The Myth of 0.9% Saline Neither Normal nor Physiological

Crit Care Nurs Q

Vol. 38, No. 4, pp. 385–389

Copyright Qc  2015 Wolters Kluwer Health, Inc. All rights reserved.

Leon Chen, MSc, AGACNP-BC, CCRN, CPEN

Normal saline is the crystalloid of choice for fluid resuscitation with its utility born out of the cholera epidemic of 1832. However, its ubiquitous usage is being challenged because of a growing body of evidence suggesting that a large volume infusion of normal saline does in fact have deleterious effects on multiple body systems. Careful considerations should be given to the physiological effects of using large amounts of normal saline as one would with another pharmacological agents. Key  words:  crystalloidsfluid  resuscitationnormal  salinephysiological   effects

I at length resolved to throw the fluid immediately into the circulation. In this, having no precedent to direct me, I proceeded with much caution . . . ounce after ounce was injected . . . when six pints had been injected, she expressed in a firm voice that she was free from all uneasiness.

FLUID RESUSCITATION using 0.9%  normal saline (NS), now the mainstay therapy for many conditions, was born out of  the cholera epidemic of the 1800s. In 1831, Dr O’Shaughnessy analyzed the blood of patients with cholera and noted the loss of large amount of water and neutral salt components. On the basis of his findings, he hypothesized that replacing the lost salt contents with tepid water and highly oxygenized salt—such as nitrate or the chlorate of potash (based on animal studies)—would be effective in  treating patients with cholera in extremis.1 In 1832, Dr Thomas Latta documented his treatment of an elderly patient with cholera using what is now recognized as intravenous fluid resuscitation. Then, with a silver syringe connected to a flexible injection tube, he injected saline into the basilica vein of the patient and noted the return of the patient’s color and alleviation of symptoms.2 Ultimately, however, the patient’s condition relapsed and died after the responsibility of her care was transferred to the hospital surgeon, who no doubt venosected the patient as that was the favored remedy for patients with cholera at the time.

Although the practice of intravenous saline solutions was first described during the cholera epidemic, the salt contents used in those days were very different from the 0.9% solution that we are familiar with currently. The idea of 0.9% saline as physiological was based on the experiments of Dr Hamburger, a Dutch physiological chemist who, in 1896, published a study in which he noted that mammalian red blood cells did not swell when the NaCl concentration of solutions was titrated to 0.92%. On the basis of his findings, he concluded that 0.9% NaCl is isotonic with the mammalian blood of most animals including humans, and thus physiological.3 Since then, 0.9% “normal saline” has become the standard intravenous solution used in clinical practice.

Although termed “normal saline,” 0.9% NS is  in  fact  supraphysiological  because  of its

abnormally high chloride content.4 Each liter of NS contains 154 meq of chloride, which exceeds the normal physiological range of 96 to 106 meq/L by approximately 1.5 times. With large volume infusion of NS, the large chloride load has been shown to have negative effects on blood pH, immune system, coagulation function, and renal perfusion.4,

EFFECT ON PH

In both animal and human studies, the infu- sion of a large amount of NS has been noted to decrease the pH of the subjects, the effect of which could last for several hours and the resultant acidosis could lead to coagulopathy and negative hemodynamics.4-7 There are 2 schools of thought behind the acidosis caused by NS: the dilutional acidosis hypothesis and the Stewart physiochemical hypothesis. The dilutional acidosis theory posits that with a large volume of NS infusion, there is dilution of serum bicarbonate concentration leading to acidosis.5 The Stewart hypothesis is based on Peter Stewart’s physiochemical findings that a strong ion difference (SID) is an inde- pendent factor for altering serum pH. Stew- art’s hypothesis emphasizes electroneurtrality and when differences are present in between the cations and anions, the body converts water (H2O) into hydrogen ion and bicarb accordingly to maintain electroneutrality.8-10 In the original equation, strong ions include sodium, chloride, and other electrolytes such as potassium and magnesium; these other electrolytes are much less in concentration, therefore not enough to cause a physiologi- cal effect. In terms of acid–base physiology in Peter Stewart’s approach, the SID is usu- ally effectively the difference between sodium and chloride. (Although hyperphosphatemia is one condition where phosphate increases so much that it can alter the SID.)8-10 When the SID increases, the serum pH becomes alkalinized and when the difference decreases, the opposite effect occurs. NS’s Na:Cl ratio is 1:1 with an SID of 0; therefore, when large volumes are infused, serum acidosis results.8-10 More balanced solutions with less chloride including lactate Ringer and Normosol/Plasma- Lyte have SIDs ranging from 21 to 42 and have less of an acidotic effect when infused in large volumes8-10 (see the Table).

EFFECT ON IMMUNE  SYSTEM

In animal studies, hyperchloremic acido- sis has been linked with increased release of inflammatory markers and cytokines.11 This pro-inflammatory response seems to be dose dependent.11 Although a clear association has been made between chloride and cytokines, the clinical implication for this phenomenon is unknown because no large study on hu- mans has yet been conducted.11,12 It makes physiological sense; however, in conditions such as severe sepsis when there is already  an overwhelming inflammatory cascade, we do not infuse NS, which further increases cytokine release. However, large-scale human study would be needed to explore its clinical impact.

EFFECT  ON COAGULATION

Large volume of NS infusion has been associated with increased blood loss and increased blood products needed in surgery and trauma literature. This association may be due to NS’s effect on lowering the pH, which is detrimental to coagulation cascade.13 The effect  of acidosis on coagulation cascade is thought to be through its inhibitory effect on thrombin and fibrinogen, which results in prolonged bleeding.14,15 Therefore, using large volume of NS to supplement for blood loss has the detrimental effect of increased bleeding and more blood product need.13-15

EFFECT ON KIDNEYS

The infusion of NS has been associated with greater interstitial edema and longer time to micturation.4,5,16 This effect was first seen in animal studies, and later confirmed in human studies where subjects were infused with NS and was compared with those infused    with

lactated Ringer. This effect on renal perfusion is likely due to the vasoconstrictive effect of chloride on the renal afferent arteries.4,5   A high chloride concentration in the renal tubules causes a depolarization effect in the macula densa and leads to activation of A1 receptors in the renal arteries, inducing a decrease in glomerular filtration rate. This vasoconstrictive effect also causes greater interstitial edema in the renal capsules, leading to compression on the tubules, which further affects urine output and tissue perfusion. These effects have not been noted when the subjects are infused with balanced solutions.4,5

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CLINICAL  IMPLICATION

Studies of both surgical patients and critically ill medical patients all have demonstrated an association of chloride-rich solutions, with worse clinical outcomes such as increased incidence of acute kidney injury, increased needs for renal replacement therapy, higher need for fluid/blood product, and most importantly, increased mortality.13,16-20 Although there is a concern with using balanced fluids in potential hyperkalemic patients, small-scale studies have demonstrated

their safety because of the limited amount of potassium contained in the balanced fluids (no more than 5 mmol/L).21,22 Rather than resuscitating patients in shock with NS only, careful consideration should be given to fluid selection much like one would with medications. The clinician should have understanding of the physiological changes NS infusion brings and be cognizant of its ill effects. Given the available literatures suggesting deleterious effects associated with large volume NS infusion, we should give more considerations to balanced crystalloid solutions as the primary resuscitation fluid

CONCLUSION

Although the resuscitation fluid of choice, NS’s high chloride content makes it neither “normal” nor physiological.” Its chloride-rich content has been associated with adverse ef- fects in pH, coagulation, renal function, and patient outcomes. Although the evidences against the use of NS are mostly animal studies or associative by nature, it is reasonable for clinicians of all discipline to understand the potential deleterious effects of large volume infusion of NS.

REFERENCE

1.   Foe¨x BA. How the cholera epidemic of 1831 resulted in a new technique for fluid resuscitation. Emerg Med J. 2003;20(4):316-318.

2.   Latta T. Letter from Dr. Latta to the Secretary of the Central Board of Health, London, affording a view of the rationale and results of his practice in the treat- ment of cholera by aqueous and saline injections. 1832.  Int  J  Epidemiol. 2013;42(2):387-390.

3.   Awad S, Allison SP, Lobo DN. The history of 0.9% saline. Clin Nutr. 2008;27(2):179-188.  doi:10.1016/j

.clnu.2008.01.008.

4.   Lobo DN, Awad S. Should chloride-rich crystalloids remain the mainstay of fluid resuscitation to prevent “pre-renal” acute kidney injury?: con. Kidney Int. 2014;86:1096-1105. doi:10.1038/ki.2014.105.

5.   Yunos NM, Bellomo R, Story D, Kellum J. Bench-to- bedside review: chloride in critical illness. Crit Care. 2010;14(4):226.  doi:10.1186/cc9052.

6.   Scheingraber S, Rehm M, Sehmisch C, Finsterer U. Rapid saline infusion produces hyperchloremic acido-

 

sis in patients undergoing gynecologic surgery. Anes- thesiology. 1999;90(5):1265-1270.

7.   Reid F, Lobo DN, Williams RN, Rowlands BJ, Allison SP. (Ab)normal saline and physiological Hartmann’s solution: a randomized double-blind crossover study. Clin  Sci  (Lond). 2003;104(1):17-24.

8.   Kishen  R,  Honore´  PM,  Jacobs  R,  et  al.  Facing  acid- base disorders in the third millennium—the Stew- art approach revisited. Int J Nephrol Renovasc Dis. 2014;7:209-217. doi:10.2147/IJNRD.S62126. eCollec- tion 2014.

9.   Omron EM, Omron RM. A physicochemical model of crystalloid infusion on acid-base status. J Intensive Care Med. 2010;25(5):271-280.

10.   Smuszkiewicz P, Szrama J. Theoretical principles of fluid management according to physicochemi- cal Stewart approach. Anaesthesiol Intensive Ther. 2013;45(2):99-105.

11.   Kellum JA, Song M, Almasri E. Hyperchloremic aci- dosis  increases  circulating  inflammatory molecules

 

The Myth of Normal Saline          389

 

 

in experimental sepsis. Chest. 2006;130(4):962- 967.

12.   Wu BU, Hwang JQ, Gardner TH, et al.  Lac- tated Ringer’s solution reduces systemic inflamma- tion compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2011;9: 710-717.

13.   Waters JH, Gottlieb A, Schoenwald P, Popovich MJ, Sprung J, Nelson DR. Normal saline versus lactated Ringer’s solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study. Anesth Analg. 2001;93: 817-822.

14.   Martini WZ. Coagulopathy by hypothermia and acidosis: mechanisms of thrombin generation and fibrinogen availability. J Trauma. 2009;67(1):  202-208;    discussion    208-209.     doi:10.1097/TA

.0b013e3181a602a7.

15.   Martini WZ. Fibrinogen metabolic responses to trauma. Scand J Trauma Resusc Emerg Med. 2009;17:2.  doi:10.1186/1757-7241-17-2.

16.   Yunos  NM,  Bellomo  R,  Hegarty  C,  Story  D,  Ho L, Bailey M. Association between a chloride- liberal vs chloride-restrictive intravenous fluid ad- ministration strategy and kidney injury  in  crit-  ically ill adults. JAMA. 2012;308(15):1566-1572. doi:10.1001/jama.2012.13356.

 

17.   Shaw AD, Bagshaw SM, Goldstein SL, et al.  Ma- jor complications, mortality, and resource utiliza- tion after open abdominal surgery: 0.9% saline com- pared to Plasma-Lyte. Ann Surg. 2012;255(5):821- 829. doi:10.1097/SLA.0b013e31825074f5.

18.   McCluskey SA, Karkouti K, Wijeysundera D, Minkovich L, Tait G, Beattie WS. Hyperchloremia af- ter noncardiac surgery is independently associated with increased morbidity and mortality: a propensity- matched cohort study. Anesth Analg. 2013;117: 412-421.

19.   Boniatti MM, Cardoso PR, Castilho RK, Vieira SR. Is hyperchloremia associated with mortality in critically ill patients? A prospective cohort study. J Crit Care. 2011;26:175-179.

20.   Raghunathan K, Shaw A, Nathanson B, et al. Asso- ciation between the choice of IV crystalloid and in- hospital mortality among critically ill adults with sep- sis. Crit  Care  Med. 2014;42:1585-1591.

21.   Van Zyl DG, Rheeder P, Delport E. Fluid man- agement in diabetic-acidosis-Ringer’s lactate versus normal saline: a randomized controlled trial. QJM. 2012;105(4):337-343. doi:10.1093/qjmed/hcr226.

22.   Khajavi MR, Etezadi F, Moharari RS, et al. Effects of normal saline vs. lactated  Ringer’s  during  re-  nal transplantation. Ren Fail. 2008;30(5):535-539. doi:10.1080/08860220802064770.

Clinical humility: a humbled patient care

When we practice clinical humility, we remove the illusion of medical omnipotence.

