Impact of Transfusing Packed Red Blood Cells Through a Rapid Infuser on Potassium Levels.

BACKGROUND: Hyperkalemia is associated with the rapid transfusion of packed red blood cells in trauma patients. Rapid infusers can infuse blood up to 500 ml/min. OBJECTIVE: This study aimed to determine whether infusing packed red blood cells through a rapid infuser impacts the potassium levels of the infused blood. METHODS: Two baseline samples were obtained to measure potassium and hemolysis scores in 12 units of expired blood prior to infusion. The blood was then infused via the Belmont Rapid Infuser into collection bags at varying infusion rates (50, 100, 250, and 500 ml/min) utilizing different gauge catheter sizes (18-gauge, 16-gauge, and Cordis catheter). Two postinfusion blood samples were collected and tested for potassium and hemolysis scores and compared with preinfusion values. This process was then repeated with fresh blood. RESULTS: The potassium levels of the samples taken from each unit prior to infusion (average difference 0.245) and after infusion (average difference 0.08) correlated well. There was no difference in potassium levels pre- and postinfusion at any infusion rate after accounting for catheter size and age of blood. The median potassium level of the fresh blood was 5.025 prior to infusion and 4.875 after infusion. The median potassium level of the expired blood was 16.05 prior to infusion and 16.4 postinfusion. There was no significant difference in the hemolysis scores between the preinfusion and postinfusion samples. CONCLUSIONS: Hyperkalemia in trauma patients undergoing massive transfusions is not a result of mechanical hemolysis from the high rates of blood infusion.

Effect of Anxiety on Individuals and Caregivers After Coronary Artery Bypass Grafting Surgery: A Review of the Literature.

BACKGROUND: Coronary artery bypass graft surgery is the most frequently performed heart surgery on adults in the United States and often results in increased anxiety in patients and their caregivers as they attempt to cope with the process of open heart surgery. OBJECTIVE: This article is a comprehensive literature review examining the current information available to health care professionals about the relationship between preoperative anxiety and postoperative surgical outcomes in patients who underwent coronary artery bypass graft surgery. METHODS: Research articles from peer-reviewed sources from 2000 to present were retrieved from CINAHL Plus, EBSCOhost, and Internet search engine Google Scholar, as well as from the Centers for Disease Control and Prevention and the National Heart, Lung and Blood Institute databases. Articles dating back to 2000 were included because of specificity of the topic. RESULTS: Research related to this particular situation supports the relationship between preoperative anxiety and negative postoperative outcomes for patients and their caregivers. However, limitations were identified during the course of the review, and further research on this particular relationship is warranted. DISCUSSION: The review of literature identified that preoperative anxiety increased the risk of poor postoperative outcomes including atrial fibrillation, acute myocardial infarction, increased risk of readmission, increased morbidity and mortality, increased health care utilization, and increased anxiety in caregivers resulting in role strain and frustration.

Serum neuron-specific enolase predicting neurological outcomes post-cardiac arrest: a review of the literature.

BACKGROUND: Coronary artery disease is a major problem in the United States, affecting 785 000 individuals, with the most serious event being a cardiopulmonary arrest. Families of post-cardiac arrest patients are left with difficult decisions to be made. OBJECTIVE: This article is a comprehensive literature review examining the current research available to health care professionals about the biomarker serum neuron-specific enolase (NSE) and its use in predicting neurological outcomes in comatose post-cardiac arrest patients. METHODS: Using the bibliographic databases CINAHL, Plus, EBSCOhost, MEDLINE, PubMed, Google Scholar, H. W. Wilson, Cochrane, and NEXUS, from the period 2003 to 2013, revealed there is minimal research or literature on NSE predicting neurological outcomes post-cardiac arrest. RESULTS: Research on this particular biomarker is relatively new, and more research is necessary to establish an adequate amount of support. At this time, an exact NSE cutoff value or its exact ability to help predict neurological outcomes is unable to be established, and further research is necessary. DISCUSSION: This literature review should provide a basic understanding of NSE and its ability to help predict neurological outcomes of post-cardiac arrest patients earlier. The research provides evidence that NSE should be considered in determining outcomes. However, more research is necessary before nursing practice is changed and implemented into patient care.

