessing basic health care and antiretroviral (ARV) therapy. The President's Emergency Plan for AIDS Relief (PEPFAR), the Clinton Foundation, the European Union, and the individual African country governments are among the providers of ARV medications and other basic health care services. However, the needs still outweigh the resources available. Persons are at increased risk of opportunistic infections and comorbidities because of malnutrition, lack of clean water, and lack of mosquito nets. Malnutrition and infections depress immune system function. Civil wars have forced many into displaced person camps in which basic sanitation and food are not available, and the crowding further increases the risk of TB and other infections. Even when ARV therapy is available, these living conditions affect the person's response to therapy.

Involvement in Nurse Education

In 2004, I accepted a position as a nurse educator with AIDSRelief/PEPFAR. AIDSRelief is a consortium of five organizations (Institute of Human Virology of the University of Maryland, Catholic Relief Services, Interchurch Medical Assistance, Catholic Medical Mission Board, and Constella Futures) that provides ARV treatment and clinical technical assistance in nine countries. I have been involved in activating clinical sites to care for persons who will begin to receive ARV therapy; individual and group mentoring and precepting; consulting about clinic flow of patients; and developing, implementing, and evaluating a nursing curriculum. In Uganda where I am involved in teaching nurses to care for persons with HIV, AIDSRelief provides free ARV therapy and HIV care to enrolled patients at approximately 20 local partner treatment facilities. As health improves, appetite increases but many persons are unable to purchase sufficient food, so malnutrition persists and can adversely affect drug absorption, and the immune responses to therapy can be blunted.

Now that availability of free or low-cost ARV therapy and care for the average person is increasing, especially in PEPFAR sites, patients, including health care providers, need access to care and, most importantly, durable therapy for a lifetime. HIV care requires a shift in the health care system from a focus on episodic care to continuity care for all HIV-infected persons. Continuity care encompasses community care, out-patient care, and hospital care. Insufficient numbers of medical officers and clinical officers are available to provide care to all HIV-infected persons and HIV^[1] patients on ARV treatment. There are few experienced ART providers in most of sub-Saharan Africa. In addition, limited evidence-based data are available for clinical decision making about HIV care in resource-limited settings.

Redesigning Nurses' Work

One proposed solution to the increasing demand for care is the shifting of HIV/AIDS care, including ART therapy, to nonphysician providers. Nonphysician providers include clinical officers whose education is similar to physician assistants and nurses. Nursing education in sub-Saharan Africa is centered in diploma schools of nursing associated with hospitals, most in rural areas. In several countries, nurses are allowed to open private practices to diagnose and prescribe for patients after having worked as a nurse or midwife for a specified number of years. In most sub-Saharan nations, the term nurse practitioner does not share a common definition with the term in other areas of the world.

Task shifting to nonphysicians will result in increased responsibilities for patient care for nurses. The use of nurses can be increased by developing and implementing critical pathways (algorithms) for clinical decision making for patient care and providing nurses with referral access to physicians with HIV expertise. In addition, the paradigm that only physicians can provide care to persons receiving ARV therapy must be changed. The purpose of this paper is to discuss the contribution of nurse practitioners to the redesign of nurses' work with HIV+ patients to increase access to care and to improve the quality of nursing care patients receive. Practitioners in general and me specifically are involved in a number of projects that will affect the redesign of nurses' work.

For the past 30 months, as part of AIDSRelief, I have traveled regularly to Uganda to assist in developing knowledge and skills for Ugandan health care providers to care for persons receiving ARV therapy. This was a major change for me because nothing in my previous career as a nurse practitioner faculty member at the University of Maryland prepared me for the sometimes risky, dangerous, but exciting settings in which I found myself. Until recently, there was war in northern Uganda where we have opened three clinics. The only way to get to two of these clinics was by air in small planes that only fly during the day, several days of the week. I had my first experience landing on a dirt runway, occasionally claimed by livestock as "their" place. One woman who lived in the area was so thrilled to have a clinic near her home because she would not have to travel over a road that was often the site of raids by the rebel forces. She was willing to make the dangerous trip monthly to get her ARV medications before the clinic opened nearer to her home.

