Outcomes Associated With Electrical Cardioversion for Atrial Fibrillation When Performed Autonomously by an Advanced Practice Provider.

OBJECTIVES: This study sought to determine the feasibility, safety, and efficacy of elective electrical cardioversion (CV) for atrial fibrillation (AF) when performed autonomously by a trained advanced practice provider (APP) using a guideline-directed protocol. BACKGROUND: APPs have emerged as an integral part of the cardiovascular team. METHODS: A licensed advanced practice nurse-clinical nurse specialist was trained and obtained credentials to perform CVs. The advanced practice nurse performed 415 CVs autonomously (APP group) in a noninvasive procedure room with an electrophysiologist (EP) immediately available in an adjacent electrophysiology laboratory. The APP performed a history and physical examination, obtained informed consent, reviewed each patient with the supervising EP, and performed the CV. An anesthesiologist administered sedation. Outcomes were compared with 387 CVs performed by an MD when the APP was not available (MD group). Patient satisfaction scores were compared before and after the APP-directed CVs were performed. RESULTS: The proportion of patients discharged in sinus rhythm was the same in the APP group as it was in the MD group (95% vs. 96%, respectively; p = 0.49). There were 4 adverse events in the CVs performed by the APP: 1 transient ischemic attack and 3 occurrences of bradycardia requiring atropine or other medication. There was 1 adverse event in the MD group, which was hypotension requiring vasopressor initiation. Patient satisfaction scores were stable after initiation of APP-driven cardioversions. CONCLUSIONS: With appropriate clinical training, an APP can safely perform CVs autonomously, using a protocol that includes a guideline-directed procedural checklist and physician supervision, with excellent patient satisfaction and outcomes.

Exposure to biological maternal sounds improves cardiorespiratory regulation in extremely preterm infants.

OBJECTIVE: Preterm infants experience frequent cardiorespiratory events (CREs) including multiple episodes of apnea and bradycardia per day. This physiological instability is due to their immature autonomic nervous system and limited capacity for self-regulation. This study examined whether systematic exposure to maternal sounds can reduce the frequency of CREs in NICU infants. METHODS: Fourteen preterm infants (26-32 weeks gestation) served as their own controls as we measured the frequency of adverse CREs during exposure to either Maternal Sound Stimulation (MSS) or Routine Hospital Sounds (RHS). MSS consisted of maternal voice and heartbeat sounds recorded individually for each infant. MSS was provided four times per 24-h period via a micro audio system installed in the infant's bed. Frequency of adverse CREs was determined based on monitor data and bedside documentation. RESULTS: There was an overall decreasing trend in CREs with age. Lower frequency of CREs was observed during exposure to MSS versus RHS. This effect was significantly evident in infants ≥ 33 weeks gestation (p=0.03), suggesting an effective therapeutic window for MSS when the infant's auditory brain development is most intact. CONCLUSION: This study provides preliminary evidence for short-term improvements in the physiological stability of NICU infants using MSS. Future studies are needed to investigate the potential of this non-pharmacological approach and its clinical relevance to the treatment of apnea of prematurity.

Iatrogenic hyperkalemia as a serious problem in therapy of cardiovascular diseases in elderly patients.

INTRODUCTION: The therapy of cardiovascular diseases has improved rapidly over the past 20 years. The most commonly used medications in cardiac patients are drugs affecting potassium homeostasis in the kidneys or the gastrointestinal tract, particularly inhibitors of renin-angiotensin-aldosterone (RAA) axis. They all can lead to hyperkalemia. This disorder may cause severe damage to the muscles and both the nervous and cardiovascular systems. OBJECTIVES: The aim of this study was to evaluate the incidence and clinical course of moderate and severe iatrogenic hiperkalemia in patients hospitalized for cardiovascular disease. PATIENTS AND METHODS: The present study analyzed a history of 26 patients with severe or moderate iatrogenic hyperkalemia, selected from among 5553 patients hospitalized in the years 2005-2006 in the Department of Clinical Cardiology of the Swietokrzyskie Cardiology Center, Kielce. They accounted for 0.46% of all patients treated at that time at the Ward. RESULTS: The concentration of potassium on admission to hospital was > 6.0 mmol/l. Before admission all patients were treated in out-patient clinics with angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, spironolactone, amiloride, triam-terene, beta-blockers, or potassium supplements administered in monotherapy or in combination. A mean age of patients was 79 years, most of them (80%) were women. The average blood potassium level was 7.3 mmol/l on admision and 5.1 mmol/l at discharge. Severe bradyarrhythmia and complete atrioventricular block requiring temporary pacing (n = 13) were observed in 21 patients (81%). Twenty-four patients (85%) had elevated levels of renal function parameters on admission. The average creatinine level on admission was 2.64 mg/dl, and 2.06 mg/dl on discharge. Ten (38%) out of 26 patients suffered from diabetes and 21 patients (81%) had arterial hypertension. Three out of 26 patients died in the hospital despite intensive therapy. CONCLUSIONS: Polypharmacy should be used with particular caution in subjects treated on the ambulatory basis. During administration of inhibitors of RAA system, particularly in elderly out patients, renal function and serum electrolytes should be appropriately monitored both prior to and during the treatment.

