Evaluating the impact of obesity on safety and efficacy of weight-based norepinephrine dosing in septic shock: A single-center, retrospective study.

OBJECTIVE: Norepinephrine is the first-line vasopressor recommended for patients in septic shock. Weight-based dosing may increase drug exposure and the risk of adverse effects in obese patients. The objective was to evaluate the safety and efficacy of weight-based norepinephrine dosing using actual body weight in the morbidly obese compared with normal weight patients. METHODS: This was a single centre, retrospective study of adult patients admitted with septic shock requiring norepinephrine for at least 12hours. The primary endpoint was the incidence of tachycardia within 48hours after norepinephrine initiation. Secondary endpoints included timing and dosing of norepinephrine when adjunctive agents were added. RESULTS: The incidence of tachycardia was similar between groups. Total norepinephrine exposure was significantly greater in obese patients on day 1 (p=0.02). Obese patients were more likely to be started on vasopressin (p<0.001) and steroids at a lower weight-based norepinephrine dose (p=0.016). CONCLUSIONS: Weight-based norepinephrine dosing using actual body weight did not result in more tachycardia in the morbidly obese compared to normal weight patients, despite greater total exposure. These results were limited by the low doses used and a small cohort. However, use of actual body weight in morbidly obese patients appears to be safe.

Nurse decision making regarding the use of analgesics and sedatives in the pediatric cardiac ICU.

OBJECTIVE: To describe nurse decision making and patient responses associated with the administration of analgesics and sedatives in the pediatric cardiac ICU. DESIGN: Prospective nonexperimental mixed methods study of pediatric cardiac ICU nursing practice. SETTING: Three tertiary academic pediatric heart centers in the United States. SUBJECTS: Pediatric cardiac ICU nurses caring for 217 patients completed 1,330 surveys. INTERVENTIONS: Four-item open-ended nurse survey completed each time an as needed dose of an analgesic or sedative was administered, an analgesic or sedative infusion/dose was titrated, and/or a new analgesic or sedative was administered. MEASUREMENTS AND MAIN RESULTS: Responses to survey questions were entered verbatim and then collapsed using a consensus process. Collapsing of the data continued until there was a working set of "symptoms," "changes," and "clinical situation managed" categories. Nurses identified 28 symptoms managed with analgesia and sedation. The most frequent symptoms included hypertension, tachycardia, crying, pain, and agitation. Nurses identified 20 patient changes that resulted from their interventions. The most prevalent changes included improved hemodynamics, calm state, sleep, comfort, and relaxed state. Nurses identified 22 clinical situations that they were attempting to manage. The most frequent clinical situations included pain, hemodynamics, procedures, hypertension, and agitation. Nurses responded that 22% of their interventions were influenced by others. CONCLUSIONS: Pediatric cardiac ICU nurses use many nonspecific indicators to describe patient level of comfort collectively. Decisions for managing patient comfort were influenced by their patients' overall hemodynamic stability.

Assessment and treatment of patients with acute tachyarrhythmia.

A tachyarrhythmia is defined as a heart rate greater than 100 beats per minute in conjunction with abnormal cardiac conduction. This article aims to inform nurses and other healthcare professionals about the predominant acute tachyarrhythmias. It focuses on the assessment and management of patients with this condition using case study examples.

How to ensure patient observations lead to effective management of tachycardia.

Tachycardia is a normal physiological response to exercise but in the healthcare setting it is considered to be an adverse sign, indicating possible serious illness such as shock. The condition can also be associated with a life threatening cardiac arrhythmia. This article aims to help nurses understand how to manage it.

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.

Monitoring the pulse as part of track and trigger.

This article (part two of four) aims to explore abnormalities of the pulse rate and the related nursing observations and actions. Measurement of the pulse is a fundamental nursing observation, which can detect a range of problems.

Treating tachyarrhythmias with radiofrequency catheter ablation.

Fast, safe, and effective, radiofrequency catheter ablation is becoming more common as a treatment for tachyarrhythmias. This article describes the procedure, which patients are eligible for it, and nursing considerations before, during, and after the procedure.

Third generation antitachycardia pacing implantable cardioverter-defibrillators.

With advanced third-generation implantable cardioverter-defibrillator (ICD) technology, patients receiving electrical therapy may only be aware of symptoms such as palpitations, or may be completely unaware of the event. Third-generation ICDs provide bradycardia back-up pacing, antitachycardia pacing (ATP), cardioversion, and defibrillation therapy. Additional benefits are noninvasive electrophysiologic testing capabilities and enhanced diagnostic features. An alternative surgical approach with a nonthoracotomy lead system is now also available.

Transcatheter ablation of tachyarrhythmias: an overview and case studies.

Transcatheter ablation techniques have recently been introduced as a treatment for patients with refractory tachyarrhythmias. These techniques include delivery of high energy direct-current (DC) or low energy radiofrequency (RF) current to permanently interrupt electrical conduction or activity in a region of arrhythmogenic cardiac tissue. Regardless of the technique, however, transcatheter ablation is a complex procedure that requires close collaboration of physicians and nurses in order to enhance the potential for achieving a successful outcome. Because cardiovascular nurses play a pivotal role in caring for a patient undergoing transcatheter ablation, this article presents the technique and the associated nursing care of two patients undergoing this treatment modality.

Differentiating between ventricular tachycardia and supraventricular tachycardia in the clinical setting.

In this article several different means of identifying VT and SVT have been discussed. Using the morphologic clues outlined, the nurse can be assisted in correctly diagnosing the dysrhythmia. Interpreting the 12-lead ECG for the diagnosis of VT and SVT is a skill that is acquired through practice and the recognition of morphologic clues on the ECG.

Wide QRS complex tachycardia.

Electrocardiographic monitoring for dysrhythmias is a major responsibility of critical care nurses, and patients with wide QRS complex tachycardias present a challenge. Criteria for differentiating the impulse origin as ventricular or supraventricular are well documented: QRS duration, QRS morphology, QRS axis, and presence of atrioventricular dissociation. However, definitive diagnosis can only be made by invasive electrophysiologic studies. Knowledge of treatment protocols is important to prevent hemodynamic deterioration. Procainamide is effective for treating ventricular and supraventricular dysrhythmias and is the drug of choice unless certainty of impulse origin exists.

Clinical decision making of critical care nurses managing computer-simulated tachydysrhythmias.

The purposes of this study were to describe the clinical decision making of critical care nurses managing computer-simulated tachydysrhythmias and to assess the major sources of error related to the management of two tachydysrhythmias: atrial flutter and ventricular tachycardia. In this descriptive study, 142 critical care nurses each completed four computerized clinical simulations (two atrial flutter and two ventricular tachycardia). Simulation performance was measured by proficiency score (comparison with expert performance), patient outcome (cure or die), and amount of data collected before the first intervention. Mean proficiency scores were 51% for atrial flutter and 35% for ventricular tachycardia. Thirteen percent of the atrial flutter and 35% of the ventricular tachycardia simulations ended in patient death. Failure to recognize ventricular tachycardia and unfamiliarity with second- and third-line treatments were major sources of error. Medication errors were the cause of death in 87% of the simulations ending in patient death. These results document the need for emphasis on dysrhythmia management in the critical care curriculum.