As the senior nurse educator in a multidisciplinary team of US and Ugandan health care providers, my focus is to improve the nursing care given to HIV+ persons. My AIDSRelief nursing colleagues and I have developed a basic curriculum that will expand the nursing services provided to persons infected with HIV. The curriculum is designed to increase the nurses' knowledge and skills in multiple areas. Content includes an overview of HIV pathogenesis and transmission, prevention of mother-to-child transmission, triage, symptom evaluation and management, ARV drug therapy, drug side effects and adverse effects, common opportunistic infections, and adherence. Individual precepting to assist in integrating the newly learned knowledge and skills into practice at the clinics is an integral part of the educational process. With the overwhelming number of patients seen daily, a major focus in working with the nurses is streamlining clinic flow and integrating satellite clinics into the main clinic. In Uganda, we have taught these classes more than 20 times. Our classes are usually small and have 8 to 10 nurses. The curriculum is demanding, but the students have learned easily and accept their role expansion as a matter of fact. A few have extreme anxiety about what their new responsibilities but know that what they do may provide the only care that their villagers will receive. I remember one nurse who said, "It's too far and too expensive for them to get to the hospital so they only go when they are extremely ill. Since I am right there, they come to me first for care before they need to go to the hospital." Nursing students are also interested in increasing their HIV knowledge and skills. When the students at one nursing school learned that I was teaching basic HIV care to the hospital and clinic nursing staff, they requested that I provide the class to them also. They were preparing for national testing and gave up their only free afternoon for the class. The session was scheduled for 1 hour, and at the end of 3 hours we had to stop.

Current and Potential Nurse Practitioner Involvement

In some countries, international health care organizations have used nurse practitioners to provide direct patient care. Nurse practitioners have been visiting faculty at a number of colleges and universities, and still others are doing research with in-country colleagues to address a variety of health issues. Another area in which nurse practitioners are intimately involved in many countries is in train-the-trainer programs.

Through AIDS/Relief, we have accomplished much. However, much more needs to be accomplished. In Uganda, as in other countries, specific plans have been established for meeting the needs of patients with AIDS. Strategies have been or are being developed to do the following.

Strengthen Community Nursing Care for Patients Infected with HIV

All persons with symptoms or opportunistic infections or those receiving ARV therapy should have home visits by nurses. Patients' families must be taught how to care for patients at home. This could also include the establishment of satellite clinics for care. One aspect of community nursing is also teaching and supervising the community workers that are home care providers. Community nurses might also provide links to the traditional healers. Nurses and nurse practitioners can make several contributions to the achievement of this objective.

Care in sub-Saharan Africa has often been confined to hospitals for the more wealthy and to home care for the poor. With the illness or death of so many parents, home care services have to be redefined. In-country nurses in sub-Saharan Africa need the opportunity to increase their skills in home-based care in the areas of symptom evaluation, monitoring of patients receiving ARV therapy, and differentiating medication side effects from adverse drug reactions. Although many health facilities currently offer community or home-based care to enrolled patients, there is wide variation in the type of services offered and in the qualifications of the persons providing care. In many areas, home-based care is provided by community health volunteers who have no formal medical background. Little has been done to teach family caregivers how to care for patients in the home and when to seek care or advice from a health care provider.

The skills and appropriate approach for selecting, training, and supervising community health volunteers are integral parts of community nursing and community health. Nurses and nurse practitioners can be a resource to in-country nurses as they determine who should be a community health volunteer and what the volunteers need to know to work effectively with patients. The nursing skills combined with advanced assessment skills that are the backbone of nurse practitioner practice will be invaluable in refining and implementing training for all community health workers to increase their skills in the assessment and care of persons in their home, including the education of family caregivers. In Uganda, strengthening community nursing is a major focus for next year. We will teach community volunteers basic home care skills such as positioning, range of motion exercises, and signs and symptoms that require immediate evaluation by a health care provider. The community health volunteers will not only be able to expand their assessment skills but will also be able to teach family members how to provide care to patients at home. One of my colleagues is surveying patients, health care providers, and community health workers to determine what characteristics are necessary for community health workers. In conversations with Ugandan nurses, they are enthusiastic, overwhelmed by the idea of increased responsibility, and a little nervous about expanding their roles. In a workshop on triage, everyone was enthusiastic to learn how to examine the mouth for thrush and the lungs for abnormal breath sounds. They could not wait to incorporate these skills into home care and were wondering when the workshop leaders were coming to see them in practice, incorporating the new skills. When the question arose about diagnosing, everyone was happy to be reassured that their job was to recognize normal compared with abnormal, not to diagnose the disease.