By Fidelindo Lim, DNP, CCRN and Justin O'Leary, MA, BS, BSN

There’s a story that goes something like this: An elderly man falls down a flight of stairs at home. In the emergency department, he’s found to have four broken ribs, a pneumohemothorax that requires two chest tubes, and a large gash on his forehead that needs 12 stitches, along with some of the usual cardiopulmonary comorbidities associated with older people. While in the hospital, the patient acquires a drug-resistant urinary tract infection, develops Clostridium difficile colitis and a deep vein thrombosis, and suffers a transient ischemic attack. About 2 months later, he’s discharged from the hospital, walking with minimal assistance, to a sub-acute rehabilitation facility. He’s a little shaken, but his wits are intact. A miracle of modern medicine? The result of excellent nursing care?

To bow before our patients

What if the patient did all that by himself and medicine had little do with it? This story illustrates the enduring physical and psychological resiliency most patients possess. When the body is under siege, say by the common cold virus, a vast, complex, and largely unseen neuro-hormonal-endocrine response mobilizes to repair it.

Now imagine the body’s elaborate response in the face of an evolving myocardial infarction. Under chronic assault by inflammation, incurable conditions, and incalculable collateral damage of invasive treatment, some patients recover, in spite of us.

We don’t mean to suggest that patients should abandon life-saving surgeries or antibiotics or that clinicians should leave the patient to heal thyself. The questions we want to ask are these: As clinicians, how much pride do we accord ourselves for our patients’ recovery? Could feeling too good about what we do to our patients be bad for our professional comportment?

What if we have nothing to do with it?

These questions call to mind one of the occupational hazards of clinical work: overidentification with the ability to cure. Taken to an extreme, this can lead to clinical vanity and false pride, the opposite of clinical humility.

Comte-Sponville described humility as a humble virtue that comes knowing the limits of one’s abilities. By extrapolation, clinical humility means to practice without the illusion of medical omnipotence. This notion creates a moral conundrum when it comes to the idea of taking pride in our work. Even more so, to pride oneself on one’s own humility is to lack it.

Does this cast a pall over the festivities of something like National Nurses Week? It shouldn’t. Celebrating our collective pride will always be tempered by the many failures of our efforts, but it should not weaken our intention to excel at what we do best. In essence, it is preferable to question oneself than to misrepresent oneself. Clinical humility results when the imperfections of medicine meet the honesty of the practitioner.

Consider the connection between clinical humility and patient-centered care, with its goal of re-focusing our sense of purpose as healthcare providers. In other words, we can’t heal the patient by ourselves or by medicine alone. When we put the patient at the center, we can appreciate the natural healing processes that occur unaided by medicine and be magnanimous in the face of unexpected patient recovery or anticipated medical success.

When I (Fidel) was an ICU nurse, I took pride in participating in the cure of critically ill patients. I became very proficient at manipulating intrusive devices, interpreting graphic waveforms, and analyzing numbers. As a young nurse, I was unconcerned with healing. But here lies the difference. Curing refers to what is done to the patient by healthcare providers. Healing, however, refers to what is done by the patient, consciously or otherwise, to restore health.

Within the context of clinical humility, Cousins says that nurses will harness their talents for influencing, stimulating, and inspiring patients to move along their healing path. In other words, pills help, but innate or inspired determination goes further.

A refreshing virtue

It’s possible that new nurses have clinical humility because they don’t have complete confidence in their abilities. This awareness keeps patient care inspired, placing trust in the patient and the body's innate ability to heal itself. Unfortunately, our accumulation of knowledge and skill may dampen our humility. And as a side effect, we might overestimate ourselves.

By reflecting on our experiences as new nurses, when we first witnessed the resiliency of the human body and its ability to heal, we might regain a sense of clinical humility. Remembering we are only a part of the greater scheme of the mysteries of healing can be humbling and virtuous.

Fidelindo Lim is a clinical assistant professor at New York University College of Nursing in New York City, NY. Justin O'Leary is a staff nurse in Urgent Care at Memorial Sloan Kettering Cancer Center in New York City, NY.

Selected References

Comte-Sponville A. A small treatise on the great virtues: The uses of philosophy in everyday life. New York, NY: Metropolitan Books; 2001.

Cousins N. The healing equation. In Carlson R, Shield B, Eds. Healers on Healing. New York, NY: Putnam Publishing Group; 1996.

Aphorisms, Sayings, Epigrams, Maxims: Small Doses for Health Care Providers

Fidelindo Lim, DNP, CCRN

The year’s end often triggers the reflection dial in people lives. This is partly in part assisted by those “year in pictures” pages put out by newspapers and magazines. We look back or better still we look around and within us to make meaning or make some sense of the novel and the quotidian of life. For health care providers, it is generally accepted, but seldom explored, that we should reflect, simply because health care is tough!

One of the accessible prompts for reflection is to use well-know or obscure aphorisms to guide along the self-introspection. Aphorisms are a short, pithy statement expressing a general truth or rule of conduct. Its various synonyms are: saying, adage, aphorism, proverb, motto, saw, axiom, dictum, precept, and epigram. For millennia, they have permanently colored health care culture and inhabit it in the same way as uncertainty (Levine and Bleakley, 2012). Florence Nightingale would probably rank as one of the top dispensers of acerbic epigrams that still resonates with current health care issues.

Here are some aphorisms that may be of special interest to nurses, randomly selected and in no particular order, for individual or collective reflection. New Year’s resolutions, anyone?

"Every nurse ought to be careful to wash her hands very frequently…. If her (his) face, too, so much the better." - Florence Nightingale

“To understand God’s thoughts we must study statistics, for these are the measure of His purpose.”—Florence Nightingale

“One of the most widespread diseases at present is diagnosis.” - Karl Kraus

“I find the medicine worse than the malady.”John Fletcher

“We can’t reach old age by another man’s road. My habits protect my life, but they would assassinate you.”Mark Twain

“Patients sue not when the patient gets angry with the doctor, but when the doctor gets angry with the patient.”-  Thomas J. Krizek

“Not everything that counts can be counted, and not everything that can be counted counts.” —Albert Einstein

I will lift up mine eyes unto the pills. Almost everyone takes them, from the humble aspirin to the multi-colored, king-sized, three-deckers, which put you to sleep, wake you up, stimulate you, sooth you all in one. It is an age of pills!”-  Malcolm Muggeridge

“Not everything that counts can be counted, and not everything that can be counted counts.” — Albert Einstein

"Let me be sick myself if sometimes the malady of my patient be not a disease to me." — Sir Thomas Browne.

"Discuss the coming on of years, and think not to do the same things still; for age will not be
denied." — Francis Bacon.

"Medicine sometimes snatches away health, sometimes gives it."— Ovid

"People will forget what you said, they will forget what you did, but they will never forget how you made them feel!" —Maya Angelou

To follow the advice of Sir Francis Bacon, “read not to contradict and confute, nor to believe or take for granted, nor to find talk and discourse, but to weigh and consider” (quoted by Harold Bloom in How to Read and Why).

 

Recognizing and Treating Vasospastic Angina

Leon Chen, MSc, AGACNP-BC, CCRN, CPEN

Fidelindo Lim, DNP, CCRN

Published in the Nurse Practitioner Journal, Oct. 2016 Issue

 A Variant Case

 A 52-year-old non-smoker female with no cardiac history was diagnosed with Hodgkin’s lymphoma where she previously received chemotherapy followed by stem cell transplant. After a period of remission, her lymphoma recurred and she is readmitted to an oncology unit for a second stem cell transplant. Her inpatient post-transplant course was largely uneventful until five days later when she started to complain of crushing sub-sternal, non-radiating chest pain, associated shortness of breath. An electrocardiogram (EKG) done at the time showed normal sinus rhythm with unremarkable findings compared with baseline EKG. Her chest pain was attributed to gastric acid reflux and she was given an antacid (Maalox) for symptom relief.

 An hour later, the patient reported worsening chest pain at rest accompanied by shortness of breath and an episode of transient unresponsiveness witnessed by her husband. The registered nurse activated the hospital rapid response system (RRT). Upon arrival of the team, the patient was responding appropriately and complained of persistent “chest pressure” rated at 7/10. The 12-lead EKG this time showed third degree heart block (See Figure 1) with a rate of 57 beats per minute. The patient’s blood pressure was 85/49, respiratory rate 22/minute, afebrile and oxygen saturation of 92% on room air. Transcutaneous pacing pads were applied and the patient was maintained on 2 L/minute nasal cannula oxygen (no drugs given since none was indicated at the time). Serial EKGs were done and a cardiology consult was requested.

 Subsequent EKG revealed normal sinus rhythm, with a heart rate of 74 and ST depression (approximately 2 mm) in leads I, aVL and V2 (See Figure 2). A succeeding EKG revealed deepened ST depression in leads I, aVL, and V2 along with ST elevation in the inferior leads (See Figure 3). An STEMI alert was activated and she was promptly transferred to an outside institution equipped with a cardiac catheterization lab.

The patient’s initial troponin was negative. Her left heart catheterization showed a 20% stenosis of the right coronary artery, and a 20% stenosis of the left anterior descending artery (Done upon transfer to Cornell). However, during the left ventricular scan, the patient became hypotensive, and her EKG exhibited a complete heart block and inferior wall ischemia. The patient was re-catheterized which showed 80-90% occlusion of the right coronary artery. She was given intra-arterial nitroglycerin, after which symptoms significantly improved. Her symptoms, along with EKG and catheterization findings are consistent with variant angina, also known as Prinzmetal’s angina.

What’s Happening Here? Pathophysiology of Prinzmetal Angina

            Prinzmetal angina was first described in the 1950s and was thought to be a distinct type of angina pectoris since it typically presents during rest and is not associated with exertion (1). The condition is also referred to as variant angina, Prinzmetal's variant angina and angina inversa. The cause was attributed the temporary occlusion of coronary vessels due to increased vascular tone (1). Subsequent studies confirmed that the mechanism of this disease is due to coronary vasospasms (2). This process is different from the occlusive changes caused by atherosclerotic coronary artery disease (4). The phenomenon occurs in approximately 2-10% of patients of the General population (3). Although the exact pathogenesis of this condition is still being debated, it is believed that endothelial dysfunction, inappropriate nitric oxide release, and calcium channel disorders are all potential causes (2). Typical symptoms include retro-sternal chest pain that occurs at rest and there appears to be a circadian pattern, with patients’ typically experiencing chest pain early in the morning. EKG changes may show transient ST elevations in severe cases (4). Troponin (normal range is less than 0.04 ng/mL) is mostly negative and coronary catheterization often shows non-occlusive coronary arteries with vasospasm (4). Traditionally, patients are treated with nitroglycerin and calcium channel blockers with great success (4). Complications of Prinzmetal angina can include dysrhythmia, heart blocks, and even cardiac arrest (5-9).

Current Best Practices

            At present there are no established guidelines in North America or Europe for the diagnosis and treatment of Prinzmetal angina due to its decreasing incidence (12) primarily attributed to the widespread availability and use of calcium channel blockers in the treatment of hypertension and other conditions (12). However, in Japan, where the incidence is three times higher compared to the United States, a practice guideline has been issued (12). Diagnosis of Prinzmetal angina is made based on the combination of clinical symptoms and invasive and non-invasive testing (11). Definitive diagnosis is made if characteristic EKG changes are noted during an attack or that vasospasm with stenosis over 90% is noted on angiography (11). A likely diagnosis is made if the symptoms appear at rest, induced by hyperventilation, and is suppressed by calcium channel blockers but not beta blockers (11) (13). No recommendation is made for specific calcium channel blockers. Acute management consists of nitrates with no specific recommendation is made for route, for chest pain relief and calcium channel blocker for long term management (12).

Management

The patient was given Aspirin 325 mg, Clopidogrel 300 mg, 4 mg of Morphine for pain, 1 liter of IV crystalloid for hypotension, and a Heparin drip was initiated at 16 units/kg/hour. Patient was transferred to another facility for cardiac catheterization and further management.

Outcome

At the time of chest pain, the patient was transferred to another facility for cardiac catheterization and stayed briefly for observation. She was eventually readmitted to her primary facility where continued treatment for her lymphoma. She was discharged home with calcium channel blockers and nitroglycerin and outpatient follow up with a cardiologist.

Clinical and Nursing Implications

            Since smoking is strongly correlated with Prinzmetal angina, smoke cessation is key to preventing recurrence of symptoms (2).The case presented here was unique in that the patient has no smoking history. Due to her vasospasm vessel distribution; her symptoms mimicked an inferior infarct with high degree heart block. This case highlights the importance of serial EKGs and if possible, telemetry monitoring for suspected Prinzmetal angina patients. The transient nature of this disease makes it elusive to a onetime 12-lead EKG. It’s important for the clinician to hold a degree of suspicion and obtain serial EKGs if the patient remains symptomatic to offset the development of myocardial infarction.

          Patients with Prinzmetal angina can have atypical presentations (e.g., blackouts and urinary incontinence) that mimics other conditions such seizure or epilepsy (4). Vigilant assessment by nurses and other clinicians is essential in ruling out other conditions. Nothing the timing of angina is crucial information to gather during health history interview. Nurses can collaborate with providers to order Holter monitoring for patients with symptoms suggestive of Prinzmetal angina to aid in definitive diagnosis (4). For patients undergoing cardiac catheterization, nurses can provide high-quality patient education using the teach-back method. The patient and their caregivers should be encouraged to ask questions and be referred to reputable sources of online information such as the American Heart Association (13).

