Evaluation of an Association Between Enoxaparin Dose per Estimated Blood Volume and Clinically Relevant Bleeding in Low-Weight Trauma Patients.

BACKGROUND: The optimal dosing for enoxaparin venous thromboembolism (VTE) prophylaxis in low-weight trauma patients is unknown. Estimated blood volume (EBV) has shown promise as a dose modifier. OBJECTIVE: To characterize the association of enoxaparin dose per EBV with the prevalence of VTE and bleeding in low-weight trauma patients. METHODS: This was a retrospective study of trauma patients admitted over a 4-year period. Included patients were adults weighing <60 kg who received a minimum of 3 consecutive doses of enoxaparin. The primary endpoint was a comparison of enoxaparin dose per EBV in patients experiencing bleeding and VTE. Secondary endpoints included comparisons of dose per body mass index (BMI) and total body weight (TBW) and the ability of dose per EBV to predict clinical endpoints. Subgroup analyses for patients weighing <50 kg were performed for all endpoints. RESULTS: A total of 189 patients were included. Statistical comparisons for VTE were not performed because of low prevalence. The dose of enoxaparin per EBV was not statistically different between patients who did and did not bleed in all analyses. Doses per BMI and TBW were also not statistically different between the groups. In patients weighing <50 kg, numerically higher doses per EBV, BMI, and TBW were noted in patients that bled versus those that did not. Enoxaparin dose per EBV was not a statistically significant predictor of bleeding in logistic regression models. CONCLUSION AND RELEVANCE: No significant associations between enoxaparin dose per EBV, BMI, or TBW and bleeding were noted in the study. Future analyses of EBV and other dose modifiers should consider inclusion of patients weighing <50 kg.

Family-witnessed resuscitation in the emergency department in a low-income country.

Cardiac arrest is often a sudden and traumatic event. Family-witnessed resuscitation was first recommended by the American Heart Association over two decades ago. Since then several global professional bodies have identified a range of potential benefits for relatives; however, it remains contentious. For nurses working in emergency departments (EDs) in low-income countries, the evidence for, and experience of, family-witnessed resuscitation is limited. This article critically appraises the literature relating to the perceptions of medical professionals and critically ill patients and their families about communication, family presence and their involvement during resuscitation in the ED. Three themes relating to family-witnessed resuscitation in the ED were identified by a focused literature search. These were: leadership and communication, limitation of policies and guidelines and relatives' views. The recommendations from this review will be used to develop emergency and trauma nursing practice guidelines in Zambia, a low-income country in sub-Saharan Africa.

Modeling the effects of ration on individual growth of Oncorhynchus tshawytscha under controlled conditions.

Fed aquaculture is one of the fastest-growing and most valuable food production industries in the world. The efficiency with which farmed fish convert feed into biomass influences both environmental impact and economic revenue. Salmonid species, such as king salmon (Oncorhynchus tshawytscha), exhibit high levels of plasticity in vital rates such as feed intake and growth rates. Accurate estimations of individual variability in vital rates are important for production management. The use of mean trait values to evaluate feeding and growth performance can mask individual-level differences that potentially contribute to inefficiencies. Here, the authors apply a cohort integral projection model (IPM) framework to investigate individual variation in growth performance of 1625 individually tagged king salmon fed one of three distinct rations of 60%, 80%, and 100% satiation and tracked over a duration of 276 days. To capture the observed sigmoidal growth of individuals, they compared a nonlinear mixed-effects (logistic) model to a linear model used within the IPM framework. Ration significantly influenced several aspects of growth, both at the individual and at the cohort level. Mean final body mass and mean growth rate increased with ration; however, variance in body mass and feed intake also increased significantly over time. Trends in mean body mass and individual body mass variation were captured by both logistic and linear models, suggesting the linear model to be suitable for use in the IPM. The authors also observed that higher rations resulted in a decreasing proportion of individuals reaching the cohort's mean body mass or larger by the end of the experiment. This suggests that, in the present experiment, feeding to satiation did not produce the desired effects of efficient, fast, and uniform growth in juvenile king salmon. Although monitoring individuals through time is challenging in commercial aquaculture settings, recent technological advances combined with an IPM approach could provide new scope for tracking growth performance in experimental and farmed populations. Using the IPM framework might allow the exploration of other size-dependent processes affecting vital rate functions, such as competition and mortality.