Have Nurses Assume Primary Responsibility for Patient Triage in All Outpatient and Community Settings

The ability to extend care to more persons with HIV/AIDS requires nurses to assume increased responsibility for clinical decision making. Skills and knowledge that will enhance the nurses' decision making emphasize the development of core competencies in clinical decision making through the implementation of critical pathways for the triage of ill patients with potentially life-threatening illnesses, continuity of care, and symptom evaluation. Importantly, education should focus also on health system strengthening through the management, administration, and supervision of outpatient HIV care clinics. Nurse practitioners are ideally suited to assist nurses in developing and refining triage skills. Pertinent history taking, focused assessment, appropriate referral, integral to nurse practitioner practice, are skills that nurse practitioners can teach nurses involved in HIV care. Triage is one of the two areas in which I now expend most of my teaching efforts. Community nurses have basic patient triage skills, and we are emphasizing symptom evaluation and management. In clinics, nurses take vital signs and a short history, but they are not secure in making the decision about who should see the medical officer that day and who can wait. Often, everyone is referred to the medical officer even when it is the end of the day and the patient could easily be seen another day. In one of the clinics I frequently visit, I think the word is out that, when the mazunga (white person) is at the triage desk late in the day, patients had better be sick to be seen or they will be told to come back in the next day or two to be seen by the medical officer (Figure 1). Clinic nurses are a little concerned about support for the increased role in triage from the medical community. They feel that their decisions may not be supported or that they do not have the authority to make triage decisions when in the clinic. In many countries, nurses are not viewed as independent decision makers about patient care.

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Figure 1.

A typical clinic waiting area in Uganda

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Figure 1.

A typical clinic waiting area in Uganda

Establish Nurse-Run Clinics in Which the Nurses Will Provide Care to Patients Across the Spectrum of Hiv

Tasks include the following:

Diagnose and manage common opportunistic infections
Assess and manage common signs and symptoms in HIV-infected patients
Provide community nursing for enrolled patients
Refer patients for palliative care
Provide palliative care
Initiate ARV therapy that follows established protocols
Follow patients on ARV therapy
Change ARV therapy according to established protocols
Recognize appropriate referral limits
Refer patients to the medical officer or clinical officer as appropriate

In Uganda, as well as in other countries, the establishment of nurse-run clinics is somewhat controversial, although community nurses routinely perform many of the functions listed above. The redesign of nursing roles and responsibilities to more effectively care for patients with HIV/AIDS requires a different level of authority, responsibility, and accountability. The clinical knowledge base and skill set for increased clinical decision making should be designed to develop clinical expertise to increase clinical judgment skills, appropriate triage skills, skills to maximize adherence, and supervision of community health workers. Algorithms can be used as guidelines for decision making with a variety of patient problems. Nurse practice acts in sub-Saharan African countries do not explicitly recognize the nurse practitioner role as it is conceptualized in the United States and other countries. In many countries midwives and nurses who have been in practice for a specified number of years are allowed to open a private clinic with physician referral. Additional education is not required. Work needs to be done to assist the nursing councils in various countries to revise the nurse practice acts to allow for role expansion. The need to provide patient care to the ever-increasing numbers of HIV-infected persons will overwhelm the traditional barriers to enhancing nursing tasks. In many health care delivery systems support seems to be growing to expand the nurses' responsibilities for more independent clinical decision making about patients.

The knowledge base and skill set needed to enhance nursing tasks can be facilitated by nurse practitioners. Nurse practitioners, nurse educators, and other nurses with HIV expertise are part of AIDSRelief. These professionals participate in developing, implementing, and evaluating algorithms; teach formal classes using the developed curriculum modules; provide individual and group precepting and mentoring; and regularly schedule continuing nursing education that reinforces selected information or skills and provides the nurse with updated information and skills. Within a few months we will have a model health care clinic where nurses and other health care providers will have the opportunity to develop their skills in an interdisciplinary setting, practice with experts, and transfer their learning to providing improved health care in their clinical setting.

The nurses' expanded skill set and knowledge base must incorporate information for both clinical and health services administration. The health services administration information will prepare the nurses to develop, implement, and evaluate the nursing roles and responsibilities in the institutional plan for delivering HIV care in that institution. They must also be prepared to design, implement, and evaluate clinic structure and flow for continuity care. The shift from episodic to continuity care is crucial to the successful therapy of patients with HIV/AIDS. The nursing staff must be full, contributing members of the health care team. Health services administration information is a difficult area to address because of the tradition of top-down decision making. To assist in the identification of real or potential bottlenecks for patients during their clinic visit, I often accompany a patient or two for their entire visit.