Bleeding risk factors affecting warfarin therapy in the elderly with atrial fibrillation.

PURPOSE: Inadequate anticoagulation among elderly individuals with atrial fibrillation (AF) is a common problem. This synthesis of the literature review describes the pathophysiology of AF, explains the mechanism of action of warfarin (Coumadin), identifies factors that contribute to warfarin (Coumadin)-associated bleeding in the elderly population, and explores alternatives to warfarin (Coumadin) therapy. Implications for advanced practice nurse practice, education, and research will be discussed. METHODS: A literature search was conducted using Academic Search Premier, CINAHL Plus with Full Text, and Medline from 1999 to 2012. Search terms included warfarin (Coumadin), warfarin (Coumadin) genetics, diet, interactions, bleeding, atrial fibrillation, genetics, anticoagulation clinic, dabigatran, apixaban, rivaroxaban, and elderly. RESULTS: The literature indicates that the potential bleeding risk associated with warfarin (Coumadin) therapy limits its use in the elderly population. However, some studies have found warfarin (Coumadin) to be more effective than aspirin in preventing stroke. The safety profiles of both medications were comparable; also, effective alternatives to warfarin (Coumadin) that do not require routine testing are now available. CONCLUSIONS: Atrial fibrillation increases the probability of an embolic stroke, especially for the elderly population. Stroke risk and bleeding risk tools, in conjunction with patient preference, determine the best stroke prevention treatment. Anticoagulant clinics manage long-term warfarin (Coumadin) therapy effectively. Newer anticoagulants offer effective alternatives to warfarin (Coumadin) therapy.

A pilot study on delirium in the intensive care unit: a creative inquiry project with undergraduate nursing students.

INTRODUCTION: Delirium continues to be a major issue in intensive care units (ICUs). Sedation and lack of rapid eye movement (REM) sleep could be important factors in the development of delirium. Improper sedation may interfere with a patient's sleep pattern, specifically time spent in REM sleep, and could be a contributor to the development of delirium. The research team has discovered through this pilot study that there is a possible correlation between sedation, disruptions, and sleep. The goal of our research was to determine the relationship between these variables using a sleep monitor to capture actual sleep activity compared with patient characteristics and real-time activity in the ICU environment. MATERIALS AND METHODS: This was a pilot study of 7 new patients, aged 65 years or older, who were intubated and sedated. Data on patient sleep cycles were collected using a wireless sleep monitor. A time sheet was placed outside each room to record time and type of interruption during nighttime hours (9 PM-6 AM). The patients were observed for 1 to 7 nights dependent on their length of stay in the ICU. RESULTS: Preliminary results demonstrated that, on average, between 9 PM and 6 AM, 48% remained awake (range, 8%-88%), 30% were in light sleep (range, 2%-50%), 18.5% were in REM (range, 2%-60%), and 3.4% were in a deep sleep (range, 0%-9%). Subject 1 remained awake 52% to 88% of the time during the entire admission of 7 days, had an Intensive Care Delirium Screening Checklist score of 5, and had a self-extubation; sedation ordered was Versed as needed. Subject 5 had no interventions done between 12 midnight and 4:50 AM, with the exception of turning once, and had an REM recorded of 60% on 1 night, which equals to 4 hours 49 minutes of rest. All patients with the exception of 1 were on fentanyl and Versed drips with varying dose adjustments throughout their admission. IMPLICATIONS: Preliminary results show that there is a relationship between lack of REM sleep and delirium. The pilot study was a useful model to demonstrate the need for further investigation in a larger population.

Neuro/Trauma intensive care unit nurses' perception of the use of the full outline of unresponsiveness score versus the Glasgow Coma Scale when assessing the neurological status of intensive care unit patients.

