Perioperative cardiopulmonary arrest competencies.

Although basic life support skills are not often needed in the surgical setting, it is crucial that surgical team members understand their roles and are ready to intervene swiftly and effectively if necessary. Ongoing education and training are key elements to equip surgical team members with the skills and knowledge they need to handle untimely and unexpected life-threatening scenarios in the perioperative setting. Regular emergency cardiopulmonary arrest skills education, including the use of checklists, and mock codes are ways to validate that team members understand their responsibilities and are competent to help if an arrest occurs in the OR. After a mock drill, a debriefing session can help team members discuss and critique their performances and improve their knowledge and mastery of skills.

Nurse-initiated defibrillation: are nurses confident enough?

OBJECTIVES: To determine the capability of nurses to identify ventricular fibrillation (VF) and ventricular tachycardia (VT) rhythms on an ECG and carry out subsequent defibrillation on their own as soon as they identify and confirm cardiac arrest. METHODS: This was a prospective cohort study to determine the capability of emergency department (ED) nurses to recognise VF or pulseless VT correctly and their willingness to perform defibrillation immediately in an ED of a teaching hospital in Hong Kong. A questionnaire was completed before and after a teaching session focusing on the identification of rhythms in cardiac arrest and defibrillation skills. Correct answers for both ECG interpretation and defibrillation decisions scored one point for each question. The differences in mean scores between the pre-teaching and post-teaching questionnaires of all nurses were calculated. RESULTS: 51 pre-teaching and 43 post-teaching questionnaires were collected. There were no statistically significant changes in ECG scores after teaching. For defibrillation scores, there was an overall improvement in the defibrillation decision (absolute mean difference 0.42, p=0.014). Performance was also improved by the teaching (absolute mean difference 0.465, p=0.046), reflected by the combination of both scores. Two-thirds (67%) of nurses became more confident in managing patients with shockable rhythms. CONCLUSION: Nurses improve in defibrillation decision-making skills and confidence after appropriate brief, focused in-house training.

ICU nurses' perceptions of potential constraints and anticipated support to practice defibrillation: a qualitative study.

AIM: The study examines the experience of intensive care nurses in caring for patients in cardiac arrest, and their perceptions of introducing nurse-led defibrillation. METHOD: This was a descriptive, exploratory and qualitative study at an intensive care unit (ICU) of an acute regional hospital in Hong Kong. Twelve registered nurses were purposefully selected for interview. RESULTS: Although all the participants were trained in basic life support, only 50% were trained in advanced cardiac life support (ACLS), and those trained in ACLS described having limited opportunities to apply their defibrillation knowledge. Whilst participants believed that they were theoretically prepared to influence the patient's resuscitation outcomes, newly qualified nurses were reluctant to be accountable for defibrillation. In contrast, experienced nurses were more willing to perform nurse-led defibrillation. Support from management, cooperation between nurses and doctors, regular in-hospital 'real-drill' programmes, sponsorship for training, and the use of alternative defibrillation equipment should be considered to encourage nurse-led defibrillation in ICU settings. CONCLUSION: Nurse-led defibrillation is an approach of delivering prompt care to critically ill patients, and a way ahead for intensive care nursing in Hong Kong. Emphasis on a consistent policy to promote nurse-led defibrillation practice is needed.

Ventricular arrhythmias and sudden death in patients with chronic kidney disease.

One in four dialysis patients will die suddenly. Most do not fall into the high-risk categories that are associated with sudden death in the general population. The cause of sudden death in the dialysis population is unknown. It may be related to factors associated with chronic kidney disease (CKD) itself, for example, inflammation, vascular stiffness, left ventricular hypertrophy, coronary artery disease, electrolyte/fluid abnormalities or autonomic dysfunction. Studies of patients with implantable cardioverter defibrillators have shown that patients with CKD are more likely to use their devices for ventricular arrhythmias but in spite of this still have a high associated mortality. Until a comprehensive risk stratification strategy is understood, minimising risk by good control of basic parameters such as fluid balance, electrolytes and blood pressure, along with careful assessment of all patients for evidence of coronary artery disease and heart failure is the mainstay of management of the CKD patient.

Electrocardiographic evaluation of cardiovascular status.

The electrocardiogram (ECG) is indispensable for the diagnosis and management of patients with a wide variety of cardiac and noncardiac diseases. The purpose of this paper is focused on recent research that used ECG, specifically the long-QT interval and microvolt T wave alternans, for the evaluation of life-threatening ventricular arrhythmias. Although remaining to be validated, QT prolongation along with other emerging electrocardiographic indices such as T wave morphology, T peak-to-T end time, or beat-to-beat QT variability may be sensitive indicators of malignant polymorphic ventricular tachyarrhythmia, torsade de pointes. Microvolt T wave alternans may provide important information in identifying a low-risk group with left ventricular dysfunction who is unlikely to benefit from unnecessary prophylactic implantable cardioverter defibrillator therapy. These ECG markers have the potential to aid in the safe administration of individualized medications, avoidance of sudden cardiac death, and provision of a noninvasive strategy to identify patients who are most and least likely to benefit from expensive prophylactic implantable cardioverter defibrillator placement.

A revised role for the hospital cardiac arrest team?

This prospective study assesses the role of the hospital cardiac arrest team. We have determined who is responsible for return of spontaneous circulation in those patients who survive to discharge. A total of 83 adult patients were analysed over a 5 month period. Fifty-five patients had cardiopulmonary resuscitation after an in hospital cardiac arrest and circulation was restored in 14 (25.5%). Eight (14.5%) patients survived to discharge. All eight survivors had circulation restored by the first responder before arrival of the cardiac arrest team. Six survivors had witnessed ventricular fibrillation and successful defibrillation by nursing staff. The two other survivors had cardiac arrests in the presence of doctors. Twenty-eight patients had pre-hospital cardiac arrests and were attended by the cardiac arrest team in the emergency department. Six patients had circulation restored by the emergency medical services prior to hospital arrival and four (14%) survived to discharge. Two patients had circulation restored in the emergency department by the arrest team and none survived to discharge. All the survivors to hospital discharge had first responder return of spontaneous circulation. We suggest a revised role for the cardiac arrest team.

Third generation antitachycardia pacing implantable cardioverter-defibrillators.

With advanced third-generation implantable cardioverter-defibrillator (ICD) technology, patients receiving electrical therapy may only be aware of symptoms such as palpitations, or may be completely unaware of the event. Third-generation ICDs provide bradycardia back-up pacing, antitachycardia pacing (ATP), cardioversion, and defibrillation therapy. Additional benefits are noninvasive electrophysiologic testing capabilities and enhanced diagnostic features. An alternative surgical approach with a nonthoracotomy lead system is now also available.