Critical care nurse最新文献

Background: The Society of Critical Care Medicine has established guidelines to manage pain, sedation, delirium, immobility, family participation, and sleep disruption in the intensive care unit, a set of interventions known as the intensive care unit liberation (ABCDEF) bundle. Adherence to these guidelines has shown positive results.

Local problem: In the intensive care units of a level I trauma academic teaching hospital in central Texas, the rate of bedside nursing staff adherence to the ABCDEF bundle was only 67.1% in January 2022. The aim of this quality improvement project was to improve adherence to the bundle.

Methods: Knowledge gaps were found to be the driver of the low adherence rate. Two primary needs were identified: (1) education on the elements of the ABCDEF bundle and (2) increased awareness and recognition of incomplete and incorrect documentation. Interventions included focused education on intensive care unit liberation.

Results: From February to June 2022, overall adherence to the ABCDEF bundle increased from 67.1% to 95.3%, ventilator use decreased by approximately 10%, and restraint use dropped by about 9%. The incidence of delirium increased, but this increase was due to incorrect patient assessment before the interventions.

Conclusion: The results of this project are consistent with literature demonstrating that a multifaceted approach to improving ABCDEF bundle adherence can produce sustainable improvement in patient outcomes. This report may help other organizations facing similar challenges improve adherence to the bundle in a postpandemic environment.

Introduction: This is the first report of a patient who developed cardiogenic shock after receiving oral chemotherapy with capecitabine and was treated with venoarterial extracorporeal membrane oxygenation combined with continuous renal replacement therapy.

Clinical findings: A 58-year-old man developed an arrhythmia that rapidly progressed to cardiogenic shock and cardiac arrest after receiving oral capecitabine tablets to treat a rectal malignancy.

Interventions: The patient was treated with venoarterial extracorporeal membrane oxygenation in combination with continuous renal replacement therapy.

Outcome: The patient made a full recovery and was discharged from the hospital.

Conclusion: The use of comprehensive supportive treatments such as extracorporeal membrane oxygenation combined with continuous renal replacement therapy in patients with capecitabine-induced cardiac arrest can rapidly reduce drug concentrations, eliminate harmful substances, and improve the prognosis.

Background: Chlorhexidine gluconate has been considered the criterion standard of oral care for patients receiving mechanical ventilation because of its ability to reduce the incidence of ventilator-associated events. Optimal concentrations and frequencies remain unclear, as do adverse events related to mortality in various intensive care unit populations.

Objective: To examine the current evidence for the efficacy of chlorhexidine gluconate in reducing the incidence of ventilator-associated events, mortality, intensive care unit length of stay, and duration of mechanical ventilation in patients receiving ventilator support.

Methods: In this integrative review, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, and Health Source: Nursing/Academic Edition were searched using terms related to mechanical ventilation and chlorhexidine gluconate oral care with dates ranging from 2012 to 2023.

Results: Seventeen articles were included in this review: 8 systematic reviews, 8 randomized clinical trials (3 of which were not included in any systematic review), and 1 quasi-experimental study. Chlorhexidine gluconate oral care was associated with a reduced incidence of ventilator-associated events, but efficacy depended on concentration and frequency of administration. With stratification by intensive care unit population type, a nonsignificant trend toward increased mortality was found among non-cardiac surgical patients who received this care.

Conclusion: The evidence regarding the efficacy of chlorhexidine gluconate oral care in reducing ventilator-associated events in specific intensive care unit populations is contradictory. Recently published guidelines recommend de-implementation of chlorhexidine gluconate oral care in all patients receiving mechanical ventilation. Such care may be beneficial only in the cardiac surgical population.

Background: Emergency resternotomy in the intensive care unit for a patient who has undergone cardiac surgery can be daunting for surgeons and critical care staff. Clinicians involved are often unfamiliar with the surgical instruments and techniques needed.

Local problem: After an emergency intensive care unit resternotomy resulted in suboptimal performance and outcome, protocols for emergency resternotomy were established and improved.

Methods: Education and simulation training were used to improve staff comfort and familiarity with the needed techniques and supplies. The training intervention included simulations to provide hands-on experience, improve staff familiarity with resternotomy trays, and streamline emergency sternotomy protocols. Preintervention and postintervention surveys were used to assess participants' familiarity with the implemented plans and algorithms.

Results: All 44 participants (100%) completed the preintervention survey, and 41 of 44 participants (93%) returned the postintervention survey. After the intervention, 95% of respondents agreed that they were prepared to be members of the team for an emergency intensive care unit sternotomy, compared with 52% of respondents before the intervention. After the intervention, 95% of respondents strongly agreed or agreed that they could identify patients who might need emergency sternotomy, compared with 50% before the intervention. The results also showed improvement in staff members' understanding of team roles, activation and use of the emergency sternotomy protocol, and differences between guidelines for resuscitating patients who experience cardiac arrest after cardiac surgery and the post-cardiac arrest Advanced Cardiovascular Life Support protocol.

Conclusion: Results of this quality improvement project suggest that simulation training improves staff comfort with and understanding of emergency resternotomy.

Background: The mortality rate of pediatric patients who require continuous renal replacement therapy is approximately 42%, and outcomes vary considerably depending on underlying disease, illness severity, and time of dialysis initiation. Delay in the initiation of such therapy may increase mortality risk, prolong intensive care unit stay, and worsen clinical outcomes.

Local problem: In the pediatric intensive care unit of an urban level I trauma children's hospital, continuous renal replacement therapy initiation times and factors associated with delays in therapy were unknown.

Methods: This quality improvement process involved a retrospective review of data on patients who received continuous dialysis in the pediatric intensive care unit from January 1, 2017, to December 31, 2021. The objectives were to examine the characteristics of the children requiring continuous renal replacement therapy, therapy initiation times, and factors associated with initiation delays that might affect unit length of stay and mortality.

Results: During the study period, 175 patients received continuous renal replacement therapy, with an average initiation time of 11.9 hours. Statistically significant associations were found between the degree of fluid overload and mortality (P < .001) and between the presence of acute kidney injury and prolonged length of stay (P = .04). No significant association was found between therapy initiation time and unit length of stay or mortality, although the average initiation time of survivors was 5.9 hours shorter than that of nonsurvivors.

Conclusion: Future studies are needed to assess real time delays and to evaluate if the implementation of a standardized initiation process decreases initiation time.