          Discharge teachings of patients diagnosed with Prinzmetal angina might include instructions related to taking calcium channel blockers and nitrates. Patients are reminded not to take calcium channel blockers with grapefruit juice due to latter’s potential to reduce presystemic clearance of the drugs decreases and subsequent increase in bioavailability that could lead to hypotension (14). To reduce the risk for orthostatic hypotension, patients are reminded to get up slowly from recumbent or sitting position and to encourage them to remain well hydrated. Since one of the most common side effects of nitrates is headache, patient’s need to collaborate with their provider on how best to manage this considering the patient’s taking into consideration potential drug interactions and potential side effects of analgesics.

 

References

1)      Prinzmetal M, Kennamer R, et al. Angina pectoris. I. A variant form of angina pectoris; preliminary report. Am J Med. 1959 Sep;27:375-88.

2)       Kusama Y, Kodani E, et al. Variant angina and coronary artery spasm: the clinical spectrum, pathophysiology, and management. J Nippon Med Sch. 2011;78(1):4-12.

3)      Akhtar MM, Akhtar R, et al. An unusual cause of blackout with transient loss of consciousness: Prinzmetal angina. BMJ Case Rep. 2012 Jun 14;2012. pii: bcr0120125539. doi: 10.1136/bcr.01.2012.5539.

4)      Bohm A, Kiss R, et al. Complications of variant angina: a case report. Can J Cardiol. 2012 Mar-Apr;28(2):245.e5-7. doi: 10.1016/j.cjca.2011.10.011. Epub 2011 Dec 16.

5)      Siliste RN, Savulescu-Fiedler I, et al. Bradyarrhythmic syncope in a patient with Prinzmetal's variant angina: a case report. Am J Emerg Med. 2013 Jun;31(6):996.e1-4. doi: 10.1016/j.ajem.2013.01.024. Epub 2013 Apr 18.

6)      Laporte F, Moulin F, et al. Sudden death caused by atypical variant angina. Arch Cardiovasc Dis. 2011 Aug;104(8-9):480-1. doi: 10.1016/j.acvd.2011.01.012. Epub 2011 Aug 23.

7)      Patel V, Yavari A, et al. A variant diagnosis for recurrent ST elevation. QJM. 2010 Oct;103(10):797-8. doi: 10.1093/qjmed/hcp167. Epub 2009 Nov 11.

8)      Wakabayashi K, Suzuki H, et al. Cardiopulmonary arrest due to persistent coronary spasm in a young woman. Are we properly diagnosing vasospastic angina? Int J Cardiol. 2011 May 5;148(3):e56-9. doi: 10.1016/j.ijcard.2009.02.044. Epub 2009 Mar 26.

9)      Chin A, Casey M. Variant angina complicated by polymorphic ventricular tachycardia. Int J Cardiol. 2010 Nov 19;145(2):e47-9. doi: 10.1016/j.ijcard.2008.12.138. Epub 2009 Feb 7.

10)  JCS Joint Working Group. Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2008): digest version. Circ J. 2010 Aug;74(8):1745-62. Epub 2010 Jul 17.

11)  Nishigaki K, Inoue Y, et al. Prognostic effects of calcium channel blockers in patients with vasospastic angina--a meta-analysis. Circ J. 2010 Sep;74(9):1943-50. Epub 2010 Jul 21.

12)  Sueda, Shozo et al. Recommendation for establishment of guidelines for Prinzmetal's variant angina and vasospastic angina in the USA and Europe. Journal of Cardiology Cases , Volume 6 , Issue 5 , e161 - e162

13)  Prinzmetal's Angina, Variant Angina and Angina Inversa. American Heart Association, Mar.-Apr. 2013. Web. 16 Nov. 2014. http://www.heart.org/HEARTORG/Conditions/HeartAttack/SymptomsDiagnosisofHeartAttack/Prinzmetals-Angina-Variant-Angina-and-Angina-Inversa_UCM_435674_Article.jsp.

14)  Sica DA. Interaction of grapefruit juice and calcium channel blockers. Am J Hypertens. 2006 Jul;19(7):768-73.

The Will to Live and Living Well

By Justin O’Leary, MS, RN and Fidelindo Lim, DNP, CCRN

This essay is published in the July 2016 Edition of the American Nurse Today – the official journal of the American Nurses Association - https://americannursetoday.com/will-live-living-well/

Some years ago, I shared with a friend one of Joey Adams’ acerbic quips, “the number one cause of divorce is marriage”. To this, my friend retorted: the number one cause of death is life! In writing this reflection, we revisit the existential question: What is life? More specifically, what to do with life, at the end-of-life? How does one define the intangible or compare one life to another without knowing the passions that move the patient to decide a certain way? In nursing, patient-centered care is a term thrown around to remind nurses to be sensitive to the uniqueness of the individual and respond accordingly. While a person’s life may have cultural influences, what accounts for the variations in patient’s perception of the meaning of "life" and "living?" Or between the will to live - to go on; and living well: to recalibrate life. How can we, as nurses, support patients as they navigate these questions, when every individual defines life and living differently?

Nurses have the privilege to meet patients with terminal illnesses who have chosen differing paths. The will to live and living well are overlapping concepts. The former is the impetus for the latter. How they are lived out can have very different trajectories. In our interactions with these patients, we struggle to find the center to which we can drop anchor and guide patients as they sail the rough or the eerily calm waters of end-of-life care.

The Choices Patients Make

Let’s consider two patients with a diagnosis of incurable cancer who have been told they each have a year to live. Patient A chooses to live his life surrounded with family and friends, experiencing all that life has to offer him. He decides to spend his savings, travel the world, host dinners, see a show, and so on. Now and then, he is back in the emergency department from the toll of his illness, but with a smile on his face and optimism that once he regains his strength, he will continue his adventure to live well – until the end. He leaves no indications of preserving tangible items for a future but instead makes the best of the "here and now." Patient B chooses a different path. From the day he is informed of his “sentence”, he decides to use the time he has left in providing for his family, to ensure they would be secure after he is gone. He goes back to work. He puts all his energies finishing his dream home and imagines his children living there. He planned his remaining year to ensure he will continue to have a physical presence in his family, after death.  Of these two patients, the nuance lies between one who is preparing for the ultimate departure and one who is unpacking, as if arriving, returning home from an exhausting journey.

          How are nurses to determine what life meant for them? No doubt nurses in hospice and palliative care deal with these questions regularly and would know how to address them. For nurses outside these settings, this could throw off the routine workflow (imagine having these conversations with patients and families between the 9 and 12 noon med passes?). Or stir considerable moral distress balancing the demands of seemingly contradictory aims of medicating and healing the patient. Here we offer a brief reflection on how nurses may affirm our patients’ will to live and their desire to live well.

Nursing The Will to Live and Living Well

          When the famous physician-writer Oliver Sacks was informed of his metastatic cancer secondary to ocular melanoma, he wrote in the New York Times (six months before his death), “I have been able to see my life as from a great altitude, as a sort of landscape, and with a deepening sense of the connection of all its parts...” His published end-of-life reflections have the calm eloquence of a lover writing to his beloved: life. We imagine, nurses too, can see life from an altitude or from an angle unknown to other health care providers. It would be unthinkable to nurse meaningfully well without weighing and considering the will to live and the living well questions, for they both resonate with the essence of nursing.

           The will to live is the mostly unconscious drive to be alive, beyond simple survival. Its closest companion is optimism. Self-preservation is at the heart of every individual’s will to live, but a moment of introspection is needed to determine what and why an individual is living. When the end of a patient’s life is in sight, what is a will to live then? Is it to continue self-preservation for as long as possible, or is it to experience the most life has to offer in the face of a time limit? With this in mind, we might be able to see terminally ill patients as willful participants of their healing, and not merely passive recipients of care. Perhaps one of the easiest ways to affirm life is to give patients choices (advance directives come to mind). For instance, simply asking the patient what beverage they would like to take their medications with not only preserves dignity and respect, it validates self-determination and free-will, albeit in small ways. Knowing the social system surrounding the patient might also provide some clues. It is essential to truly look, listen, and feel when the nurse is with the patient and family.

          Living well in the face of terminal illness has the stubborn determination of experience-life while-you-can attitude, a sort of resilience building. However, it also echoes the bargaining phase of the Kübler-Ross model of the death and dying process. A promise to live well is an exercise in self-redemption and humility. No matter what motivates the patient, our role as nurses is not to judge, but simply to be present and validate the patient’s experience. We can support resiliency by assisting the patient to make connections with families and friends, helping them see their overall situation on proper perspective, and set realistic goals (e.g., what can be achieved during the shift). Here, the role of palliative take cannot be over-emphasized. One simply cannot live well in pain or suffering. When compared with patients treated with standard chemotherapy alone, patients receiving chemotherapy plus palliative care lived an average of 3.5 months longer – months that can be dedicated to living well.

          The will to live and living well – one is important, the other is impressive. Wisdom lies in caring to know the difference.

Reference

My Own Life. Oliver Sacks on Learning He Has Terminal Cancer By OLIVER SACKS FEB. 19, 2015 New York Times

http://www.nytimes.com/2015/02/19/opinion/oliver-sacks-on-learning-he-has-terminal-cancer.html

Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19; 363(8):733-42.

 

"Real Simulation"

by Jeffrey Phillips BS, RN (NYUCN '14)

Jeffrey Phillips is an RN at NewYork-Presbyterian Weill-Cornell Medical Center's Emergency Department. He is also the assistant director of the Emergency Department's Nurse Residency Program.  Jeffrey is beginning premedical course work at Columbia University starting this summer.

            A quick change in a patient's condition leads to major expressions of concern from clinical staff.  Hairs stand on the back of necks and shirts moisten as the chain of second guessing begins.  The patient monitor shows signs of decompensation, and proposals of how to proceed are hurried.  Luckily for the staff, a man behind a tinted glass panel says, "thank you everyone, let's stop there".  A collective exhale and shared glances say, where did we go wrong. 

This patient is a clinical simulation - also known as high fidelity simulation. The stakes are low although the venue is real.  A team of nurses and doctors stand inside the same treatment room they frequent daily, where similar circumstances have taken place with real people.  The difference here is that the plights of the rubber and plastic patient are calculated to educate strengthen the treatment team. 

At New York University's College of Nursing, a dedication is made to simulation based learning. Students are exposed to simulation exercise for the duration of their clinical training.  Upon graduation, I thought my days of simulation lab would be replaced solely by real, fleshy human beings.  But two years and roughly fifteen intensive simulations later, my career in imagination continues.  I have encountered push back from coworkers who do not see the utility in simulation learning as I do.  They see it as a cheap and nearly useless exercise that cannot provide the education that a real patient can.  But I want to speak from personal experience via the modern day soap box. 

Simulation provides an opportunity to place participants in circumstances that are not readily available in everyday clinical scenarios.  It takes a lot of luck (or bad luck) to be part of unique circumstances requiring unusual procedures, heroic measures, or non-traditional medications.  For example, in fall of 2015 I completed a stellar two day course in pediatric emergencies.  It consisted of quick succession simulations, dense debriefings, and (spoiler alert) the course concluded with a large mass casualty simulation involving all 40-50 clinical staff participants, along with 20-30 patients and actors.  The simulation came complete with the realities of disaster response: a restriction on supplies, medications, blood products, and clinical staff, as well as convincing acting from volunteers playing the role of stressed and at times aggressive family members.  The situation was loud, communication was difficult, and stress was inevitable.  The 20 minute scenario kept pulses elevated for the duration.  Afterwards, discussions included reflections about the challenges of patient care in such a situation, as well as somber stories of real-life similarities.

The success of simulation only comes with high attention to detail and realism.  The goal is to mirror the stress and decision making necessary in a real life situation. With that experience and a thoughtful debriefing from the instructor, the group can tease out mistakes in a safe environment.  And if the simulation is realistic enough, the participants will take those lessons into a real life patient encounter.  I can recall a specific instance, after having been introduced in simulation to the push-pull method of fluid administration in pediatrics, that I took the initiative to administer fluid resuscitation in this manner to a child.  Without that knowledge, my exposure to the procedure would have been delayed and the patient may have suffered.  If an opportunity arises to take part in simulation, seize it.  I encourage everyone to investigate opportunities in simulation labs at their respective institutions, as well as simulation based specialty conferences.  A real patient tomorrow may be thankful for practice on a plastic patient today.

 

To be or not to be…CERTIFIED Why should I seek CERTIFICATION for my nursing specialty?

By Larry Z. Slater, PhD, RN-BC, CNE

Clinical Assistant Professor

New York University Rory Meyers College of Nursing

New York, NY

In its landmark report on The Future of Nursing, the Institute of Medicine (IOM, 2010) advocated that the nursing profession “foster a culture of lifelong learning” (p. 14) in order to allow the nurses to be integral partners in meeting the nation’s current and future healthcare demands. Continuing education has been used by nurses over the course of their careers to maintain skills while also developing additional, necessary competencies to keep pace with a rapidly expanding healthcare landscape. Although not specifically identified in the IOM report, nursing certification may serve as an important means of promoting and fostering a lifelong learning culture through continuing education within healthcare organizations.

