Evidence-Based Practice: Use of STOP-BANG Questionnaire to Identify Obstructive Sleep Apnea.

Certified Registered Nurse Anesthetists (CRNAs) provide care for patients with undiagnosed obstructive sleep apnea (OSA). This evidence-based practice project demonstrated that the STOP-BANG Questionnaire (SB) identified patients with OSA preoperatively and reduced hypoxemia in the postanesthesia care unit (PACU). Evidence from the literature is described; based on this evidence, a change in clinical anesthesia practice was made. Four literature databases were searched using keywords from the following PICOT (patient, intervention, comparison, outcome, time) question: Do patients (P) who have high SB scores (I) compared with patients who do not have high SB scores (C) have a higher incidence of pulmonary complications (O) postoperatively (T)? Five observational cohort studies were critically appraised. The results consistently found that patients with an SB score of 3 or greater had significantly greater postoperative pulmonary complications, including lower oxyhemoglobin saturation (SpO2) in the PACU. At the Brooke Army Medical Center in San Antonio, Texas, the SB was implemented during the preanesthesia assessment. A query of the electronic medical record identified patients with undiagnosed OSA and patients with hypoxemia (SpO2 < 94%) in the PACU. Implementation of the SB increased identification of undiagnosed OSA by 78% preoperatively and reduced the incidence of hypoxemia in the PACU.

Association between Manchester Triage System discriminators and nursing diagnoses. / Associações entre discriminadores do Sistema de Triagem de Manchester e diagnósticos de enfermagem.

OBJECTIVE: To analyze the association between Manchester Triage System flowchart discriminators and nursing diagnoses in adult patients classified as clinical priority I (emergency) and II (very urgent). METHOD: Cross-sectional study conducted in an emergency department in southern Brazil between April and August 2014. The sample included 219 patients. Data were collected from online patient medical records and data analysis was performed using Fisher's exact test or the chi-square test. RESULTS: 16 discriminators and 14 nursing diagnoses were identified. Associations were found between seven discriminators and five problem-focused nursing diagnoses, including the discriminator Cardiac pain and the diagnosis Acute pain. Three discriminators were associated with four risk nursing diagnoses, among these Acute neurological deficit with the diagnosis Risk of ineffective cerebral tissue perfusion. CONCLUSION: Significant associations were found between Manchester Triage System discriminators and the nursing diagnoses most frequently established in the emergency department.

Application of prone position in hypoxaemic patients supported by veno-venous ECMO.

INTRODUCTION: Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is an advanced respiratory care therapy allowing replacement of pulmonary gas exchange. Despite VV-ECMO support, some patients may remain hypoxaemic. A possible therapeutic procedure for these patients is the application of prone positioning. OBJECTIVE: The primary aim of the present study was to investigate modification of the PaO2/FiO2 ratio, in VV-ECMO patients with refractory hypoxaemia. The secondary aim was to evaluate the safety and feasibility of prone positioning for patients with severe Adult Respiratory Distress Syndrome supported by ECMO. METHODS: We retrospectively reviewed the electronic records and charts of all patients supported by VV-ECMO who experienced at least one pronation. Complications related with prone positioning were also recorded. First PaO2/FiO2 ratio was analysed during four different time steps: before pronation, one hour after pronation, at the end of pronation and one hour after returning to supine. RESULTS: A total of 45 prone positioning manoeuvers were performed in 14 VV-ECMO patients from November 2009 to November 2014. The median duration of prone positioning cycles was 8 hours (IQR 6-10). No accidental dislodgement of intravascular lines, endotracheal tubes, chest tubes or a decrease in ECMO blood flow was observed. During the first prone positioning for each patient, the median PaO2/FiO2 ratio recorded was 123 (IQR 82-135), 152 (93-185), 149 (90-186) and 113 (74-182), during PRE-supine step, 1 h-prone positioning step, END-prone positioning step, and POST-supine step respectively. CONCLUSIONS: The application of prone positioning during VV-ECMO has shown to be a safe and reliable technique when performed in a recognised ECMO centre with the appropriately trained staff and standard procedures.