Implementing increased clinical decision-making and health services administration skills can be achieved in resource-limited settings with a variety of approaches. Perhaps the most useful model to be used in the future will be intensive training sessions provided by nurse practitioners in specific geographic regions of each country. The purpose of these workshops would be to provide nurses with the basic knowledge and skills to assume expanded responsibilities for patient care and additional responsibility for clinic management and flow. The intensive workshop must be followed with individual mentoring or precepting sessions at the district health facility. The mentoring would best be done by nurse experts in clinical care and experts in health systems management.

Individual nurses who will be starting ARV therapy for patients require additional education for this task. Nurse practitioners would be responsible for intensive education to assist the "prescribing" nurses to develop in-depth knowledge about the criteria for starting ARV therapy, first- and second-line therapies, when to change therapy, and when to stop therapy. Clear lines of communication and referral to physicians must be established before the nurse moves to this level of responsibility. Evaluation of performance must be done at least monthly for several months. At the present time, there is little communication and articulation of nursing care with other providers. In AIDSRelief we have a strong commitment to interdisciplinary patient care. However, as the nurse expert, I have complete autonomy in determining the curriculum and teaching methodologies for the nurses. To assist the Ugandan nurses and physicians in working together, our interdisciplinary team uses every opportunity presented to demonstrate how to work, learn, and deliver care together. Many nurses are still seen and see themselves as subservient to physicians, clinical officers, and other providers. This may negatively affect their ability to work in a collegial role with physicians or to assume increased autonomy for nursing care.

Sustainability Strategies

As I write this article, we are in the process of opening two model clinics in Kampala and Jinja, Uganda, that will be used as teaching clinics for all health care providers. This gives us the opportunity to role model interdisciplinary patient care, clinical decision making, triage, assessment skills, community nursing, and more independent practice of Ugandan nurses.

The overriding goal of assisting the nurses to redesign their work is to develop sustainable programs that will prepare in-country nurses to provide the technical assistance necessary to continue advances in nursing roles and responsibilities. One approach under discussion is developing train-the-trainer programs. Nurse practitioner educators would be valuable in developing and implementing a train-the-trainer approach. In-country nurses with significant HIV experience and knowledge should be identified to participate in this program. The purpose of the program is to provide nurse trainers with instructional strategies and skills to use in educating other nurses for entry-level practice with HIV-infected patients in resource-limited settings.

Personal Reflections

Overall, my experience has been positive. Although we are headquartered in Kampala, the capital city, most of our time is spent in the rural areas. We generally are away for 1 or 2 weeks at a time. The accommodations range from shared rooms in hospital guesthouses to modest hotels (Figure 2). I had to learn to live without hot water and electricity, be meticulous in my handwashing, drink only boiled water, sleep under a mosquito net, do without salads, take my malaria prophylaxis, and use primitive toilet facilities. I have learned to appreciate the local foods, especially matoke served with a nut sauce.

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Figure 2.

Guest house room

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Figure 2.

Guest house room

We have several clinics in northern Uganda. This area of the country has been the site of a long civil war. Although I never felt concerned about my physical security or safety, some of the memories will stay with me forever. In the evening when we would be walking into town for dinner, hundreds of children, called the night visitors, would be walking in the opposite direction, to the safety of the hospital compound to avoid kidnapping by the rebel forces. We often found one or two sleeping on our guesthouse porch. We encountered several women who had their ears and lips cut off by the rebels to prevent them from hearing or sharing information. Many live in abject poverty, totally dependent on charitable organizations for all basic necessities, but their spirit remains unbroken. With the peace talks slowly moving forward, some are choosing to return to their original villages and farms. However, each day I know that I have made a difference to someone.

Other areas, not involved in civil war, also contributed many unforgettable memories. In the villages, I saw small farms growing coffee, tea, vanilla, sugar cane, and papyrus. I had the opportunity to see children learning their tribal dances and playing soccer. I have seen Lake Victoria, elephants up close and personal, zebras, hippopotamuses, and birds of spectacular colors. The best memories are the people I have met and those with whom I have worked.

How to Get Involved

If any nurse practitioner wants to get involved in opportunities such as this, I would suggest contacting the nongovernmental organizations that provide health care. You could also be the nurse for a group coming on a mission to build schools or orphanages or to do other charitable work. If you are a faculty member, some schools are interested in faculty exchange programs. Depending on the length of time you would be spending in a country, you might need a work permit or nursing registration.

In summary, the needs are many and the rewards are tremendous. Nurse practitioners are in a position to make unique contributions to improve the care of HIV− patients receive in resource-limited settings.