The American Board of Nursing Specialties (ABNS, 2005) defines certification as a “formal recognition of the specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty to promote optimal health outcomes.” The American Nurses Credentialing Center (ANCC, n.d.) states that certification “enables nurses to demonstrate their specialty expertise and validate their knowledge to employers and patients” while also “empower[ing] nurses with pride and professional satisfaction.” In addition, as more and more hospitals seek Magnet designation, nursing certification may help organizations meet multiple Magnet standards that demonstrate nursing excellence (Fritter & Shimp, 2016).

So what does this mean for the professional nurse? What are the pros and cons of certification? Fritter and Shimp (2016) summarized some of the benefits and perceived barriers for nursing certification from the nurse’s perspective. Benefits included feeling empowered to climb clinical ladders within an organization, increased confidence in patient care and interprofessional collaboration skills, an enhanced sense of autonomy, and a higher sense of professionalism and pride. Barriers to certification included a lack of institutional support, a lack of reward for becoming certified, the cost of the examination, and the length of time that a nurse has been out of school (typically due to fear of the examination process). Fritter and Shimp also highlighted benefits that certification brings to the organization. Certification of nurses not only helps with Magnet recognition, it can decrease nurse turnover and improve nurse satisfaction, while also improving patient outcomes and satisfaction. In a literature review on the impact of nursing certification, Martin, Arenas-Montoya, and Barnett (2015) reported a positive correlation between certification and selected patient indicators, with higher rates of certification related to lower patient fall rates, decreased rates of hospital acquired infections, and decreased mortality and failure to rescue events.

Nursing certification is available for almost every nursing specialty (see Additional Resources below for a comprehensive list of certifications by specialty organization). In order to become certified, a nurse must typically validate that they have achieved a certain number of clinical hours to demonstrate specialty experience, pay an examination/certification fee (with a discount if the nurse is a member of the specialty organization sponsoring the certification), and then pass a certification examination to demonstrate knowledge within the specialty. Once certification is achieved, the nurse is then able to place the provided credentials after their name. Certification is usually valid for 2 to 5 years, depending on the specialty. During that time, a nurse must maintain clinical practice and achieve a certain number of continuing education hours. In order to renew the certification, the nurse will have to validate clinical and continuing education hours and pay a renewal fee. If the nurse does not maintain clinical or educational competencies, then the certification will be lost.

In deciding whether or not to seek certification, a nurse should explore not only the certification requirements, but institutional factors related to certification. This includes whether or not the organization provides public recognition of certification (e.g., plaques on the unit, certification listed on name badge), financial remuneration (e.g., additional pay of $1 per hour if certified), and clinical advancement (e.g., promotion from Staff Nurse I to Staff Nurse II). In addition, some organizations may provide in-house examination preparation courses, reimburse for taking a course elsewhere, or reimburse for the cost of the examination (sometimes only if the individual passes the examination). However, even without organizational recognition or remuneration, the professional benefits, as well as positive impact on patient outcomes, cannot be ignored and may be the overriding factors in choosing to seek certification.

In order to heed the IOM’s (2010) call to promote a culture of lifelong learning, it is important for professional nurses to look to certification as a mechanism to improve nurse and patient satisfaction and outcomes. Whether a new graduate nurse or a nurse with many years of experience, it is never too early or too late to consider achieving certification in a nursing specialty. Together, certified nurses can impact The Future of Nursing and the future of healthcare in the U.S. and beyond.

Additional Resources:

·         For additional information on nursing certification, ABNS provides a bibliography (http://www.nursingcertification.org/wp-content/uploads/2015/03/ABNS-Certification-Bibliography-2015.pdf) that includes studies and articles on the value of certification, including nurse and patient outcome studies.

·         Wolters Kluwer maintains a list of Nursing Certification Boards by Specialty, that is updated regularly. The list can be found at http://www.nursingcenter.com/career/guideto-certification.

References:

American Board of Nursing Specialties. (2005). A position statement on the value of specialty nursing education. Retrieved from http://www.nursingcertification.org/wp-content/uploads/2015/03/value_certification.pdf

American Nurses Credentialing Center. (n.d.). About ANCC. Retrieved from http://www.nursecredentialing.org/About-ANCC

Fritter, E., & Shimp, K. (2016). What does certification in professional nursing practice mean? MedSurg Matters, 25(2), 8-10.

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.

Martin, L. C., Arenas-Montoya, N. M., & Barnett, T. O. (2015). Impact of nurse certification on patient satisfaction and outcomes: A literature review. The Journal of Continuing Nursing Education, 46(12), 549-554. doi:10.3928/00220124-20151112-06

 

Reflections On The Culture of Safety (1st Place Winner of AAMN 2016 National Nurses Week Essay Contest)

By Fidelindo Lim, DNP, CCRN

Clinical Assistant Professor

New York University Rory Meyers College of Nursing

The notion of "culture of safety" implies not merely the absence harm or injury or preventable death, but also the un-measurable feeling that one is in "good hands" even in bad times. The romantic idea (often revived during Nurses' Week) is that of Florence Nightingale doing her nightly rounds, reassuring the soldiers, while beneath the blankets, incurable infections and pain lurk. And yet, somehow, the soldier-patients felt re-assured and safe, though countess of them did not survive to thank Nightingale for the "culture of safety" that emanated from the nurses and her advocacy. A good part of the culture of safety is the feeling or vibes that comes with a peaceful and unhurried attention that nurses provide to patients without the doctor's order and has no expiration date.

How does the "culture of safety" relate to me as a male nurse? I do not think safety has gender, though different cultures assign specific values to what or who is considered safe. For example, the bias that male persons are more authoritative or that people of color (e.g., immigrants from certain countries) may have lower safety standards, undermines the culture of safety because it breeds mistrust between people and leaves long lasting stigma. To uphold gender equality - that male and female nurses are equally capable - and therefore must be given the same opportunity pays homage to a culture of safety based on equity. A deeper understanding of safety and quality in patient care demands that health care workers examine their own values. The kind of conversation that does not judge, but validates the common good that we try to achieve for our patients.

I became a nurse at nineteen. At 22 (the year was 1990), I was working in 500-bed hospital in New York City. One night, a patient expressed his reservations about my clinical competence (was I a safe nurse?) based on the idea that I "looked too young". I didn't ponder much about this, but sometimes I wonder if the patient's doubt, sublimated by saying I didn't look old enough to nurse him, is a symptom of general mistrust? Of nurses? Of the health care system? By extrapolation, is it possible that more senior nurses (administrators and supervisors) hold a certain bias that younger nurses (e.g., new grads) may be prone to lapses in safe practices, not because they are young and inexperienced, but rather because the senior nurses have instilled a feeling of mistrust among young nurses, of potentially committing the ultimate calamity of killing a patient? In return, new grads (and nursing students) internalize self-doubt. And self-doubt undermines a culture of safety because it throws conscientious people into silence and destabilize their confidence.

But times have changed.

Nurses are now the undisputed most trusted of all professions for the last decade and a half according to the Gallup Poll. If culture of safety is closely tied with trust, it probably makes sense to put as many bedside nurses in all kinds of safety councils, committees, teams, commissions, think-tanks, and organizations. This year's theme for nurse’s week, “Culture of Safety - It starts with YOU”, highlights the humble idea that nurses are the chosen guardians and defenders of patient safety by the public – for good.

 

Fidelindo A. Lim, DNP, CCRN

Fidel Lim has worked as a critical care nurse for 18 years and concurrently, since 1996, has been a faculty member at New York University Rory Meyers College of Nursing.  As the faculty advisor to various student groups (Undergraduate Nursing Student Organization, Asian Pacific-Islander Nursing Students Association, Men Entering Nursing, and the LGBT group) he has, among other things, fostered salience in nursing education.  His work as a Nurse Educator in a Magnet-designated hospital provides sustainable staff-focused educational support.  He is particularly interested in bridging gaps in nurse engagement and practice excellence.  Dr. Lim has published articles on an array of topics ranging from clinical practice, nursing education issues, LGBT health disparities, reflective practice, men in nursing, and Florence Nightingale among others.

The Little Things We Do

By Fidelino A Lim, DNP, CCRN

In December 2001, the graduating class of New York University’s College of Nursing asked me to give a speech during their pinning ceremony. As part of nursing education, the pinning ceremony goes back to the time Queen Victoria presented a pin to Florence Nightin­gale for her pioneering work during the Crimean war.

Today, a pin may be presented to a graduating nursing student by a faculty member, a mentor, or a loved one as a symbolic welcome to the profession. My own pinning happened in 1987, and I still recall the overwhelming emotion I experienced as I inched ever closer to becoming a nurse.

It’s not easy to think of something original to say to a group of enthusiastic future nurses. The NYU program coordinator suggested I speak from the heart. After digging deep into my heart—hoping to channel Florence Nightingale—I decided to share my impressions of what patients thank us for when they say “Thank you, nurse.” Over the years, I’ve noticed that the predominant theme of those thank-you cards we get from patients is gratitude for the little things we do for them—answering the call light promptly, speaking compassionately, giving them something to drink, placing the phone by their ear when they’re unable to, holding their hand, bringing them a newspaper, and (my personal favorite) trimming their nails and washing their hands. (I did so much of that I could have been accused of illegally practicing podiatry or cosmetology!) I never heard a patient say, “Thanks, nurse. That catheter was really fabulous!” But many patients recall, even years later, the time you washed their hair.

Recently, when I reread Florence Nightingale’s Notes on Nursing: What It Is, and What It Is Not, I realized she was writing about similar little things. Referring to keeping the bedside spotless and other housekeeping issues, she admonished, “If a nurse declines to do these kinds of things ‘because it is not her business,’ I should say that nursing was not her calling.” These little, seemingly menial gestures may not get us nominated for the Nobel Peace Prize. But as with peacemakers, what nurses do moves and soothes the human heart and spirit. The enchanting (though not entirely mysterious) thing is that as we strive to bring about positive changes in our patients, we’re transformed ourselves. I’m certainly not the same “nurse-person” I was at my pinning ceremony 22 years ago.

In one of the final post-conferences of my undergraduate training, we were asked what field of nursing we were interested in practicing. I enthusiastically replied that I’d like to be a nurse-teacher so I could touch more lives in a shorter time through health education. (I imagined a classroom of students as opposed to a few patients.) I still believe in teaching, but less on merely reaching more nursing students as on touching their lives and influencing them to make patient teaching as routine as taking temperatures. I’m convinced the nurse’s best weapon is patient education to help prevent or control disease.

Today, nurses walk a delicate line between tradition and technology, computer skills and compassionate service. To bring greater awareness to their challenge, I sometimes ask nursing students, “If you were Florence Nightingale, what would you do if your patient’s arterial blood gas results showed a pH of 7.25, carbon dioxide of 58, bicarbonate of 29, and a partial pressure of arterial oxygen of 80?” One time a student replied without missing a beat, “I’d open the windows to provide pure clean air, hold the patient’s hand, and call for immediate intubation.” I grinned with satisfaction that at least for that student, my teaching had been a success.

These days, “pure” perhaps refers to evidence-based knowledge and “clean” to the honest, no-nonsense compassion we give patients. To our new colleagues, I’d like to stress that whatever field of nursing you pursue, don’t forget to do the little things, share your knowledge with all, and invoke Florence Nightingale—the founder of modern nursing for our modern times.

Fidelindo A. Lim is a Clinical Assistant Professor at the NYU Rory Meyers College of Nursing, New York University in New York, N.Y. The American Nurses Association originally published the above essay in the June 2009 issue of American Nurse Today.

Speed of Sound: Critical Care Ultrasonography at the Forefront

Leon Chen, MS, RN, AGACNP-BC, CCRN, CPEN

Critical Care NP – Memorial Sloan Kettering Cancer Center

“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is most adaptable to change.”

-Attributed to Charles Darwin (Probably falsely)

                Ultrasound machines outside the realm of radiology started in the 1980s with trauma services. Trauma surgeons took advantage of the expediency ultrasound provided in diagnosing free fluid inside the body. Emergency medicine also embraced this technology for similar reasons. When a crashing patient arrive at the Emergency Department, often we don’t have time to wait the super STAT diagnostic test to not come in time. Bedside ultrasound allows the clinician to answer clinical questions in real time and make life and death decisions. After much posturing and political fighting, American College of Echocardiography and American College of Emergency Physicians reached consensus that Emergency Physicians have the training to utilize bedside ultrasound to make clinical decisions (1). Critical care medicine has the same need for speedy tests and thus the American College of Chest Physicians (ACCP) also put out a consensus statement establishing the standard of training for critical care ultrasound (2). As a Critical Care Medicine NP with Emergency Nursing background, having the opportunity to learn and utilize this technology is extraordinarily exciting.