Associações entre discriminadores do Sistema de Triagem de Manchester e diagnósticos de enfermagem / Asociación entre el Sistema de Triage Manchester y el diagnóstico de enfermería / Association between Manchester Triage System discriminators and nursing diagnoses

Resumo OBJETIVO Analisar associações entre discriminadores do Sistema de Triagem de Manchester e Diagnósticos de Enfermagem em pacientes adultos, classificados com prioridade clínica I (emergência) e II (muito urgente). MÉTODO Estudo transversal realizado na unidade de emergência do sul do Brasil, entre abril e agosto de 2014. Amostra de 219 pacientes. Os dados foram coletados no prontuário online e analisados estatisticamente, com teste exato de Fisher ou qui-quadrado. RESULTADOS Encontrou-se 16 discriminadores e 14 diagnósticos de enfermagem. Houve associação entre sete discriminadores e cinco diagnósticos de enfermagem do tipo foco no problema, dentre Dor precordial ou cardíaca com o diagnóstico Dor aguda. Também houve associação entre três discriminadores com quatro diagnósticos de enfermagem de risco, dentre Déficit neurológico agudo com o diagnóstico Risco de perfusão tissular cerebral ineficaz. CONCLUSÃO Existem associações significativas entre discriminadores do Sistema de Triagem de Manchester e diagnósticos de enfermagem mais frequentemente estabelecidos na Unidade de Emergência.

Resumen OBJETIVO Analizar asociaciones entre los discernidores del Sistema Triaje de Manchester y los Diagnósticos de Enfermería en pacientes adultos con prioridad clínica I (emergencia) y II (muy urgente). MÉTODO Estudio transversal realizado en la unidad de emergencia del sur de Brasil, entre abril y agosto de 2014, con la muestra de 219 pacientes. La colecta de datos fue realizada en el prontuario online de los pacientes. El análisis estadístico fue realizado con el uso del Test Exacto de Fisher o chi-cuadrado. RESULTADOS Fue identificado el uso de 16 discernidores y 14 diagnósticos de enfermería. Hubo una asociación entre siete discernidores y cinco diagnósticos de enfermería del tipo foco en el problema, entre estos Dolor precordial o cardíaca y Dolor agudo. También hubo asociación entre tres discernidores y cuatro diagnósticos de enfermería de riesgo, entre estos Déficit neurológico agudo con el diagnóstico Riesgo de perfusión tisular cerebral ineficaz. CONCLUSIÓN Existen asociaciones significativas entre los discernidores del Sistema Triaje de Manchester y los diagnósticos de enfermería más frecuente establecidos en la Unidad de Emergencia.

Abstract OBJECTIVE To analyze the association between Manchester Triage System flowchart discriminators and nursing diagnoses in adult patients classified as clinical priority I (emergency) and II (very urgent). METHOD Cross-sectional study conducted in an emergency department in southern Brazil between April and August 2014. The sample included 219 patients. Data were collected from online patient medical records and data analysis was performed using Fisher's exact test or the chi-square test. RESULTS 16 discriminators and 14 nursing diagnoses were identified. Associations were found between seven discriminators and five problem-focused nursing diagnoses, including the discriminator Cardiac pain and the diagnosis Acute pain. Three discriminators were associated with four risk nursing diagnoses, among these Acute neurological deficit with the diagnosis Risk of ineffective cerebral tissue perfusion. CONCLUSION Significant associations were found between Manchester Triage System discriminators and the nursing diagnoses most frequently established in the emergency department.

Assessment and management of the septic patient: part 2.

Sepsis has gained increasing publicity in recent years, and there is now a strong focus of clinical education and training following the Surviving Sepsis Campaign. The assessment and management of a septic patients is far from simple and requires a systematic approach in both identifying and managing the condition. This second part explores sepsis care bundles and the research that underpins each of the interventions. These discussions will enable nurses to understand why each component of the sepsis care bundle is important and thus enable them to rapidly prioritise care, as early effective interventions have been shown to optimise patient outcomes.

Inhaled epoprostenol to support the severely hypoxemic patient with acute respiratory distress syndrome.

This article presents a case study demonstrating various rescue therapies considered in the care of a patient with severe, refractory hypoxemia secondary to acute respiratory distress syndrome. In particular, inhaled epoprostenol (Flolan) is becoming an increasingly common alternative to nitric oxide in the treatment of severe, refractory hypoxemia. Research comparing the 2 inhaled vasodilators suggests that epoprostenol is equally efficacious, easier to administer, less costly, and has fewer adverse effects. This article, using a case study approach, discusses the practical implications of this emerging therapy.

High-frequency percussive ventilation using the VDR-4 ventilator: an effective strategy for patients with refractory hypoxemia.

High-frequency percussive ventilation (HFPV) has been used for patients with severe respiratory compromise refractory to conventional mechanical ventilation. It frequently results in equivalent or improved oxygenation and ventilation at lower peak pressures than conventional ventilation, thus minimizing secondary ventilator-associated lung injury. The only ventilator currently available that delivers HFPV is the volume diffusive respirator (VDR-4; Percussionaire Corp, Sandpoint, Idaho). High-frequency percussive ventilation is delivered via a pneumatically powered, pressure-limited, time-cycled, high-frequency flow interrupter and provides small tidal volumes with 300 to 700 oscillations per minute. Following transition to HFPV, respiratory status often stabilizes or improves within a few hours. The unique gas flow mobilizes significant volumes of pulmonary secretions, further facilitating gas exchange. This article reviews the operating principles of HFPV, the functional components of the VDR-4, and the special nursing care considerations to include sedation, hemodynamic assessment, skin and oral care, nutrition, and weaning from ventilation.