Source : http://www.medscape.com/viewarticle/569057

Starting a Career in Critical Care Nursing

2009-05-01T21:33:00.000+07:00

IS CRITICAL CARE NURSING RIGHT FOR ME?
If you are thinking of starting your career in critical care, take this mini quiz.

1.	I enjoy learning new things and constantly challenging myself.	YES	NO
2.	I learn quickly and am able to solve problems.	YES	NO
3.	I like to figure out why things are happening to my patients.	YES	NO
4.	I handle myself well under pressure.	YES	NO
5.	I like to network and discuss issues with other healthcare professionals.	YES	NO

If you answered YES to any of these statements, Critical Care Nursing may be right for you!

Source : http://www.medi-smart.com/cc28.htm

The Faces of ICU Nursing

2009-04-18T09:52:00.000+07:00

A long time ago, if someone said, "I'm a nurse," people had a good idea about where they worked. Nurses generally worked in schools, a physican's office, or in hospitals doing general floor duty. But not anymore. With technology changing at lightening speed, nursing is now highly diversified and specialized. This trend in specialized care is most evident in intensive care nursing.
Giving more specialized care to a wider range of patients is a challenge, but one that is being met by ICU nurses at University of Maryland Medical Center (UMMC), Baltimore, MD, everyday. Regina Hogan, RN, MS, Becca Workman, RN, MS, and Judy Slide, RN, BA, are ICU patient care services managers at UMMC and each one has a unique perspective about her specialty.
The Many Faces of ICUs
Even though intensive care units are sub-specialized - ICUs that provide care to critically ill patients with varying needs - Hogan, Workman, and Slide see similarities between their units. As managers, they see the need to attract new and talented nurses to intensive care nursing. Providing top notch, quality care requires many qualified nurses to fill their staffing schedule.
The Cardiothoracic ICU
At UMMC, the intensive care units are divided into subspecialties - neurocare and surgery, women's and children's health, medicine, and shock trauma. Hogan, a nurse for the last 20 years, is the patient care services manager of the cardiothoracic ICU. She and her staff typically care for cardiac and thoracic patients after they come out of the OR. They also care for a large number of postoperative esphogectomy patients. Hogan says, "More of these procedures are done at our hospital than at any other hospital in the area."
Another exciting dimension to her job is the unit's involvement with the National Emphysema Trial. In a partnership with The John Hopkins Hospital, UMMC surgeons are performing lung volume reductions on patients. A lung volume reduction involves removing parts of the lung that are no longer functional. Hogan said, "My staff and I have a great opportunity to grow professionally by caring for these [emphysema] patients. The technology is amazing and it's always changing."
The Medical/Oncology ICU
Workman is the medical/oncology ICU patient care services manager. A nurse since 1978, she was drawn to oncology nursing by her desire to care for cancer patients. She and her staff are focused on helping their patients through crisis situations. "Nurses need to be compassionate and try to understand what the patients and their families are going through," says Workman. Besides caring for critically ill cancer patients, her ICU staff also cares for patients awaiting organ transplants. Workman says, "Our hospital is one of the largest solid organ transplant centers in the country."
The Neurocare ICU
Judy Slide is the patient care services manager for the neurocare ICU. Slide's patients are critically ill patients that require specialized neurological monitoring and care. A nurse for 22 years, Slide said she's amazed by the changes in technology since entering the nursing field.
One piece of equipment used in neurocare not commonly found in other intensive care units is a device that measures intracranial pressure. Using a fiberoptic probe, Slide's staff can constantly monitor a patient's condition. However, she added, "A neuro ICU nurse has to be able to pick up slight changes in a patient's condition even before they register on a monitor." Physicians rely on a nurse's keen ability to observe minute changes in level of consciousness. Without it, patient care may be jeopardized.
The Common Threads of Intensive Care Nursing
One way that nurses can learn more about intensive care nursing is through a program at UMMC called the Critical Care Nurse Fellowship Program. This program provides the opportunity for nurses from other specialties, as well as new graduates, to learn more about ICU nursing. When talking about the program Hogan says, "every new grad I've brought in the ICU has succeeded. They are wonderful critical care nurses. I'm proud of that." Slide and Workman also agree - if given the chance, nurses will rise to the challenge.
Teamwork is another common thread that runs throughout the units. When discussing the teamwork displayed by ICU nurses, Workman says, "nurses are each others' back up and support. When you see a patient in crisis, everyone's concern is to make sure they get the best chance possible of making it."
Slide and Hogan have had similar experiences on their units. Each told stories about how their nurses work together in times of crisis to help each other out. When you have to work so closely with one another, comaraderie naturally develops. Because "ICU nurses work closely with the physicians, teamwork makes it a rewarding experience," says Workman.
Meeting Challenges was Never This Fun
Like anything else, there is a downside to working in an ICU. Working long hours and dealing with life and death situations everyday can take it's toll even on the best of us. "When people are really sick, you feel like you want to be in two places at once," said Hogan. Financially, nurse managers face the challenge of balancing a unit budget. Hogan says, "without sacrificing the quality of care patients receive, a nurse manager is responsible for keeping the unit financially viable." Addressing staffing issues and the high acuity of their patients can also be a daunting task for ICU nurses. Nevertheless, all three managers enjoy what they do. "My job is to serve my staff. By meeting their needs, they can better meet the needs of the patients," says Hogan.
There is diversity and common ground in ICU nursing. The nurses at University of Maryland Medical Center strive to meet today's healthcare challenges, helping to serve the needs of their community. Next time someone asks you what you do, say it and say it proud, "I'm a nurse and I'm everywhere."