Evaluation of an international health partnership to capacity build emergency, trauma and critical care nurse education and practice in Zambia: An experience from the field.

AIM: To evaluate an international health partnership project to capacity build emergency, trauma and critical care nurse education and practice in Zambia. BACKGROUND: Zambia continues to face a significant workforce challenge and rising burden of communicable and non-communicable diseases, compounded by the COVID-19 pandemic. In response to these, the Zambian Ministry of Health is investing in specialised nurses. Emergency, trauma and critical care nursing education and training were seen as one of the solutions. North-south partnerships have been identified as a force for good to capacity build and develop emerging specialities. SOURCES OF EVIDENCE: We use an evaluative approach, which includes desk research, a rapid literature review and documentary data analysis from published papers, government reports and project documentation. Ethics committee approval was sought and gained in both Zambia and the UK. DISCUSSION: A critical review of the evidence identified three key themes: challenges with changing education and practice, developing Zambian faculty for sustainability and the effect of an international health partnership project on both Zambia and UK. The outcomes from this project are multifaceted; however, the main achievement has been the implementation of emergency, trauma and critical care graduate programmes by the Zambian faculty. CONCLUSION: This experience from the field outlines the benefits and limitations of a north-south partnership and the importance of transparency, shared ownership and collegiate decisions. It has facilitated knowledge exchange and sharing to capacity build emergency, trauma and critical care nursing. IMPLICATIONS FOR NURSING PRACTICE: Lessons learned may be applicable to other international nursing partnerships, these include the need for deep understanding of the context and constraints. Also, the importance of focusing on developing long-term sustainable strategies, based on research, education and practice was noted. IMPLICATIONS FOR NURSING POLICY: This paper outlines the importance of developing nursing education and practice to address the changing burden of disease in line with Zambian national policy, regional and international standards. Also, the value of international nursing partnerships for national and international nursing agendas was described.

Combined effects of elevated rearing temperature and dietary energy level on heart morphology and growth performance of Tasmanian Atlantic salmon (Salmo salar L.).

Cardiac abnormalities may pose a threat to salmonid aquaculture due to their potential detrimental effect on fish health and welfare. The teleost heart is an extremely plastic organ with important morphological differences between wild and farmed fish that include ventricular shape, alignment of the bulbus arteriosus and epicardial fat deposition. However, little is known about how different factors and interactions among them may affect cardiac morphology of Atlantic salmon. To determine whether rearing temperature could induce cardiac malformations in large Tasmanian Atlantic salmon, we examined a range of cardiac morphology indicators and growth parameters in a population of 1-2 kg seawater salmon (n = 60 temperature-1 diet-1 ) exposed to control and elevated temperatures of 15 and 19°C, respectively, while fed one of two commercial feeds with different dietary energy levels. Most fish possessed conspicuous fat around the heart with a tendency towards a rounded ventricle and a more obtuse angle of the bulbus arteriosus. However, fish showed no significant differences in heart shape and bulbus alignment in relation to water temperature and dietary energy. These results suggest that cardiac morphology of large Atlantic salmon is unlikely to be affected by rearing temperature and dietary energy during the grow-out phase.

Protein sources influence both apparent digestibility and gastrointestinal evacuation rate in juvenile slipper lobster (Thenus australiensis).