Non-invasive ventilation after cardiac surgery outside the Intensive Care Unit.

BACKGROUND: Non-invasive ventilation (NIV) can prevent or treat postoperative acute respiratory failure. NIV after discharge from the Intensive Care Unit (ICU) has never been described in the setting of cardiac surgery. METHODS: This study enrolled 85 patients who received NIV in the main ward as treatment for respiratory failure. The patients had the following conditions: atelectasis (45 patients), pleural effusion (20 patients), pulmonary congestion (13 patients), diaphragm hemiparesis (6 patients), pneumonia (4 patients) or a combination of these conditions. RESULTS: Eighty-three patients were discharged from the hospital in good condition and without need for further NIV treatment, while two died in-hospital. Four of the 85 patients had an immediate NIV failure, while eight patients had delayed NIV failure. Only one patient had a NIV-related complication represented by hypotension after NIV institution. In this patient, NIV was interrupted with no consequences. Major mistakes were mask malpositioning with excessive air leaks (7 patients), incorrect preparation of the circuit (one patient), and oxygen tube disconnection (one patient). Minor mistakes (sub-optimal positioning of the face mask without excessive air leaks) were noted by the respiratory therapists for all patients and were managed by slightly modifying the mask position. CONCLUSION: In our experience, postoperative NIV is feasible, safe and effective in treating postoperative acute respiratory failure when applied in the cardiac surgical ward, preserving intensive care unit beds for surgical activity. A respiratory therapy service managed the treatment in conjunction with ward nurses, while an anesthesiologist and a cardiologist served as consultants.

Oxygen delivery to patients after cardiac surgery: a medical record audit.

OBJECTIVE: To describe how intensive care nurses manage the administration of supplemental oxygen to patients during the first 24 hours after cardiac surgery. METHODS: A retrospective audit was conducted of the medical records of 245 adult patients who underwent cardiac surgery between 1 January 2005 and 31 May 2008 in an Australian metropolitan hospital. Physiological data (oxygen saturation measured by pulse oximetry and respiratory rate) and intensive care unit management data (oxygen delivery device, oxygen flow rate and duration of mechanical ventilation) were collected at hourly intervals over the first 24 hours of ICU care. RESULTS: Of the 245 patients whose records were audited, 185 were male; mean age was 70 years (SD, 10), and mean APACHE II score was 17.5 (SD, 5.14). Almost half the patients (122, 49.8%) were extubated within 8 hours of ICU admission. The most common oxygen delivery device used immediately after extubation was the simple face mask (214 patients, 87%). Following extubation, patients received supplemental oxygen via, on average, two different delivery devices (range, 1-3), and had the delivery device changed an average of 1.38 times (range, 0-6) during the 24 hours studied. Twenty-two patients (9%) received non-invasive ventilation or high-flow oxygen therapy, and 16 (7%) experienced one or more episode of hypoxaemia during mechanical ventilation. A total of 148 patients (60%) experienced one or more episodes of low oxygenation or abnormal respiratory rate during the first 24 hours of ICU care despite receiving supplemental oxygen. CONCLUSION: These findings suggest that the ICU environment does not protect cardiac surgical patients from suboptimal oxygen delivery, and highlights the need for strategies to prompt the early initiation of interventions aimed at optimising blood oxygen levels in cardiac surgical patients in the ICU.

Retinopathy of prematurity: an eye toward better outcomes.

Retinopathy of prematurity (ROP) results from the abnormal growth of blood vessels in the vascular bed supporting the developing retina. Estimated to cause up to 500 new cases of blindness in the U.S. each year, ROP affects primarily infants born at less than 1,500 g. Although its etiology is not well understood, ROP is thought to occur as a result of a complex interaction between oxygen and vascular growth factors. This article briefly reviews the history of ROP, discusses its pathophysiology, and addresses the risk factors and strategies for prevention.

Patients' and nurses' perspectives on oxygen therapy: a qualitative study.