Source : http://include.nurse.com/apps/pbcs.dll/article?AID=20007100310

Intensive Care Nurse-Community

Cardiovascular Risk After Ischemic Attack Predicted By Ultrasound

Thalidomide Does Not Improve Survival In Small Cell Lung Cancer, Study Finds

Sleep-Disordered Breathing Linked With Behavior Problems in Asthma

Prasugrel Approved for Use During PCI, FDA Announces

Why H1N1 Flu Spreads Inefficiently

Chronic Kidney Disease and its Management

Risk factors

Symptoms

Signs

Issues that should be discussed with the patient6

In newly diagnosed with eGFR less than 60 ml/min/1.73 m2

All stages of CKD3

Additional management for CKD stage 3 includes3

Additional management for CKD Stages 4-5 includes3

Renal replacement therapy

WHO Issues Patient Care Checklist for Influenza A (H1N1)

High-Dose Intravenous Esomeprazole May Reduce Recurrent Peptic Ulcer Bleeding

ASMBS 2009: Elderly Obese Patients Benefit From Weight Loss Surgery

Vasopressin and Epinephrine vs. Epinephrine Alone in Cardiopulmonary Resuscitation

Description

Hypothesis

Drugs/Procedures Used

Principal Findings

Interpretation

Conditions

Therapies

Study Design

Randomized. Blinded. Parallel. Stratified.

Primary Endpoints

Secondary Endpoints

Patient Population

Exclusions:

Recession-Related Surge in Nursing Employment Just a Blip, Study Cautions

Administration of PRN Range Opioid Analgesic Orders for Acute Pain

Abstract

Introduction

Methods

Data Analysis

Results

Respondent Characteristics

Timing and Titration

Relationship of Respondent Characteristics and Comfort in Titration and Vignette Responses

Figure 1.

Figure 2.

Factors to Consider in Opioid Administration

Discussion

Timing

Titration

Relevance of Findings

Limitations

Summary

Pacemaker and Automatic Internal Cardiac Defibrillator

Basic Concepts

Pacing Codes

Table

Pacemaker and ICD Indications

Magnet Inhibition

Pacemaker Malfunctions and Complications

ICD Complications

Resuscitation

Admission and Difficulties Surrounding a Safe Discharge

Summary

Multimedia

References

Serious Parenteral Medication Errors Common in Intensive Care Units

Home-Based Care Administered by Skilled Nurses Comparable to Standard Care for Obstructive Sleep Apnea

Proper Oral Hygiene May Cut Risk of Pneumonia in Critically Ill Patients

Evidence-Based Catheter-Care Procedures May Reduce Bloodstream Infection Rate

Clinical Context

Study Highlights

Clinical Implications

Sedatives and Hypnotics May Increase Risk for Suicide in Elderly Patients

World Health Organization Issues Guidelines on Hand Hygiene in Healthcare

Clinical Context

Study Highlights

Clinical Implications

Nurse Practitioners, HIV/AIDS, and Nursing in Resource-Limited Settings

Abstract

Introduction

Issues that should be discussed with the patient⁶

In newly diagnosed with eGFR less than 60 ml/min/1.73 m²

All stages of CKD³

Additional management for CKD stage 3 includes³

Additional management for CKD Stages 4-5 includes³