                To learn ultrasound, one would need a good teacher. Dr. Elena Mead, my pulmonary critical care attending at Memorial Sloan Kettering Cancer Center’s ICU became my mentor in ultrasound early on. We bonded over this fascinating technology and through her help and MSKCC’s support I embarked on a journey to be one of the first NPs to be certified by American College of Chest Physicians in critical care ultrasonography. The program entails video lectures, in-person didactics and simulation, submission of a portfolio of ultrasound images to be critiqued and a final comprehensive exam at ACCP’s annual meeting. The process took about one year and I successfully passed my exam. Bedside ultrasound is now part of my repertoire of diagnostics tests but by far my favorite. I’ve spoken at various educational conferences about the advantage of bedside ultrasound in critical care and am now working with Dr. Mead to train all the NP/PAs in the ICU in this diagnostic tool. We at MSKCC also recently held our very first bedside ultrasound workshop that was open to the public. The workshop included didactics, images review and finally hands-on practice with live models.

            Late last year I treated a patient who was in respiratory distress. Her differentials included pneumonia, flash pulmonary, pulmonary embolism and pneumothorax. Her portable chest x-ray was grossly clear which ruled out several of those differentials. With a bedside echo, I was able to quickly determine that her respiratory distress is due in part to her acute right ventricular strain (Figure 1) and this pointed me to a potential pulmonary embolism. For a patient who was unstable and likely not tolerate supine positioning for CT, bedside ultrasound proved to be difference maker in rapid diagnosis and decision making.

The stethoscope was created over 200 years ago by a physician who didn’t like the standard practice of auscultation at that time (placing ear on patient’s chest). With time and advancing technology, portable ultrasound machines may be replacing stethoscopes around clinicians’ neck.

Figure 1: Apical 4 chamber view of a patient’s heart with severe right ventricular enlargement and pressure overload.

1) Douglas et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance: endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine. Circulation. 2008 March 18; 117(11): 1478–1497

2) Mayo, Paul H., Yannick Beaulieu, Peter Doelken, David Feller-Kopman, Christopher Harrod, Adolfo Kaplan, John Oropello, Antoine Vieillard-Baron, Olivier Axler, Daniel Lichtenstein, Eric Maury, Michel Slama, and Philippe Vignon. "American College of Chest Physicians/La Société De Réanimation De Langue Française Statement on Competence in Critical Care Ultrasonography." Chest 135.4 (2009): 1050-060.

 

Carbapanem-Resistant Enterobacteriaceae (CRE)

By Nick Deuz

Student Nurse Hunter-Bellevue School of Nursing, Class 2016

         Protocols for the prevention of the transmission of multi-drug resistant organisms (MDROs) have been implemented throughout many, if not all, healthcare systems. The most common protocol is the Centers for Disease Control and Prevention ‘s (CDC) Standard Precautions (Siegal et al., 2007). With such practices implemented, however, there are still multi-drug resistant organisms (MDRO) that play a major threat to the patient’s safety. In an acute long-term inpatient facility, the transmission of CRE is on the rise (CDC, 2013). According to the CDC (2013), CRE is an incurable MDRO. It is also considered an urgent level type of threat that requires intensive observation and prevention. CRE is considered the most dangerous MDRO because of its resistance to basically all types of antibiotics (CDC, 2013). In order to prevent the spread of the pathogen in the healthcare setting, preventative measures needs to be established. Such measures include surveillance, health care compliance to the Standard Precautions, and other guidelines for the prevention of CRE (CDC, 2012).

Carbapemens: Antibiotics of Last Resort

            CRE has the ability to fight off the Carbapanem and the Cephalosporin class of antibiotic (Rapp & Martin, 2008). The CDC (2013) considers the Carbapanems the antibiotic of last resort. This type of antibiotic is broad-spectrum and has the ability to treat infections caused by Gram-negative bacteria. It is considered more stable than the penicillins, cephalosporins and monobactams (Rapp & Martin, 2008). Yet, inappropriate use of these broad-spectrum antibiotics can lead to the development of CRE. Starting off with a carbapanem antibiotic as the initial drug for infection treatment can result in a greater chance of developing CRE (Rapp & Martin, 2008). If CRE infection arises in a person after the initial antibiotic treatment, then the person is limited to treatment. This is because drug treatment options for CRE are very limited as only three medications; Colistin, Tigecycline and Amikacin have been reported to have some activity against CRE (Zurawski, 2014). Therefore, carbapenems should be the last medication used for treatment of infections in order to prevent CRE (Rapp & Martin, 2008).

            The limited treatment options for CRE make it a very dangerous MDRO that can be fatal for patients who contract it (CDC, 2013). In order to stop the spread, the public, especially healthcare workers, should be more aware of its transmission. Nurses especially should be more mindful of the spread of infection since they are the person who provides the most direct care to the patient. This is especially true in an acute inpatient facility where the patients are sicker and are seen more frequently by the nurses. In the case of a busy schedule, the nurse may not feel the need or may forget to follow CDC protocol and perform proper hand hygiene due to the hectic nature of working in an acute care. Hand Hygiene and the education of the nurses in regards to infection prevention are part of the core guidelines for CRE prevention (CDC, 2012).

All employees must wash hands before… and after …

            Effective interventions on controlling the spread of CRE needs to be done before incidences of the pathogen rises and infects more people. Research has to be mobilized to test not only new antibiotics but also to look into the barriers in infection control compliance. According to Schwaber and Carmeli (2008), there should be more research that helps better understand the trends and treatments of these malicious organisms. MDRO is a public health threat and therefore, a concerted effort should be invested in educating the public, the primary care providers, the informal caregivers in the community and the patients. Community-based organizations can start public health education based on the unique characteristics of the populations at risk (i.e. education materials in a language other than English). More effort should be placed in helping develop new evidenced-based guidelines that ensure appropriate prevention control strategies for facilities are implemented. Education of pre-licensure health care providers  (nursing and medical students) should focus on measurable competencies. It might also be beneficial for government to provide financial incentives to test new medication for CRE using current knowledge in bimolecular science and targeted therapies. A strong political will is needed to allow congress to enact laws that pro-active in infection control. There is so much more research and more opportunity to expand on the development of prevention strategies against CRE.

Summary

            In spite of advances in medical technology, the march of MDROs remains a challenge, both in institutional settings and public health spheres. Compliance with Standard and Transmission-Based precautions remains at the heart of infection control and cannot be over-emphasized. The implementation of the eight core measures for CRE prevention suggested by the CDC must be taken seriously by all health care providers and patients. The education of staff and future nurses must take into account hardwiring infection and control competencies that are translated to bedside practice. Now, more than ever, prevention is more important in the advent of emerging incurable infections.

References

Centers for Disease Control and Prevention. (2012). Guidance for Control of          Carbapenem-Resistant Enterobacteriaceae (CRE): 2012 CRE Toolkit [Data File]. Retrieved from http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf

Centers for Disease Control and Prevention. (2013a). Antibiotic Resistance Threats in the United States [Data File]. Retrieved from http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf

Centers for Disease Control and Prevention. (2013b). Vital Signs [Data File]. Retrieved from http://www.cdc.gov/vitalsigns/pdf/2013-03-vitalsigns.pdf

Rapp, R.P., & Martin, C. (2008). Carbapenem Antibiotics: Maximizing Response and Minimizing Resistance. Pharmacy Practice News, Special Edition, 43-50.

Schwaber, M. J., & Carmeli, Y. (2008). Carbapenem-Resistant Enterobactericeae: A Potential Threat. The Journal of the American Medical Association, 300(24), 2911-2913.

Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Health Care Infection Control    Practices Advisory Committee. (2007). 2007 Guideline For Isolation Precautions:         Preventing Transmission of Infectious Agents in Health Care Settings. American     Journal of Infection control35(10), S65-S164.

Zurawski, R. M. (2014). Carbapenm-Resistant Enterobacteriaceae: Occult Threat in the     Intensive Care Unit. American Association of Critical-Care Nurses, 34(5), 44-52. 

A Nurse-Teacher’s Thanksgiving Reflections

By: Fidelindo Lim, DNP, CCRN

Clinical Assistant Professor

New York University College of Nursing

          The nursing profession continues to evolve. My role as a nursing faculty allows me the privilege to see future nurses embrace what is yet to be, beyond the linear columns of the nursing care plan. What I see students do in clinical, outside the bulleted educational outcomes, are subtle reminders that caring cannot be truly taught in school, they simply manifest as the natural, almost evolutionary tendencies of women and men in nursing. Recently, a student of mine spent a good hour braiding the hair of her patient who was diagnosed of stage 4 ovarian cancer - two days earlier. The patient had bilateral above knee amputation and will probably never set foot in a hair salon, but the student brought a semblance of normalcy to a life thrown off balance. Outside the room, I could hear beauty parlor reflective conversation between the student nurse and the patient. Suddenly, cancer seems insignificant. When the patient examined her neatly arranged corn rows in front of the mirror, we all saw life, not imminent death. I often recall this story to myself to remind me that the very essence of nursing is human bonds. As a faculty, I partner with my students not simply to teach them learn the ropes but to strengthen nursing's umbilical connection with life - till the end.

This Thanksgiving…

Think and thank those who continue to move us in positive ways, including the patients who enrich our nursing practice simply because their lives have crossed with ours - by accident or incident.

Note:  The above essay was chosen one of the 12 winners of Inspired Nurses contest through Lippincott Solutions. The essay will be featured in the 2016 Lippincott Publisher calendar.

Are we over-treating fever?

By Chen, Leon MS, RN, AGACNP-BC, CCRN, CPEN

Nurse Practitioner, ICU – Memorial Sloan Kettering Cancer Center in NYC

          “You took away her fever. You raised her spirit.” Those words echoed to the tune of soft pleasant music in the new Tylenol commercial. The uplifting, alleviating effect of antipyretics can be attested by many who have suffered from a fever at one point in their life. I still remember in simulation labs, we’re quizzed on the temperature considered to be febrile and our expected immediate follow-up answer of “I’ll administer some Tylenol”. Treating fevers has been drilled into our core medical knowledge. But in actuality, our ability to mount a fever stem from an evolutionary need to survive from an infection and to take it away may not be beneficial.

          Our body’s ability to generate heat actually produces a hostile environment for bacterial growth. In vitro studies have shown that pathogen growth is stunted at a core temperature above 37 degrees Celsius. (1) In clinical studies, the patients who are able to generate a febrile response have been associated with lower risk of mortality. (2)(3) Of course, fever has its downsides, including increasing metabolic demand, oxygen demand and in children, potential febrile seizures. So what are we to do? Do we treat the fever or do we not treat the fever? And what do we do about fever in the ICU population? To help us answer the question, the Acetaminophen for Fever in Critically Ill Patients with Suspected Infection study (HEAT trial) has just been published by New England Journal of Medicine. In the study, researchers randomized 700 ICU patients with fever (body temperature>38 degrees Celsius) to either receiving IV Tylenol or placebo every 6 hours until ICU discharge, resolution of fever, cessation of antibiotics, or death. The primary outcome was ICU-free days from randomization to day 28 on follow-up.

         The result of this study showed that early administration of Tylenol to treat fever due to probably infection had no effect on the number of ICU-free days. (4)This study adds on to the increasing number of negative trials showing that less intervention or more conservative management strategies are acceptable and does not cause harm. Given that ICU patients are already at risk for organ dysfunction in the setting of polypharmacy and their critical illness, I hesitate to further burden their system with Tylenol.  Therefore, in patients with suspected infection, antibiotic is the ultimate treatment and antipyretics should only be an afterthought.

References

1. Prescott, Lansing M, John P. Harley, Donald A. Klein, Gloria Delisle, and Lewis Tomalty. Microbiology. Boston, Mass: WCB/McGraw-Hill, 1999. Print

2. Weinstein MP, Iannini PB, Stratton CW, Eickhoff TC. Spontaneous bacterial peritonitis. A review of 28 cases with emphasis on improved survival and factors influencing prognosis. Am J Med. 1978 Apr;64(4):592-8.

3. Ahkee S, Srinath L, Ramirez J. Community-acquired pneumonia in the elderly: association of mortality with lack of fever and leukocytosis. South Med J. 1997 Mar;90(3):296-8.

4. Young et al. Acetaminophen for Fever in Critically Ill Patients with Suspected Infection. N Engl J Med. 2015 Oct 5. [Epub ahead of print]

Participatory Caring

By: Sang-Hyun Jeon

Accelerated Nursing Student NYU College of Nursing – Class 2015, December

             The desire to care for another is deeply rooted in human biology, something of an innate virtue. I’d like to think that our Neanderthal ancestors were concerned as much as we are about patient safety. However, it is the dynamic psychology of caring that sets us apart. To positively enter into a patient’s scenario, in our modern times, requires the purposeful interpretation of what it means to provide patient-centered care. This reflection brings me back to the time before I officially started nursing school. What attracted me to initially pursue a degree in psychology is my fascination with observing how the mind interacts with the outward self. Observing is one thing, becoming an active participant is another. And this is what ultimately drew me to nursing – to be an active participant in the caring process.

       I am now in my final semester in an BSN Accelerated program at NYU College of Nursing. Every opportunity I have had in caring for patients continues to validate my sincere desire to care for others. Along the way, I become more aware on how my nursing education is changing me, not just to be more technically competent, but to become a better nurse-person. The trust the patients bestow upon me sustains my confidence that a male person can be very proficient in the caring arts. Do patients make a distinction of how a male or a female nurse cares for them? This is hard to say, not only because patient interactions are unpredictable, but more so because the desire to be cared for and the passion to care cannot be simplified in the dichotomy of genders.