INTRODUCTION: : This study compares the Full Outline of Unresponsiveness (FOUR) Score scale with the Glasgow Coma Scale (GCS) when evaluating a patient's level of responsiveness in the neuro/trauma intensive care unit of a large medical center. This new scoring tool evaluates 4 functional categories: eye response, motor response, brainstem reflexes, and respiratory pattern. AIMS AND METHODS: : A total of 57 patients 18 years or older were randomly selected as a convenience sample of those admitted to the neuro/trauma intensive care unit and were assessed using both the standard GCS and the FOUR Score scale. The raters then completed a short survey (43 completed) to compare the 2 tools. RESULTS: : Rater agreement was very good with the FOUR Score scale and for the GCS; however, nurses favored the use of the FOUR Score scale (81.4%) over the GCS (0.00%) to assess the neurological responsiveness of their patients as the generally accepted assessment tool. CONCLUSION: : The FOUR Score scale provides a reliable neurological assessment of intubated patients where the GCS does not differentiate patient status once intubated.

A retrospective study evaluating response time and survival from a cardiopulmonary arrest: a creative inquiry project with undergraduate nursing students.

Cardiopulmonary arrest is a major health problem that claims lives daily in the United States. The adoption of a new standard of care or healthcare technology needs to be evaluated based on patient outcomes. This review focuses on this problem and possible solutions. This retrospective study reviews clinical characteristics of cardiac resuscitative events associated with "code blue" team response. Team-based investigations are led by a faculty mentor and typically span 2 to 4 semesters. Students take ownership of their projects and take the risks necessary to solve problems and get answers. This review indicates areas of concern that need to be improved to create better patient outcomes. Findings include that improved documentation will provide data elements for review analysis that then may be utilized to improve care related to cardiac arrest.

Energize staff to create a research agenda.

There is a need to explore and align priorities for building the foundation for nursing research in any institution. The Delphi technique was chosen as means of setting priorities for nursing research. This method enlisted feedback from all levels of nurses from various practice areas and various nursing roles. A series of 3 rounds of surveys provided feedback. Mixed methods were utilized to reach consensus on the various themes/topics that emerged in each round. In the final survey round, nurses ranked the final themes as to the level of importance, which resulted in identification of the key top 5 priorities. The priorities are the foundation for a research agenda for the coming years. The nursing research council, led by the clinical nurse specialist chairperson, reviewed the results and generated a comprehensive review of literature for current evidence on each priority topic. Evidence was critiqued, rated, and resulted in research questions that formulated the research agenda. The priorities were integrated within the pillars of excellence that are the foundation of the institutions' strategic goals. Using this technique provides a beneficial and structured way to gain input from those who need to own the work of building nursing research within an institution. Positive factors, such as beginning with input from all levels, the ease of providing feedback, and using a Delphi method study to bring alignment within an organization, serve to strengthen nursing research into a much broader scope and focus.

Amiodarone use to prevent postoperative atrial fibrillation after cardiac surgery.

Atrial fibrillation is the most common complication occurring after coronary artery bypass graft surgery. The purpose of this article was to examine the incidence of, risk factors related to, and complications caused by postoperative atrial fibrillation. The pathophysiology and treatment of atrial fibrillation and postoperative atrial fibrillation will also be discussed.

Improving communication and cost-effectiveness in the intensive care unit through palliative care: a review of literature.

Approximately 20% of deaths in the United States each year occur in the intensive care unit. This article reviews the literature on this important topic to critical-care nurses.

Benchmarking to the international pressure ulcer prevalence survey.