[The oculocardiac reflex in blepharoplasties]. / Der okulokardiale Reflex bei Blepharoplastiken.

The oculocardiac reflex (OCR) is a well-known phenomenon in ophthalmic surgery, but is rarely described in aesthetic blepharoplasty surgery. It was first mentioned in 1908 by Ascher and Dagnini. Since then, ophthalmologists and anaesthesiologists have regarded the onset of the oculocardiac reflex as a significant intraoperative problem, which is undermined by several case reports that describe dysrhythmias which have haved caused morbidity and death. Per definition the OCR is caused by ocular manipulation and involves intraoperative bradycardia by a change of 20 beats/minute compared to the preoperative heart rate or any dysrhythmia during the manipulation via a trigeminal-vagal-mediated reflex arc. Having operated on a 48-year-old, healthy woman in our clinic, who underwent a cardiac arrest during the blepharoplasty procedure, followed by a successful resuscitation, we investigated the onset of the OCR in our blepharoplasty patients within the last 3 years. The onset of the OCR was noted in 22 of 110 (20 %) blepharoplasty patients, mainly affecting younger, low-weighted patients operated under local anaesthesia. Awareness and treatment of this potentially life-threatening oculocardiac reflex are necessary. In most cases the onset of the reflex may be avoided by a gentle operation technique and by refraining from severe traction to the muscle or fat pad. The best treatment of a profound bradycardia caused by the OCR is to release tension to the muscle or fat pad in order to permit the heart rate to return to normal. Intraoperative monitoring is of utmost importance.

Adverse medical events associated with cataract surgery performed under topical anaesthesia.

BACKGROUND: Cataract surgery in Australia is increasingly performed in an elderly population with multiple medical comorbidities. The purpose of this study was to investigate the frequency and type of adverse medical events associated with cataract surgery performed under topical anaesthesia with light sedation. METHODS: Retrospective analysis was undertaken for 631 consecutive cases of clear corneal phaco-emulsification and implant surgery performed under assisted topical anaesthesia, by a single surgeon (TR) in a private ophthalmic day surgery unit. In the 238 patients who underwent bilateral surgery, data from the first procedure for each patient were analysed, unless the second procedure was associated with greater morbidity. RESULTS: A total of 393 procedures were included in the study. The mean age was 73 +/- 11 years with 75% of patients having at least one significant medical comorbidity. The most common comorbidities were hypertension (51%), gastro-oesophageal reflux (19%), angina and myocardial infarction (14%), diabetes (13%) and asthma (9%). Significant intraoperative adverse medical events requiring intervention occurred in four cases (1%): bradycardia occurred in three cases and hypotension in one case. None of these adverse events resulted in death or hospitalization. There were no postoperative adverse events, hospitalizations or deaths within 7 days. Minor changes in heart rate, blood pressure and oximetry not requiring intervention were observed in 35 cases (9%). CONCLUSION: This retrospective analysis shows that cataract surgery performed under assisted topical anaesthesia is safe with a low rate of systemic complications despite being performed in an elderly population.

Score indices for predicting electrophysiologic outcomes in patients with unexplained syncope.

INTRODUCTION: Our ability to predict a positive electrophysiologic (EP) study in the evaluation of unexplained syncope is suboptimal. AIMS: In patients with unexplained syncope, we defined clinical predictors of bradyarrhythmia and ventricular tachycardia (VT) diagnosed during EP study, constructed diagnostic score indices for bradyarrhythmia and VT, and evaluated the predictive power of each score index. METHODS: All patients evaluated in the Arrhythmia Clinic for unexplained syncope from January 1, 1996, through December 31, 1998, were identified and enrolled in the study. Five hundred eight patients (325 [64%] men; mean+/-SD age, 64+/-17 years) underwent EP testing. We analyzed elements from historical data and noninvasive laboratory findings as predictors of bradyarrhythmia and VT diagnosed on EP study. RESULTS: Fifty-eight patients (11%) had sinus node dysfunction, 94 (19%) had atrioventricular (AV) node disease, 92 (18%) had His-Purkinje system disease, and 101 (20%) had VT. Models were fit using logistic regression analysis. Predictors were assigned weighted scores, and a score index was formulated. The area under the curve associated with sinus node dysfunction, AV node disease, His-Purkinje system disease, and VT models was 0.64, 0.60, 0.84, and 0.60, respectively. CONCLUSIONS: We have constructed diagnostic score indices for EP outcomes of bradyarrhythmia and VT in syncope. Of all the score indices, the model for His-Purkinje system disease has the highest predictive power.