      The characteristics and qualities male nurse should possess to be successful in nursing can be as generic as those seen in nurses’ job description such as to be able to provide safe and quality patient care. But nursing is much larger than that. The gratitude that patients express when they are satisfied with their patient care experience rarely mentions the words “quality” and “safety”. Working with autistic children as a volunteer in New York allowed me to appreciate the value of altruism, particularly since the clients couldn’t verbally express their emotions. But, I derived satisfaction simply for being there and for being of help when needed. I think this is one of the enduring covenants of nursing – to be there (as soon as possible) when needed. Often nurses are summoned to the patient’s room by the call bell. However, better nurses have the magical skill of appearing at the bedside before the patient realizes he or she needs something. An insightful anticipation of the patient or the family’s caring needs is a remarkable quality of any nurse. Compassion will be genuine when the nurse truly allows himself or herself to be in the caring moment with the patient. Perhaps this is easier said than done, in settings where there are conflicting priorities. But I am optimistic that I can rise above the challenges and be a full participant and partner in health care delivery.  

 

 

Defusing Bigotry at the Bedside

By Fidelindo Lim DNP, CCRN and Daniel Borski, BA, BSN, RN

          In more than a decade nurses have earned the public’s trust and has garnered the highest rating in honesty and ethical standards among the professions (Gallup, 2013). The onus is upon every nurse to remain true in treating every patient with unrestricted compassion and respect (ANA, 2008).  All health care professions subscribe to similar code of conduct that upholds the primacy of the patient’s interest (ANA, 2008). As health care become more complex and complicated, these ideals are sometimes tested during patient-provider interactions.

          A New York Times article about a racist verbal attack by a patient against a physician has revived age-old questions on how health providers should respond when they become the target of racial epithets (Jain, 2013). A variation on the same theme is what if the patient is homophobic? Last year, a senior male nursing student and I walked to the bedside of a 65-year-old patient who was admitted for a fractured humerus. After the customary introduction, the patient rolled his eyes and contemptuously said (to no one in particular) “I have a broken arm and two gay guys just walk in; I’m screwed”. There was fury in his face and I was flushed with anger. Holding ourselves in check, the student and I ignored the patient’s comment and focused on inspecting his broken arm. Inwardly, I seriously doubted whether I can sincerely continue caring for this patient. Getting out of the patient’s sight was a great relief.

          How do nurses in general; lesbian, gay, bisexual, and transgender (LGBT) nurses in particular, remain the ambassadors of goodwill and live up to the public’s trust under anti-gay verbal aggression? Was our experience an isolated incident? Recent findings indicated that the overwhelming majority (92%) of a national sample of LGBT persons reported that society has become more accepting of them in the past decade and anticipate that even greater acceptance will be felt in the next decade (PEW, 2013). Likewise, the attitude of the general population towards LGBT is increasingly positive, with 59% of those surveyed reporting that LGBT relationships are morally acceptable (Newport & Himelfarb, 2013). This favorable shift in social attitudes may suggest that future LGBT workers might find themselves in more welcoming and inclusive environment than their predecessors. However, the demographic and cultural disparities between providers and patients may cause occasions for socially conditioned prejudice to manifest under stressful situations. Younger LGBT health professionals who have never experienced prejudice and are “out” at work may have acquired a sense of false assurance that everyone is an LGBT ally. Homophobic and racist remarks whether uttered by a patient or a colleague casts a long shadow and LGBT nurses may not have considered its possibility.

          The exact number of LGBT nurses cannot be fully known. Extrapolating from the current consensus that approximately 5 to 10% of the population is LGBT (Grant, Grant, Koskovich, Somjen, Frazer, & Bjerk, 2009), there could around 170,000-340,000 nurses who are LGBT out of the 3.4 million nurses (RNs and LPNs) in the U.S. (Health Resources and Services Administration, 2013). In spite of this significant number, very little is written about their experiences with regards to patient interactions. Reflecting on my experience, I wonder what other LGBT nurses would have done under similar circumstances.

          With national polls now showing that majority of the nation supports gay marriage, one might think that homophobia is a thing of the past. However, homophobia, along with other prejudices such as racism, anti-Semitism and sexism, is still present in our society. Being subjected to homophobic remarks from those under our care, whose dignity we are sworn to uphold, creates a morale distress and needs further exploration in health care. How should an LGBT healthcare provider interact with an outwardly homophobic patient under their care?  A review of current literature offers very little guidance on how to cope with such situations. Does the provider “cover” to avoid a possible confrontation? Do they ignore the patient’s aggression, either verbal or physical? Do they have the patient re-assigned; can the nurse request a different assignment? How do these dynamics impact patient health outcomes and staff job satisfaction?

            Other prejudicial situations are similar. A patient could be racist and refuse care from a staff of a particular race. A sexist patient may devalue the skills of workers of a certain gender.  These examples are different from homophobia in that the basis of the discrimination comes from outwardly recognized characteristics. Sexual orientation and gender identity are less obvious though it spans across all races and ethnicity. LGBT nurses who “pass” in their outward appearance of the gender they identify with (e. g. a masculine gay nurse or a feminine lesbian nurse) may be assumed to be heterosexual. As a result, unsuspecting patients and colleagues might express homophobic remarks around them, forcing them to remain in the closet or lead a double life (Giddings and Smith, 2001). For transgender nurses, particularly those who do not “pass” for the gender they identify with, their experiences might be very different, though very little is reported in the literature. It is likely that minority stress may be experienced by closeted nurses and for those who are advocating for inclusiveness but are unsupported or spurned by administrative leaders or colleagues.

          Reporting homophobic aggression perpetrated by a patient may go unreported due to staff fear of unwanted attention, lack of system process for reporting incidents and from the continued emphasis that health care is about the patient – not the staff. Balancing on the limits of what the staff is willing to compromise will prove to be a litmus test for LGBT nurses that go beyond making excuses for our patient’s intolerance and prejudice.

Found in the October 2015 Issue of Nursing 2015 Magazine
Lim, F. A., & Borski, D. B. (2015). Defusing bigotry at the bedside. Nursing, 45(10), 40–44. http://doi.org/10.1097/01.NURSE.0000469238.51105.20

References

Gallup. (2013). Honesty/Ethics in Profession. Retrieve February 5, 2014 from http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx

Giddings, L. S., & Smith, M. C. (2001). Stories of lesbian invisibility in nursing. Nursing Outlook, 49, 14–19.

Grant, J. M., Koskovich, G., Frazer, S., & Bjerk, S. (2010). Outing age 2010: public policy issues affecting gay, lesbian, bisexual and transgender elders. Washington, D.C.: National Gay and Lesbian Task Force Policy Institute.

Health Resources and Services Administration. (2013). The U.S. nursing workforce: Trends in supply and education. Department of Health Human Services.

Jain, S. (2013). The Racist patient. Annals of Internal Medicine, 158, 632.

Newport, F., & Himelfarb, I. (2013). In U.S., Record-High Say Gay, Lesbian Relations Morally OK. Gallup Politics. Retrieved February 14, 2014 from http://www.gallup.com/poll/162689/record-high-say-gay-lesbian-relations-morally.aspx

PEW Research Center. (2013). A survey of LGBT Americans: Attitudes, experiences and values in changing times. Retrieved February 14, 2014 from http://www.pewsocialtrends.org/2013/06/13/a-survey-of-lgbt-americans/1/


Understanding Antibiotic Resistance and How to Prevent It

By: Fidel Lim, DNP, CCRN

Faculty- NYU College of Nursing

        More that eighty years ago Alexander Fleming identified Penicillin. After returning from vacation, he found that a mold inhibited bacterial growth around a staphylococcus culture dish. It wasn’t until D-Day in 1944 when the drug fully made its public health debut, when enough of it became available to allow unlimited treatment of allied service men suffering from infections.

          A World War II ad reads: “Penicillin kills gonorrhea in four hours. See your doctor today.” Well, a lot has happened since the medical establishment prematurely declared victory over infectious diseases with the discovery antibiotics (Sulfa was the first antibiotic used in 1938). Today’s headlines are much more likely about fears of new epidemics like the Ebola, Middle East Respiratory Syndrome (MERS) and Clostridium infection the growing menace of antibiotic resistance.

          Antibiotic resistance is not exactly a new phenomenon. In the 1940s and 50s Streptomycin and INH (Isoniazid) already showed some resistance to the TB bacilli (Porter, 1997). According to the 1998 report of the Institute of Medicine’s forum on Emerging Infections, strains of Staph Aureus resistant to Penicillin were isolated as early as 1945. The chairman of the forum testified that resistance inevitably occurs as bacteria adapt to the presence of antibiotic in their environment.

          Today we have MRSA, VRE, VISA, VRSA and MDRTB or XD RTB. If you know what these letters stand for, then chances are you have taken cared of a patient with a resistant infection. And for sure you have already been to at least one conference telling us how astronomically expensive it is to treat resistant infections, not to mention the high rate of mortality.

How do Bacteria Become Resistant?

          How bacteria develop resistance against antibiotics is simply a manifestation of the Darwinian notions of the struggle for existence. Bacteria evolve in order to survive. The CDC informs us that bacteria may develop the ability to neutralize or evade the effect of the antibiotic. Exposure to antibiotics therefore provides selective pressure, which makes the surviving bacteria more likely to be resistant.

          In addition, bacteria that were at one time susceptible to an antibiotic can acquire resistance through mutation of their genetic material or by acquiring pieces of DNA that code for the resistance properties from other bacteria. The DNA that codes for resistance can be grouped in a single, easily transferable package. This means that bacteria can become resistant to many antimicrobial agents because of the transfer of one piece of DNA. Some bacteria develop the ability to neutralize the antibiotic before it can do harm, others can rapidly pump the antibiotic out, and still others can change the antibiotic attack site so it cannot affect the function of the bacteria (for the full article, log on to http://www.cdc.gov/drugresistance/threat-report-2013/

          In March 1994, Newsweek magazine published “The End of Antibiotics.” The article warned the public that by means of some clever mechanism, bacteria creates resistance by dismembering the drug, by changing the bacterial cell wall so that antibiotics can’t get in or by pumping out the antibiotics out of the bacteria.

          Human hosts are not exactly the helpless victims in the creation of resistance. We live in the age of pills - patients often demand antibiotics from physicians and Nurse Practitioners and too often they are accommodated. An interview with a British doctor in the 1980s revealed what might be a common practice at the time, not only in Britain but elsewhere. It informed that prescribing pills was a way of avoiding a more time-consuming analysis and treatment. Writing a prescription (antibiotics) pleases the patient and relieves the physician of his or her high case volume. Repeated and improper uses of antibiotics are primary the causes of the increase in drug-resistant bacteria.

         However, no matter how grim the predictions may be, the situation is not hopeless. A Wall Street Journal article “Curbing Antibiotic Use in War on ‘Superbugs’” (September 3, 2008- reported by Laura Landro)  informed us that hospitals are turning to a new breed of antibiotic SWAT team to win the war against resistant organism. The effort known as antimicrobial stewardship programs will team top pharmacist, infectious disease specialists and microbiologist. This group will monitor the hospital’s use of antibiotics and restrict prescription of certain drugs (for example: Vancomycin) when they become resistant. These new efforts is partially the result of the federal Medicare program plans not to reimburse preventable hospital acquired infections, many of which are cause by resistant organisms.

Nurses’ Role in Preventing Antibiotic Resistance

As a Staff Nurse:

  • Be vigilant with how your unit utilizes antibiotics – ask your local ID team
  • Actively participate in “Pharmacy Committee” meetings and learn what your hospital is doing to address antibiotic resistance
  • Always give antibiotics on time and avoiding skipping a dose
  • Check your patient’s Culture and Sensitivity reports and act as a patient advocate by informing the M.D. if the bacteria are sensitive to a narrow-spectrum antibiotic (preferred than a broad-spectrum antibiotic)
  • Always observe Standard and Contact precautions when caring for patients with resistant organism infections
  • Participate in unit-based surveillance studies to look at trends of resistant infection
  • Read evidence-based and best practice recommendation by logging on to: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=11

What the General Public Can Do to Prevent Antibiotic Resistance

The CDC recommends:

  • Talk with your healthcare provider about antibiotic resistance:
    • Ask whether an antibiotic is likely to be beneficial for your illness
    • Ask what else you can do to feel better sooner
  • Do not take an antibiotic for a viral infection like a cold or the flu.
  • Do not save some of your antibiotic for the next time you get sick. Discard any leftover medication once you have completed your prescribed course of treatment.
  • Take an antibiotic exactly as the healthcare provider tells you. Do not skip doses. Complete the prescribed course of treatment even if you are feeling better. If treatment stops too soon, some bacteria may survive and re-infect.
  • Do not take antibiotics prescribed for someone else. The antibiotic may not be appropriate for your illness. Taking the wrong medicine may delay correct treatment and allow bacteria to multiply.
  • If your healthcare provider determines that you do not have a bacterial infection, ask about ways to help relieve your symptoms. Do not pressure your provider to prescribe an antibiotic.