Apparent digestibility and gastrointestinal evacuation rate were measured to assess the potential of five commercially available protein sources for their inclusion in feeds for juvenile slipper lobster, Thenus australiensis. Protein sources tested were fishmeal, krill meal, lupin meal, soybean meal and squid by-product meal. Apparent digestibility of crude protein ranged from 79.6% to 95.3%, with fishmeal protein significantly less digestible than lupin meal, squid by-product meal and soybean meal. Gastrointestinal evacuation rate was estimated from marker replacement, where yttrium oxide replaced ytterbium oxide. Faeces were collected every 3 h for 48 h, and a kinetic model was used to calculate the rate and time for the second marker to replace the first marker. Gastrointestinal evacuation (≥ 95%) was completed between 4 and 6 h with no significant differences among protein sources. Faeces consisted of both markers in equal parts 2.7 to 5.0 h after the feed switch, with lupin meal reaching the midpoint significantly faster than squid by-product meal and reference feed. The present study is the first in crustaceans to examine the relationship between apparent digestibility and gastrointestinal evacuation, showing more digestible protein sources had slower evacuation rates. The combined approach provides deeper insight into crustaceans' digestive physiology and helps understand their ability to digest specific ingredients. Further research is recommended to understand protein requirements in a broader context to verify highly digestible protein sources meet all nutritional requirements.

Service evaluation of a COVID-19 critical care orientation programme.

BACKGROUND: During the first wave of the COVID-19 pandemic in the UK, south London had the highest number of COVID-19 patients admitted to critical care. At one hospital, staff being redeployed to critical care were invited to attend an orientation to critical care workshop. AIM: To carry out a service evaluation of the training outcomes from rapidly redeployed staff who completed the workshop during the first wave of the COVID-19 pandemic (March-July 2020). METHODS: Two stages were used, the first was a post-workshop evaluation questionnaire completed immediately after the training, with the second involving a single centre e-survey questionnaire two months later. FINDINGS: In total 131 health professionals attended the workshop, and 124 (95%) post-course evaluations were completed. Some 116 staff were contacted for the e-survey, with a response rate of 34% (n=40). Overall, the training was well evaluated. Of the 40 respondents, 70% (n=28) had volunteered, but only just over half (n=21, 52%) went on to work in critical care. CONCLUSION: This article describes the organisational response of one NHS acute hospital to the unprecedented challenges that arose from the COVID-19 pandemic. The service evaluation identified the importance of a pedagogical approach, which not only delivered clinical content, but also allayed anxiety for health professionals preparing to work in a new environment.

The 'sleeping elephant': The role of mentorship of critical care nurses in Zambia.

AIM: To develop and evaluate a Zambian context-specific mentorship model that supports registered nurses completing emergency, trauma and critical care programmes in Zambia. BACKGROUND: In Zambia, emergency and trauma and critical care nursing are relatively new specialties, with education and training programmes less than a decade old. A train the trainer mentorship programme was developed and delivered at two colleges of nursing. Ethics approval was gained in both Zambia and the UK. SOURCES OF EVIDENCE: Documentary data analysis and focus groups were used. Focus groups included stakeholders and nurses in practice who had completed the train the trainer programme and were using the mentorship model. DISCUSSION: The critical review of the literature revealed there was a paucity of evidence on the role of mentors in critical care. However, national documentation identified that most post basic education programmes are at Diploma Level with limited content that focuses on bedside teaching, mentorship and assessment content. CONCLUSION: Feedback from representatives attending the stakeholder workshops and focus groups which included participants who had completed the training programme enabled the mentorship model and workshop to be developed and evaluated. IMPLICATIONS FOR NURSING PRACTICE: Nurses are the backbone of healthcare systems in Africa and the world. Mentorship and assessment in practice enables nurses to develop the competence and skills to lead practice, support peers and junior colleagues. IMPLICATIONS FOR NURSING POLICY: This paper has identified the need for a context-specific formalised mentorship model to support specialist practice and this project has provided the foundations for mentorship of emergency, trauma and critical care nurses in Zambia.

Standardizing Multidisciplinary Rounds: Creation of an Efficient and Effective Process to Care for the Critically Ill.

OBJECTIVE: To describe the impact of a standardized rounding process on rounding time and multidisciplinary member attendance. BACKGROUND: Rounding efficiency and effectiveness are often compromised by lack of standardization of important elements including start time and location, the attendance of multidisciplinary representatives, patient presentation highlights, and physician workflow. In 2017, the study authors noted inefficiencies and process failures in multidisciplinary rounds within our ICU. METHODS: We conducted a retrospective review of rounding data before and after the implementation of a simplified and streamlined rounding template for ICU nurses and measures to standardize rounding processes and attendance. RESULTS: Rounding time was decreased by 25% in postimplementation phase. Additionally, attendance of respiratory therapists, clinical dietitians, and case managers improved. CONCLUSIONS: We suggest the piloting of these strategies in other ICUs that experience similar inefficiencies and process failures during multidisciplinary rounds.