PURPOSE: Authors and team members from the naval medical center at portsmouth (NMCP), virginia, obtained data on the prevalence and incidence of pressure ulcers (PUs) in our agency and compared them to national benchmark data as a basis for improving our wound care protocols. SUBJECTS AND SETTING: health care facilities throughout the nation volunteered to participate in the data collection process for a multiday PU prevalence survey performed in february 2009, including nmcp. Each facility collected prevalence data during a preselected 24-hour period out of the 72-hour time frame selected by the national study. METHODS: A standardized 1-page data collection form for each subject included demographic data, use of wound care protocols and pressure redistribution surfaces, PU stage and location, risk assessment using the braden scale for pressure sore risk, head-of-bed position, turning and repositioning, mobility, weight, incontinence, documentation of a PU within 24 hours of admission, device-related ulcers, and adequacy of documentation. Facility-specific data on a second form included braden scale score, bed type, use of pressure redistribution devices on the heels, hospital unit, turn schedule use, plastic brief use, presence of incontinence-associated dermatitis, and nursing documentation. Chart reviews were performed to determine hospital- versus non-hospital-acquired PU occurrence. Each PU was recorded separately and linked to its identifying stage. RESULTS: The PU incidence of adults managed in acute care inpatient units at NMCP was 6.6% and the prevalence was 10%. The most common location of facility-acquired PUs was the heels (50%). In contrast, national benchmarking data found that the highest incidence of PUs occurred in the sacral region. CONCLUSIONS: Benchmarking allows health care professionals to compare outcomes in their agencies to outcomes in comparable facilities. Identification of areas in which agency outcomes compare negatively to benchmark data should prompt implementation of quality improvement initiatives. National PU prevalence surveys provide a benchmark to evaluate an individual facility's care and treatment of patients at risk for pressure ulceration. The true benefit of participation in such surveys, however, is determined by local health care professionals' ability to use national data to improve clinical practice.

Functional status versus quality of life: where does the evidence lead us?

The interchangeable use of functional status with quality of life has lead to various interpretations when discussing outcomes related to functional status. The literature revealed gaps in the measurement and blurred conceptualization of functional status. Given the prognostic importance of functional status measures, the results highlight the importance of developing a reliable and efficient means of obtaining a measure of functional status resulting in the advancement of nursing science. Having a clear and concise measure of functional status will enable clinicians to implement effect treatment plans that would lead to a faster recovery, higher level of functional status, and a greater well-being.

Evidence-based practice in a military intensive care unit family visitation.

BACKGROUND: The dissatisfaction of family members with a restrictive visiting policy in a combined intensive care and step-down unit provides an opportunity for staff to develop better ways to meet the needs of patients and their families. A review of the evidence-based practice (EBP) literature as the measure of significance indicated that less restrictive visitation policies enhance patient and family satisfaction and offer many physiologic and psychological benefits to the patient. OBJECTIVE: The purpose of this study was to determine whether a less restrictive visitation policy could be implemented in the adult critical care department of a naval medical center. METHODS: Staff was educated on the use of EBP, specifically the Iowa-based model, and a less restrictive visitation policy was developed and implemented. RESULTS: Evaluation of the postintervention survey findings revealed higher patient and family satisfaction. CONCLUSIONS: The findings from this EBP project suggest that a more open visitation policy is feasible in adult critical care units, with an increase in overall satisfaction of patients and their families with regard to their stay in the intensive care unit.

Skill set requirements for nurses deployed with an expeditionary medical unit based on lessons learned.

Based in Kuwait 3 years apart, the authors recount how nurses and corps staff, along with their physician counterparts, came together to form well-run medical facilities under adverse circumstances. Their respective hospitals became competent organizations because of specific formulas for success, along with preparation, identification of required skill sets, and making improvements based on experience. This article describes the training of medical, nursing, and corps staff, the facilities and resources required for managing casualties, and some of the more commonly encountered combat injuries and conditions.

Cardiopulmonary resuscitation: how far have we come?

In the 43 years since it was first described, cardiopulmonary resuscitation (CPR) has grown from an obscure medical theory to a basic first aid skill taught to adults and is now the near-universal technique used in CPR instruction. This article provides insight into the history of CPR. We explore the phenomenon of sudden cardiac arrest, the historical roots of CPR, current practice data and recommendations, and the society's role in the development of this life-saving technique. We conclude with a review of CPR's economic impact on the healthcare system and the ethical and policy issues surrounding CPR.