The pharmaceutical revolution that started in the 1950s has no doubt saved millions of lives, but is has also brought in new unimaginable problems. In his best selling book “The Greatest Benefit to Mankind: A Medical History of Humanity, Roy Porter tells us “the euphoria of the age of Penicillin has turned to anxiety…medicine will have to redefine its limits even as it extends its capacity”. Antibiotic resistance may be inevitable, but we must take a cue from the bacteria itself: we have to evolve in the way we treat and prevent infections if we are to survive.

References

Global consensus conference on infection control issues related to antimicrobial resistance: final recommendations. American Journal of Infection control. 1999;27(6):503-13.

Porter R. The Greatest Benefit to Mankind: A medical history of humanity. New York: W.W. Norton and Company:1997.

Begley S. The end of antibiotics. Newsweek. 1994; March 28:49-52.

Landro L. Curbing antibiotic use in war on ‘superbugs’. Wall Street Journal. September 3, 2008.

Barry J. The great influenza. New York:Viking:2004.

CDC. Get smart: know when antibiotics work. Available at: http://www.cdc.gov/drugresistance/community/anitbiotic-resistance-faqs.htm. Accessed on September 15, 2008.


Going Banana Over Potassium

By Fidelindo Lim, DNP, CCRN

Clinical Assistant Professor

New York University College of Nursing

          Among the many electrolytes, potassium takes celebrity status. It commands attention from most clinicians and it is perhaps the most prescribed electrolyte replacement after sodium chloride, followed by magnesium and phosphorous. In Cardiac Units, it is one of the staple drugs, the clinical twin of digoxin. Name brand orange juice products, bottled water and milk are now advertised as “potassium-rich” to lure not only the cardiac-compromised consumers but the general public. Potassium – it does the body good!

The Health Benefits of Potassium 

          When patients ask why we are giving them potassium, our standard reply is “it’s good for your heart.” But there is more to that. According to the National Council on Potassium in Clinical Practice (Cohn, Kowey, Whelton, & Prisant, 2000) there is evidence to support that high potassium diets may reduce the risk of stroke. As every nurse already know, sodium and potassium have an inverse relationship. Diets high in sodium will not only lead to hypertension, but it will also promote urinary excretion of potassium and therefore loose its health benefits. So, potassium can reduce stroke by lowering sodium levels and consequently maintaining normal blood pressure.

          Studies also show that reduction in blood pressure after potassium supplementation is three times higher in African-Americans than in White Americans. This is not new. Caralis et al. (1984), suggests that when potassium level is below 3.5 mmol/L, potassium supplementation is essential even in asymptomatic patients with mild to moderate hypertension.

          For patients with history of arrhythmia and myocardial infraction (MI), the threshold for potassium replacement is higher, at 4.0 mmol/L. The association between higher mortality from MI and ventricular fibrillation patients with potassium levels less than 3.9 mmol/L  (normal range: 3.5 to 5.0  mmol/L  has been known for some time (Duke, 1978). This knowledge becomes more important than ever based on the findings that currently, less than 2% of Americans consume the recommended minimum daily requirement for potassium, due primarily to inadequate plant food intake (NutritionFacts.org, n.d.).

          Another important consideration is for patient’s taking digitalis. The effect of digitalis is enhanced in the presence of hypokalemia. Maintaining a normal potassium level is important in preventing digoxin toxicity and minimizing the potential adverse reactions of digitalis.

Pass the dried figs please…

          Potassium should come from food sources. Fruits and vegetables are excellent sources of potassium. Its bicarbonate precursors, favorably affect acid-base metabolism, which may reduce risk of kidney stones and bone loss (Health.gov, 2008). Potassium-rich fruits and vegetables include leafy green vegetables, fruit from vines, and root vegetables. The recommended daily intake for potassium is as follows (Health.gov, 2008):

Age Group

Recommended Daily Intake

Children 1 to 3 years of age

3,000 mg/day

Children 4 to 8 years of age

3,800 mg/day

Children 9 to 13 years of age

4,500 mg/day.

Adolescents and Adults

4,700 mg/day.

          When teaching patients about dietary sources of potassium, most nurses stop short at bananas, although it contains average amounts of potassium compared with other food sources. One medium banana has approximately 422 mg of potassium; whereas one baked sweet potato has 694 mg (131 calories) (Health.gov, 2008). The New England Journal of Medicine published the following categories of excellent sources of dietary potassium:

Highest Content (>1000 mg [25 mmol] per gram)

                          Dried figs

                          Molasses

Very High Content (>500 mg [12.5 mmol] per gram)

                           Dried Fruits (dates, prunes)

                           Nuts

                           Avocados

                           Bran cereals

                           Wheat Germ

                           Lima beans

High Content (>250 mg [6.2 mmol] per gram)

       Vegetables: Spinach, tomatoes, broccoli, winter squash, beets, carrots, cauliflower,

       Fruits: bananas, cantaloupe, kiwi, oranges, mangos

       Meats: ground beef, steak, pork, veal, lamb

          Eight ounces of orange juice supplies approximately 450 mg of potassium. A glass of milk and a can of regular V-8 juice are also rich in potassium but unfortunately also loaded with sodium or sugar. The drawback of some of the potassium-rich food is cost and potential for weight gain (sweet potatoes with molasses, anyone?). In other words, for cardiovascular health, don’t limit yourself with bananas. Some people are even allergic to it or simply dislike its taste. For a list of excellent food sources of potassium check out the US Department of Agriculture Dietary Guidelines: http://www.health.gov/dietaryguidelines/dga2005/document/html/appendixB.htm#AppB1

Potassium Replacement

          In institutional settings, compliance with potassium therapy can be a challenge. Tablets are better tolerated than the liquid form for patients who can swallow. Compliance is also enhanced by the dosing schedule. The less frequent the patient takes the pill, the better the compliance. So, instead of giving 20 mEq BID, ask the doctor to order it as 40 mEq once a day as clinical condition allows. In patients taking diuretics, dietary consumption of potassium rich food is not enough and must be coupled with potassium supplement – an important teaching moment for patients and caregivers.

Making Potassium Easier to Swallow

          Mixing potassium liquid with juice or ice makes it easier to swallow. To prevent the occlusion of feeding tubes (very annoying), give the liquid form instead of crushing the pills. Lastly, it is important to note that magnesium is an essential co-factor for potassium uptake and maintenance of intracellular potassium level. Therefore, potassium supplement works best when the magnesium level is within normal range (1.5 – 2.5 mEq/L). The clinically thinking nurse would be inclined to check the magnesium level when receiving orders to replace potassium.

Summary

          Evidence from large, longitudinal studies, using worldwide sampling indicates that high-quality diets rich in potassium might achieve greater health benefits, including blood-pressure reduction (by extension a reduction in stroke and other cardiovascular events), than aggressive sodium reduction alone (Opari, 2014). Nurses are at the forefront of patient education. Discharge instructions and public health education using the teach-back method may help improve health literacy among high-risk populations.

           African-Americans commonly have a relatively low intake of potassium and a high prevalence of elevated blood pressure and salt sensitivity, this population subgroup may especially benefit from an increased dietary intake of potassium (Health.gov, 2008). 

References

Cohn, J., Kowey. P., Whelton, P., & Prisant, L. M. (2000). New guidelines for potassium replacement in clinical practice. Archive of Internal Medicine, 160(16), 2429-2436.

Caralis, P. V., Matterson, B. J., & Perez-Stable, E. (1984). Potassium and diuretic-induced ventricular arrhythmia in ambulatory hypertensive patients. Mineral Electrolyte Metabolism, 10 (3), 148-154.

Duke, M. (1978). Thiazide-induced hypokalemia: Association with acute myocardial infarction and ventricular fibrillation. JAMA, 239(1), 43-45.

Health.gov. (2008). Dietary Guidelines for Americans 2005. Retrieved from http://www.health.gov/dietaryguidelines/dga2005/document/html/appendixB.htm#AppB1

Oparil, S. (2014). Low sodium intake--cardiovascular health benefit or risk? New England Journal of Medicine, 371(7), 677-679. doi: 10.1056/NEJMe1407695.

Stuck Inside a Cloud: Optimizing Sedation To Reduce ICU-Associated Delirium in Geriatric Patients

Chen, Leon MS, RN, AGACNP-BC, CCRN, CPEN Lim, Fidelindo A. DNP, RN, CCRN

"Never slept so little

Lost my concentration I could even lose my touch

Talking to myself

Crying out loud

Only I can hear me

I'm stuck inside a cloud..."

-George Harrison

Abstract:

Elderly population account for over 50% of all intensive care admissions and during their stay, up to 87% of them suffer from delirium. There is a large body of evidence demonstrating increased mortality and worse cognitive function for elderly patients who become delirious during their intensive care unit stay. While the cause of delirium is multi-factorial, inappropriate and outdated sedation methods are preventable causes. We review the current best evidences and provide what we believe are the best sedation strategies that are in line with the Society of Critical Care Medicine’s Pain, Agitation and Delirium (PAD) best practice guideline to reduce the incidence of ICU-associated delirium.

Background

The critically ill elderly patients (age 65 and older) account for 42-52% of all intensive care unit (ICU) admissions in the United States and they have to fight an uphill battle while they’re there. (1) Along with the initial insults that brought them to the ICU, they are vulnerable to various iatrogenic complications. One injury that significantly contributes to negative patient outcome is ICU-associated delirium. (2) It is estimated to affect up to 80% of all ventilated patients and this number increases to 87% for older ICU patients, which amounts to billions of dollars every year in health care costs in addition to the immeasurable burden on the patient, their family and care providers. (1)(3) Even though delirium among hospitalized older adults is highly prevalent, the exact mechanism remains still elusive despite increasing research. (3) Delirium is characterized as an acute fluctuation of mental status and cognitive function. (3)(4) Patients who are delirious can be hyperactive with features similar to those who are acutely psychotic (e.g., agitation, hallucination, delusion, and combative behavior) or hypoactive with presentations that mimic depressive mood disorder (e.g., flat-affect, inattention, disorganized thoughts and depression). (4) Often times overlooked or mistaken as simple agitation, depression or downplayed as simply confusion resulting from advanced age, it's increasingly evident that delirium is a major contributor to increased ICU length of stay, increased likelihood of transfer to skilled nursing facility and post-traumatic stress disorder (PTSD) after discharge. (5-7)(10) Notably, among the elderly critically ill population, the duration of a patient's delirium is positively associated with increased mortality. (8) Similarly, patients who suffered ICU-associated delirium have been noted to suffer from enduring cognitive impairment long after their ICU discharge. (6) Those who remained delirious for extended periods of time exhibited more severe level of cognitive dysfunction. (6) Despite evidence suggesting ICU-associated delirium is crucial to patient outcomes; its incidence is mostly grossly under diagnosed and therefore untreated. (5) If used properly and routinely, validated delirium screening tools such as the Confusion Assessment Method for ICU (CAM-ICU) should be able to assist clinicians to accurately identify and treat delirium. (4)

The development of ICU-associated delirium is multifactorial. For the ICU patients, endotracheal intubation, its resultant pain and discomfort and the choices of sedations providers use to maintain ventilator synchrony remain significant risk factors. (9) Pain is a major contributor to delirium and it is often overlooked by bedside nurses as well as providers. (3)(5) Patients who were later discharged from ICU often recollect the painful procedures that they endured while hospitalized and how they contributed to their distress. (3)(7) In an emergent setting, patients are being induced and then paralyzed for intubation without adequate analgesia and sedation after intubation. (11)(12) Upon arrival in the ICU, it is traditionally thought to be more beneficial to keep mechanically ventilated patients in a state of deep sedation partly so that patients won't have recollection of their unpleasant experience. (7)(12) In order to achieve this, patients are maintained in deep sedation using sedatives such as benzodiazepines, leading to a state of unresponsiveness, except to painful stimuli. (7)(12) There is now a growing body of evidence showing that this strategy of using benzodiazepines as the primary sedation to keep patients deeply sedated while inadequately treating their pain, under dosing on analgesia, is a flawed paradigm and that leads increases time of intubation, ICU and overall hospital length of stay and mortality. (3)(7)(12)(13) To manage behavioral symptoms of delirium, anti-psychotics such as haloperidol are used although it has never been shown to decrease the duration of delirium. (14) Similar pharmacological agents (eg.,olanzapine, and quetiapine) given concomitantly with haloperidol did not shorten the duration of delirium. (14) The current evidence emphasizes optimization of analgesia and sedation along with strategies to reduce deep sedation in order to prevent ICU-associated delirium. (3)(7)(10)(12) This article will discuss the optimal sedation strategies to reduce the incidence of delirium, highlights key practice guidelines from the Pain, Agitation, Delirium (PAD) Care Bundle and explore the role of critical care nurses in its implementation.

Review of Sedation Strategies

Hypnotics or Opioids?