The development of critical care nursing education in Zambia.

BACKGROUND: Critical care services reflect the healthcare services they support. In many low-to-middle-income countries (LMICs), balancing a sparse workforce, resources and competing demands to fund services, is a significant challenge when providing critical care. In Zambia, critical care has evolved significantly over the past 10 years. This article explores the provision of critical care services and the review and validation of a critical care nursing course. OBJECTIVES: To review the literature relating to critical care nursing in sub-Saharan Africa to support a review and validation of the current critical care nursing course and to prepare a framework for a Bachelor of Science (BSc) in critical care nursing programme in Zambia. RESULTS: A search of the published literature identified key themes, including a paucity of evidence, limited educational opportunities, a lack of national and international opportunities, protocols and standards, and the challenges of providing technical services. The subsequent review and validation took account of these themes. CONCLUSION: This project has had an impact on improving critical care nurses' knowledge and skills and provided the foundations for the BSc in critical care nursing.

'I'll never be the same': the impact of an international elective.

BACKGROUND:: many undergraduate student nurses have the opportunity to undertake an international elective-that is, a placement in another country. The benefits of undertaking an elective include developing cultural competence, understanding different healthcare systems and experiencing a different culture. AIM:: the aim of the study was to evaluate the impact of a faculty-structured international travel elective to Zambia for undergraduate UK nursing students. METHODS:: a descriptive phenomenology approach was used to discover and explore the students' experiences of their elective. FINDINGS:: 6 students participated in semi-structured interviews. Themes that emerged included the importance of preparing for the elective, different nursing cultures, realities and patient safety concerns. CONCLUSION:: this study found that students involved in an international elective to Zambia overall had a positive experience but did report some challenges; the findings contribute to the body of evidence relating to international electives.

Liver proteome response of pre-harvest Atlantic salmon following exposure to elevated temperature.

BACKGROUND: Atlantic salmon production in Tasmania (Southern Australia) occurs near the upper limits of the species thermal tolerance. Summer water temperatures can average over 19 °C over several weeks and have negative effects on performance and health. Liver tissue exerts important metabolic functions in thermal adaptation. With the aim of identifying mechanisms underlying liver plasticity in response to chronic elevated temperature in Atlantic salmon, label-free shotgun proteomics was used to explore quantitative protein changes after 43 days of exposure to elevated temperature. RESULTS: A total of 276 proteins were differentially (adjusted p-value < 0.05) expressed between the control (15 °C) and elevated (21 °C) temperature treatments. As identified by Ingenuity Pathway Analysis (IPA), transcription and translation mechanisms, protein degradation via the proteasome, and cytoskeletal components were down-regulated at elevated temperature. In contrast, an up-regulated response was identified for NRF2-mediated oxidative stress, endoplasmic reticulum stress, and amino acid degradation. The proteome response was paralleled by reduced fish condition factor and hepato-somatic index at elevated temperature. CONCLUSIONS: The present study provides new evidence of the interplay among different cellular machineries in a scenario of heat-induced energy deficit and oxidative stress, and refines present understanding of how Atlantic salmon cope with chronic exposure to temperature near the upper limits of thermal tolerance.

Efficacy, Safety, and Timing of 5% Sodium Chloride Compared With 23.4% Sodium Chloride for Osmotic Therapy.

