Exploring population pharmacokinetic models in patients treated with vancomycin during continuous venovenous haemodiafiltration (CVVHDF).

BACKGROUND: Therapeutic antibiotic dose monitoring can be particularly challenging in septic patients requiring renal replacement therapy. Our aim was to conduct an exploratory population pharmacokinetic (PK) analysis on PK of vancomycin following intermittent infusion in critically ill patients receiving continuous venovenous haemodiafiltration (CVVHDF); focussing on the influence of dialysis-related covariates. METHODS: This was a retrospective single-centre tertiary level intensive care unit (ICU) study, which included patients treated concurrently with vancomycin and CVVHDF between January 2015 and July 2016. We extracted clinical, laboratory and dialysis data from the electronic healthcare record (EHR), using strict inclusion criteria. A population PK analysis was conducted with a one-compartment model using the PMetrics population PK modelling package. A base structural model was developed, with further analyses including clinical and dialysis-related data to improve model prediction through covariate inclusion. The final selected model simulated patient concentrations using probability of target attainment (PTA) plots to investigate the probability of different dosing regimens achieving target therapeutic concentrations. RESULTS: A total of 106 vancomycin dosing intervals (155 levels) in 24 patients were examined. An acceptable 1-compartment base model was produced (Plots of observed vs. population predicted concentrations (Obs-Pred) R2 = 0.78). No continuous covariates explored resulted in a clear improvement over the base model. Inclusion of anticoagulation modality and vasopressor use as categorical covariates resulted in similar PK parameter estimates, with a trend towards lower parameter estimate variability when using regional citrate anti-coagulation or without vasopressor use. Simulations using PTA plots suggested that a 2 g loading dose followed by 750 mg 12 hourly as maintenance dose, commencing 12 h after loading, is required to achieve adequate early target trough concentrations of at least 15 mg/L. CONCLUSIONS: PTA simulations suggest that acceptable trough vancomycin concentrations can be achieved early in treatment with a 2 g loading dose and maintenance dose of 750 mg 12 hourly for critically ill patients on CVVHDF.

Depressive symptoms after a myocardial infarction and self-care.

This descriptive study examined depressive symptoms impacting the performance of self-care behaviors in patients (N = 62) who have experienced a myocardial infarction (MI). Having had a prior MI is inversely associated with decreased self-care behaviors at 30 days. Depressive symptoms of agitation and loss of energy significantly impacted self-care performance 30 days after discharge from the hospital. A variance of 21% (P < .05) in patients who experienced a prior MI and exhibited depressive symptoms of agitation and loss of energy at 30 days suggests patient vulnerability after discharge and a window for therapeutic interventions.

Over time: reflections after a myocardial infarction.

Self-care is especially important after a heart attack when daily lifestyle changes are needed. Performance of self-care behaviors after a myocardial infarction assists individuals in minimizing the progression of coronary heart disease. Uncovering patients' reflections after myocardial infarction provides a therapeutic window to target self-care interventions.

A successful 39-week pregnancy on hemodialysis: a case report.

Pregnancy in women on hemodialysis is very uncommon, and rates of spontaneous abortion, hypertension, pre-eclampsia, polyhydramnios, pre-term labor, and premature birth are high. This article documents a successful 39-week pregnancy in a woman who conceived at Stage 5 in chronic kidney disease and who started hemodialysis at 7 weeks gestation. The dialysis prescription included 3-hour treatments 5 times weekly. Blood urea nitrogen levels and fluid removal by ultrafiltration were managed according to the recommendations in the available literature. Erythropoietin and IV iron were utilized liberally for her worsening anemia. She was closely monitored by a multidisciplinary team at the dialysis center and by the perinatologist in her health care system. Pre-term labor and premature birth were avoided; however, she developed hypertension, pre-eclampsia, and polyhydramnios. She delivered a healthy female by scheduled cesarean section. There is limited data on management of this minority population, and much can be learned regarding mineral metabolism, safety and use of medications, control of hypoalbuminemia, and care practices to reduce the incidence of maternal complications and premature birth.

The Therapeutic Relationship: Enhancing Referrals.

PURPOSE: This article focuses on the ways rehabilitation nurses use the therapeutic relationship to lessen barriers some veterans experience when a referral to mental health treatment is recommended. DESIGN: Veterans presenting with posttraumatic stress symptoms are discussed, and possible interventions within the therapeutic relationship are proposed. METHOD: Veterans' perception of mental health stigma, building a collaborative therapeutic relationship, recommending a referral and assessments of stress responses, posttraumatic stress symptoms, suicide risk, and intervention strategies are proposed. FINDINGS: When changes in functioning and suicidality occur in veterans with posttraumatic stress disorder symptoms, it is important to screen and engage veterans at risk. CONCLUSIONS AND CLINICAL RELEVANCE: When veterans in the rehabilitation process present with a need for mental health referral, barriers to treatment may include the stigma of mental health treatment. Rehabilitation nurses using the therapeutic relationship act as change agents to assist veterans in overcoming these barriers to treatment. The therapeutic relationship provides nurses with a foundation to provide opportunities for veterans to be supported and to seek treatment.

Teaching/learning health promoting behaviors through telehealth.

Associate degree nursing students in a community setting apply self-efficacy theory while helping clients with chronic health problems take personal responsibility for health-related behaviors. Students meet weekly with clients in an apartment complex for seniors and use the telephone to work toward achieving desired short-term health outcomes. Between weekly meetings, they use the telephone to coach clients while establishing a trusting relationship. The role of the faculty member in supervising students is explored.

Reflecting on a self-care process in the home setting for traumatic brain injury survivors.

An estimated 5.3 million Americans are living with disabilities from traumatic brain injuries. Traumatic brain injury (TBI) can cause a wide range of functional changes affecting thinking, emotions, and behaviors, or a combination of any of these. Reflecting on a self-care process for patients in TBI home rehabilitation programs becomes critical for nurses who desire to optimize patient functioning. As the young patients' brain plasticity impacts adjustments to deficits and injury, applying the self-care process in the home setting provides a natural healing environment. As TBI survivors recognize and regulate their own behaviors, application of nursing actions dynamically match this change.

Nursing protocol for telephonic supervision of clients.

Access to care, client vulnerabilities, technology, and health costs affect not only the delivery of health care but also the roles, responsibilities, and opportunities for nurses. Patients are often managed in the home or discharged from hospitals before they or their families are ready. To address some of these needs, nurses are utilizing telehealth opportunities. For many nurses, telehealth translates to telephonic nursing. This article provides an algorithm that nurses can utilize in order to safely monitor patients in their homes. This can be a cost-effective program, particularly for those who are homebound or for persons, such as the elderly or those with chronic illness, who have long-term needs that vary between relative health and acute illness. This algorithm serves as a guide in our nursing practice for the telephonic supervision of patients in the home environment.

High-fidelity simulation-based training in neonatal nursing.

Simulation-based training is a novel approach that facilitates the use of higher order thinking skills. Simulation-based training challenges medical professionals to develop cognitive, technical, and behavioral skills through the use of mannequins, working medical equipment, and human colleagues. During scenarios, trainees must make use of their knowledge base, analyze and synthesize factors contributing to the crises, and evaluate the effects of their actions. Feedback indicates that simulation-based training programs are more pertinent to and better accepted by adult learners than traditional programs. The instructional methodologies used in simulation-based training programs are more in line with the tenets of adult learning.