AIM: This paper is a report of a study to describe patients' and nurses' perspectives on oxygen therapy. BACKGROUND: Failure to correct significant hypoxaemia may result in cardiac arrest, need for mechanical ventilation or death. Nurses frequently make clinical decisions about the selection and management of low-flow oxygen therapy devices. Better understanding of patients' and nurses' experiences of oxygen therapy could inform clinical decisions about oxygen administration using low-flow devices. METHODS: Face-to-face interviews with a convenience sample of 37 adult patients (17 cardio-thoracic: 20 medical surgical) and 25 intensive care unit nurses were conducted from February 2007 to September 2007. Interviews were audio-taped, transcribed verbatim and then analysed using a thematic analysis approach. FINDINGS: The patients identified three key factors that underpinned their compliance with oxygen therapy: (i) device comfort; (ii) ability to maintain activities of daily living; and (iii) therapeutic effect. The nurses identified factors, such as: (i) therapeutic effect, (ii) issues associated with compliance, (iii) strategies to optimize compliance, (iv) familiarity with device, (v) triggers for changing oxygen therapy devices, as being key to the effective management of oxygen therapy. CONCLUSION: Differences between the patients' and nurses' perspective of oxygen therapy illustrate the variety of factors that impact on effective oxygen administration. Further research should seek to provide a further in-depth understanding of the current oxygen administration practices of nurses and the patient factors that enhance or hinder effectiveness of oxygen therapy. Detailed information about nurse and patient factors that influence oxygen therapy will inform a sound evidence base for nurses' oxygen administration decisions.

The Oxygen Supply and Demand Framework: a tool to support integrative learning.

Critically ill patients are at high risk for inadequate oxygen supply, increased oxygen demand and inadequate cellular oxygenation. Understanding and managing the physiological consequences of critical illness requires nurses to integrate knowledge of patient assessment, physiology and pathophysiology, and critical care interventions into their clinical decision-making. The Oxygen Supply and Demand Framework incorporates interrelated physiological concepts that influence balance between oxygen supply and demand and, consequently, supports an integrated understanding of critically ill patient situations. In this article, we present the Oxygen Supply and Demand Framework as an integrative tool for use by educators, students and critical care nurses to guide the process of patient assessment, interpret data, inform selection of appropriate interventions, and understand the rationale for all aspects of patient management.

Respiratory assessment in adults.

Respiratory disorders are among the most common reasons for admission to critical care units in the U.K. However, anecdotal evidence suggests that nursing assessment of patients' respiratory function is not performed well because it is not considered a priority and the implications of respiratory dysfunction are underestimated. It is essential that nurses are able to recognise and assess symptoms. of respiratory dysfunction to provide early, effective and appropriate interventions, thus improving patient outcomes. This article highlights the role of the nurse in respiratory assessment and discusses the implications of clinical findings.

Clinical validation of the signs and symptoms and the nature of the respiratory nursing diagnoses in patients under invasive mechanical ventilation.

AIMS: The aims of this study were to validate the signs and symptoms of the respiratory nursing diagnoses impaired gas exchange, ineffective airway clearance and ineffective breathing pattern in patients under mechanical ventilation; to verify whether intubation time and ventilatory modalities were related factors for respiratory nursing diagnoses; to verify the occurrence of shared signs and symptoms in the diagnoses and compare them with North American Nursing Diagnosis Association's proposition and to ascertain whether respiratory nursing diagnoses occur in isolated or associated patterns. BACKGROUND: The need for mechanical ventilation is common in several patients admitted to intensive care units. Therefore, critical care nurses should identify the respiratory nursing diagnoses of high incidence. DESIGN AND METHODS: Descriptive observational study, with 177 evaluations of surgical and medical critically ill adult patients undergoing invasive mechanical ventilation. The study adopted Fehring's Modified Clinical Diagnostic Validity Model, with a suggested alteration. RESULTS: The critical signs and symptoms were the same as proposed by North American Nursing Diagnosis Association, when the diagnoses were separately identified, although no particular sign and symptom was found for ineffective breathing pattern. Impaired gas exchange and ineffective airway clearance were identified as having 88 (49.7%) evaluations sharing the critical signs and symptoms. Intubation time and ventilation modality were related factors for the development of ineffective airway clearance and ineffective breathing pattern. CONCLUSION: The critical signs and symptoms of impaired gas exchange were abnormal blood gases and hypoxemia. For ineffective airway clearance, they were rhonchi and decreased breath sounds. No highlights were found for ineffective breathing pattern signs and symptoms. Validation by experts has confirmed these findings. The interface between ineffective airway clearance and impaired gas exchange was confirmed by the presence of the shared critical signs and symptoms. RELEVANCE TO CLINICAL PRACTICE: Studies like this are relevant to clinical practice because they evaluate the adequacy of Taxonomy II for patients under mechanical ventilation in clinical practice, thus allowing for the intensive care nurses to go from one mechanical and routine practice to a critical, reflexive practice, committed to professional progress.