BACKGROUND: Bolus doses of 23.4% sodium chloride (NaCl) are commonly used for the treatment of intracranial hypertension; however, delays in administration may occur in patients without central intravenous access. At our institution, equiosmolar bolus doses of 5% NaCl have emerged as potential alternatives to 23.4% NaCl because they may be safely administered through peripheral lines. OBJECTIVES: We sought to assess the efficacy in reducing intracranial pressure (ICP), time to administration, and safety of 5% NaCl as compared with 23.4% NaCl for the treatment of intracranial hypertension. METHODS: Patients admitted from July 2012 to June 2014 who received boluses of 5% NaCl or 23.4% NaCl for a sustained ICP >20 mm Hg were included. Data collected included measurements of ICP, time to administration, and adverse events. RESULTS: A total of 44 patients were identified; 11 received 5% NaCl, and 33 received 23.4% NaCl. The median percentage reductions in ICP at 30, 60, and 120 minutes in patients who received 5% versus 23.4% NaCl were 34% versus 26% ( P = 0.850), 48% versus 40% ( P = 0.700), and 46% versus 30% ( P = 0.064), respectively. The median time to administration was shorter in the 5% NaCl group (7 vs 11 minutes, P = 0.364). Both groups had a 27% rate of adverse events and no infusion site reactions. CONCLUSIONS: These data suggest that 5% NaCl may be as effective as 23.4% NaCl at lowering ICP if given at equiosmolar doses, has a shorter time to administration, and has no difference in the prevalence of adverse events.

Temperature dependent growth, feeding, nutritional condition and aerobic metabolism of juvenile spiny lobster, Sagmariasus verreauxi.

We examined the effects of temperature on the growth, feeding, nutritional condition and aerobic metabolism of juvenile spiny lobster, Sagmariasus verreauxi, in order to determine if temperature acclimated aerobic scope correlates with optimum for growth and to establish the thermal tolerance window for this emerging aquaculture species. Juvenile lobsters (initial weight=10.95±0.47g) were reared (n=7) at temperatures from 11.0 to 28.5°C for 145days. All lobsters survived from 14.5 to 25.0°C while survival was reduced at 11.0°C (86%) and all lobsters died at 28.5°C. Lobster specific growth rate and specific feed consumption displayed a unimodal response with temperature, peaking at 21.5°C. Lobster standard, routine and maximum metabolic rates, and aerobic scope all increased exponentially up to maximum non-lethal temperature. Optimum temperature for growth did not correspond to that for maximum aerobic scope suggesting that aerobic scope is not an effective predictor of the thermal optimum of spiny lobsters. Plateauing of specific feed consumption beyond 21.5°C suggests that temperature dependent growth of lobsters is limited by capacity to ingest or digest sufficient food to meet increasing maintenance metabolic demands at high temperatures. The nutritional condition of lobsters was not influenced by temperature and feed conversion ratio was improved at lower temperatures. These findings add to a growing body of evidence questioning the generality of aerobic scope to describe the physiological thermal boundaries of aquatic ectotherms and suggest that feed intake plays a crucial role in regulating performance at thermal extremes.

Nursing a critically ill tetanus patient in an intensive care unit in Zambia.

The global incidence of tetanus has been gradually reducing. Improvements in vaccination and health education programmes and the World Health Organization campaign to eradicate maternal and neonatal tetanus have all resulted in fewer presentations globally. Unfortunately, tetanus mortality remains a significant problem for many developing countries, owing to inadequate vaccination programmes or to conflict or humanitarian disasters during which vaccination programmes are stopped or there is sporadic cover. This case study explores the care of a tetanus patient in an intensive care unit in Zambia, a lower-middle-income country in sub-Saharan Africa.

Malaria: diagnosis, treatment and management of a critically ill patient.

Malaria is a significant cause of mortality in many countries and remains the most prevalent parasitic tropical infection. The World Health Organization estimates that 50% of the world's population is at risk of malaria, with most deaths occurring in sub-Saharan Africa. This case study explores the management of a malaria patient admitted to a critical care unit in Zambia, a lower-middle-income country in sub-Saharan Africa. While malaria is prevalent in Zambia and other countries, in the UK all malaria is imported and less frequently seen by health professionals. This case study will raise the profile of malaria, including its recognition, diagnosis and treatment. This information will assist nurses in both low- and high-income countries to translate theory into practice and improve nurses' understanding of a condition rarely seen in UK critical care practice.