Benzodiazepines such as midazolam and lorazepam are the main agents used in the ICU to maintain sedation. (3)(12)(13) It acts on the BZ receptors and thus accentuates the effect of Gamma-Amino Butyric Acid(GABA) that provides a neuro-inhibitory affect that leads to sedation. (3) They also provide anxiolytic and amnesiac effects that make them favorable agents for sedation. (3) Adverse reactions include respiratory and hemodynamic depressions. (3) When used as intravenous boluses, midazolam has a short onset and short half-life (elimination half-life is between 1.5 to 2.5 hours) while lorazapam is more potent, therefore emergence from short-term sedation takes longer. (3) As a continuous infusion, the short half-life of midazolam no longer applies due to its penetration of peripheral tissues, and active metabolites. (7) In addition, the elderly are commonly more sensitive to the sedative effect of benzodiazepines due to worse hepatic function and renal insufficiency. (3) All of which contributes to delayed emergence from benzodiazepines. When comparing patients who were sedated using benzodiazepines with those maintained on non-benzodiazepines, patients who were on non-benzodiazepines had shorter duration of mechanical ventilation and ICU length of stay. (13)

Propofol is an anesthetic agent that inhibits GABA receptors thus producing its sedative effect. (2)(3)(12) Its short acting onset and half-life make it a popular agent for induction and maintenance of sedation, especially in those patients who require constant neurological assessment. (2)(3) Adverse reactions include respiratory and hemodynamic depression. (2)(3) A rare adverse reaction is propofol infusion syndrome (PRIS) which is associated with prolonged infusion time at high infusion rate. (15) Compared with benzodiazepines, propofol has not been associated with longer ICU length of stay and prolonged mechanical ventilation. (2)(3)(7)(12-13)

Dexmedetomidine (Precedex) is a selective alpha-2 agonist that produces sedation and analgesic effects. (2-3) The advantage to its use is unique in that it does not cause respiratory depression and can be used in non-intubated patients. (3) The main adverse reactions are bradycardia and hemodynamic instability that are more prevalent when bolus doses are given. (3) There is some evidence that dexmedetomidine can reduce the incidence of delirium. (2-3)(7)

Fentanyl and morphine infusions are the main mu-receptor stimulating opioids used as analgesic for ventilated patients. (2)(3) Fentanyl's advantage is that it provides a degree of anxiolytic properties and less likely to cause hypotension. (3)(16-17) As an intravenous bolus, it also has a relatively short onset and elimination half-life (elimination half-life 2 hours). (3) However, this property is altered by impaired hepatic function and its active metabolites. (3)(16-17) The use of morphine as an infusion for sedated and ventilated patient is less recommended due to higher potential to cause delirium. (16) In addition, its vasodilatory effect makes its use less favorable in critically ill patients who are already hemodynamically unstable. (16)(18) Remifentanil is another agent used in the ICU and its favorable aspects include less active metabolites and short onset and half-life (elimination half-life 3-10 minutes).(16)(18) However, remifentanil has been associated with immunosuppression; therefore its usage in patients who are already immunosuppressed or are at risk for it should be judicious. (7)(16)(18)

Due to the high incidence of unrecognized and under-treated pain in the critically ill population, the resultant contribution to delirium and the hypnotics sparing effect of opioids, there is a movement to use analgesic as the primary sedation for mechanically ventilated patients. (5)(16-17) Several studies that have examined the feasibility, safety and efficacy of this "analgosedation" strategy have found positive results in reduction of ventilator time, incidences of delirium, hospital length of stay and long-term mortality. (6-18)

Sedation Vacation or Targeted Light Sedation?

Sedation vacation, also known as spontaneous awake trials is a strategy where heavily sedated patients are woken up daily by reducing the dosage of their sedative to the point where they're spontaneously awake or are visibly uncomfortable. The sedation will then be restarted but at a reduced dose. (3)(19-20) Many thought this strategy would contribute to pain, agitation and PTSD in these mechanically ventilated patients. (5) However, data on this strategy showed the exact opposite effect. (7)(12)(19-20) Patients who underwent daily sedation vacation had less symptoms of PTSD upon discharge and less cognitive dysfunction. (3)(7)(19-20) In addition to more favorable neurological function, those who underwent daily sedation vacation also had fewer days mechanically ventilated, decreased length of stay and decreased long-term mortality.(19-20) A drawback of this strategy is that it resulted in increased incidences of agitation and self-extubation, however, re-intubation rate and mortality were unchanged. (19-20)

Another sedation strategy challenges the tradition of deep sedation strategy by maintaining patients on targeted light sedation at all times without the mandatory sedation vacation. (7)(19-20) Using validated sedation scales such as Richmond Agitation and Sedation Scale (RASS), patients receive either intermittent sedative boluses or only low sedative infusions to achieve a sedation level of RASS 0 to -2 (0 being awake and alert, -2 being arousable by voice). (19-22) Similar to studies on sedation vacation, the targeted light sedation strategy also achieved favorable outcomes such as less time on ventilator, less delirium and shorter length of stay. (19-20)

Interestingly, combining these two strategies does not provide a synergistic effect on delirium. 20(19) In the Sedation Lightening and Evaluation of A Protocol (SLEAP) trial, combining daily sedation vacation and targeted light sedation strategy showed no difference in time on ventilator or length of stay when compared to the control group that used only one sedation strategy. (20) Patients who were managed on the combined strategy paradoxically received more sedation due to high incidences of agitation and pain while at the same time; nurses reported increased workload and reported more ventilator issues. (20) Neither of these strategies can be used universally without discretion. (3)(19-20) For example, patients who are under neuromuscular blockade are not candidates for sedation vacations or light sedation. (3)(19-20) Patients who are withdrawing from alcohol are similarly unsuitable for the aforementioned sedation strategies. (3)(19-20)

Highlights of PAD Guidelines and Nursing Implications

The role of critical care nurse in managing mechanically ventilated patient is crucial and cannot be understated. Frequent bedside monitoring of patient's pain, agitation and delirium levels and titrating intervention accordingly is key to the success of any sedation protocol. (3)(5)(23) It is imperative that critical care nurses across all levels become early adopters or “champions” of the PAD care bundle. Below are the highlights of the latest guidelines on managing PAD in the critical care setting espoused by the Society of Critical Care Medicine (SCCM) and the American College of Critical Care Medicine (ACCM). (3)

Pain Guidelines

Universally considered as the fifth vital sign, pain is routinely assessed and evaluated by critical care nurses. Implementation of the pain aspect of the PAD care bundle must acknowledge well-known barriers of pain management such as knowledge deficits, misconceptions about assessment, lack of experience, resistance to the use of validated tools, limited competences or assessment skills, poor communication, and not accepting patients’ descriptions of pain as the gold standard. (24) There is historical evidence that patients' experiences of pain and distress do not fully agree with nurses' and assistant nurses' assessments and the staff may underestimate pain among intensive care elderly patients. (25) The PAD care bundle includes the following key points (26):

  • Performing routine pain assessments every 2-3 hours and more frequently as needed in all ICU patients, regardless of whether patients can self-report their pain or not.
  • Self-reporting is considered the “gold standard” in pain assessment.
  • Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable pain assessment tools for use in ICU patients.
  • Patients are considered to be in significant pain if they self-report their pain intensity of 4 or greater (0–10 Numeric Rating Scale [NRS]) or have either a BPS score of 6 or greater (BPS range = 3–12) or a CPOT score of 3 or greater (CPOT range = 3–8) if they cannot self-report.
  • Treat pain promptly, within 30 minutes of recognizing significant pain levels.
  • First optimize pain management and sedate patients only if needed.

A holistic and comprehensive pain assessment that incorporates an algorithm is essential, particularly among the hospitalized older adults. (26-27) Renal and hepatic functions must be taken into considerations as well as patient and family preferences within the overall context of quality and safety.

Agitation and Sedation Guidelines

A profusion of sedation scales have been studied and used in critical care. Both the Richmond Agitation-Sedation Scale (RASS) and the Sedation-Agitation Scale (SAS) are considered the most valid and reliable subjective scales for use in critically ill adult patients. (28) It is incumbent upon critical care nurses be able to use these tools, along with other relevant tools such as the CAM-ICU with high reliability. (4)(21-23) The PAD care bundle includes the following key points (26):

  • Assessment and documentation of sedation/agitation must be performed in all ICU patients, using either the RASS or SAS sedation scale, at least four times per nursing shift (e.g., every 2–3 hours), and more frequently as needed.
  • Medication orders for sedation must have specified parameters in order to prevent oversedation.
  • The choice of sedative agent to use in critically ill patients must be informed by the following factors: a) the specific indications for sedation and the sedative goals for each patient; b) the compatibility between the clinical pharmacology of a sedative, its side effect profile, and the relative contraindications for its use in a critically ill patient; and c) the overall costs (not limited to pharmacy costs) associated with using a particular sedative.

With a set of sedation protocol in place, its functional implementation depends in various factors such as the critical care nurse's judgment and acceptance of the protocol. (7) Therefore when the institution establishes a sedation protocol, it's important to educate and gain the acceptance of the nursing staff and take into consideration the additional workload in order to plan staffing accordingly. (7)(20)(23) Sedation strategies that relies heavily on hypnotics are a practice that is engrained in many experienced clinicians; therefore introducing alternative strategies such as analgosedation might meet resistance at first. (7)(16)(20)(23) Understanding the implications of particular sedation strategies and their implications on patient outcomes is essential in translating protocols into practice.

Delirium Guidelines

ICU-associated with delirium is a major independent contributor to mortality and other negative outcomes such as prolonged duration of mechanical ventilation, prolonged hospitalization, post-discharge institutionalization, and increased health care cost, and long-term cognitive dysfunction among others. (2-3)(10)(12) The PAD care bundle includes the following key points (26):

  • Identify and treat reversible causes of delirium in critically ill patients.
  • Treatment should include both non-pharmacologic and pharmacologic strategies, with an emphasis on implementing non-pharmacologic interventions first.
  • Pharmacologic treatment of delirium should include: a) adequate analgesia; b) discontinuation of benzodiazepines (except in patients with suspected ethanol or benzodiazepine withdrawal); c) resumption of patients’ psychiatric medications, if indicated; d) treatment of drug withdrawal syndromes, if suspected; and e) antipsychotics, if clinically indicated.

The emphasis on non-pharmacologic strategies in the prevention and treatment of delirium rest largely within the nursing domain. The American Association of Critical Care Nurses (AACN) endorses the use of CAM-ICU or the Intensive Care Delirium Screening Checklist (ICDSC) as assessment tools. (29) Collaborative interventions such as early mobility with physical and occupational therapy have been shown to reduce ICU length of stay, reduced prevalence of delirium and lower sedative use. (30) Compliance to activity orders (e.g., out-of-bed as tolerated) requires coordinated nursing care and support from management stakeholders to maintain staffing mix that meets national benchmarks. Nurses can use motivational interactions to encourage patients to comply with exercise and activity regimen to ensure compliance.

Another nursing-sensitive aspect of delirium prevention is optimizing rest and sleep among critically ill patients. Various strategies such having patients use earplugs, clustering nursing activities, enforcing dedicated quiet times during the day and night, reduced lighting or dimming hallway lighting, and minimizing volume of staff voices have all been shown to improve sleep and reduce delirium among patients. (26)

Translation to Practice

Implementation of best practice evidence remains a challenge in health care. The current Pain, Agitation, and Delirium (PAD) Care Bundle brings special attention to the process and approach to PAD management rather than specific recommendations for using certain medications in different clinical situations. (2) For this reason, a collaborative and interdisciplinary management that is patient-centered is called for. Given the available evidence, it is recommended to implement sedation strategy that prioritizes opioid usage for pain management with judicial usage of hypnotics if not outright avoided. (3) The optimal strategy should begin at the moment of intubation. Once a patient is intubated, continuous infusion of fentanyl or remifentanyl should be initiated at an adequate rate with intermittent boluses given until the patient reports no pain or shows no sign of pain. (11) If the patient remains agitated and is refractory to verbal reassurance and opioid boluses, non-benzodiazepine hypnotics such as propofol can be given as intravenous boluses. If the decision to start continuous hypnotic infusion is made, preference should be given to drugs such as propofol and dexmedetomidine, both of which are less associated with delirium than benzodiazepines. (3)(7)(12-13) Further agitations can be managed by antipsychotics such as haloperidol. (14) Either daily sedation vacations or targeted light sedation strategy can be used but not in conjunction. (20)

Conclusion

Older adults in critical care settings remain vulnerable to delirium and more likely to have poorer outcomes. (8) Pain, agitation, and delirium are closely interwoven pathophysiologic phenomena and each one invariably impacts the outcomes of the other. Inadequate or inappropriate choices of sedation contribute to the development of delirium and poorer outcomes. (12) Benzodiazepines have been found to be associated with higher incidence of delirium, prolonged mechanical ventilation days and longer ICU days. (13) Inadequate treatment of pain also contributes to delirium and should be adequately addressed. (9) Sedation vacation and targeted light sedation are proven strategies that decrease delirium, PTSD and other long-term negative outcomes. (2-3)(12)(19-20)

It is important for clinicians to be aware of the various factors that contribute to the development of ICU delirium, optimize sedation strategies for mechanically ventilated patients to improve overall patient outcomes. The ICU PAD care bundle does not propose a specific drug treatment strategy for all ICU patients, but maintains that treatment goals focus on patients’ pain management as a priority and to use appropriate pharmacological agents that are not associated with inducing delirium to sedate patients when necessary. (26) It is essential that critical care nurses become full partners in the implementation and evaluation of the PAD care guidelines paying close attention to patterns unique to older adults.

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