Cardiovascular alterations and management

This chapter reviews the support of cardiovascular function in the face of
many compromises to the system. It focuses on two of the most prevalent and fatal diseases affecting the heart: coronary heart disease and heart failure. These diseases are also a common comorbidity in elderly patients admitted to critical care units. The first section on coronary heart disease reviews the pathophysiological concepts of myocardial ischaemia and associated complications, with detailed consideration of the clinical implications, assessment and associated management. Heart failure is discussed in terms of the body’s compensatory mechanisms and the clinical sequelae and associated clinical features of heart failure. Nursing and medical management is outlined including the management of acute exacerbations of heart failure. Finally, other cardiovascular disorders commonly managed in critical care units are reviewed, ranging from other forms of heart failure to hypertensive emergencies and aortic aneurysms. The case study presented at the end of the chapter highlights the key aspects of the management of coronary heart disease and heart failure in patients admitted to critical care units.

Managing women with acute physiological deterioration: student midwives performance in a simulated setting

OBJECTIVE: Midwives' ability to manage maternal deterioration and 'failure to rescue' are of concern with questions over knowledge, clinical skills and the implications for maternal morbidity and, mortality rates. In a simulated setting our objective was to assess student midwives' ability to assess, and manage maternal deterioration using measures of knowledge, situation awareness and skill, performance. METHODS: An exploratory quantitative analysis of student performance based upon performance, ratings derived from knowledge tests and observational ratings. During 2010 thirty-five student, midwives attended a simulation laboratory completing a knowledge questionnaire and two video, recorded simulated scenarios. Patient actresses wearing a 'birthing suit' simulated deteriorating, women with post-partum and ante-partum haemorrhage (PPH and APH). Situation awareness was, measured at the end of each scenario. Applicable descriptive and inferential statistical tests were, applied to the data. FINDINGS: The mean total knowledge score was 75% (range 46-91%) with low skill performance, means for both scenarios 54% (range 39-70%). There was no difference in performance between the scenarios, however performance of key observations decreased as the women deteriorated; with significant reductions in key vital signs such as blood pressure and blood loss measurements. Situation, awareness scores were also low (54%) with awareness decreasing significantly (t(32)=2.247, p=0.032), in the second and more difficult APH scenario. CONCLUSION: Whilst knowledge levels were generally good, skills were generally poor and decreased as the women deteriorated. Such failures to apply knowledge in emergency stressful situations may be resolved by repetitive high stakes and high fidelity simulation.

Nursing handover from ICU to cardiac ward: standardised tools to reduce safety risks

BACKGROUND: Standardising handover processes and content, and using context-specific checklists are proposed as solutions to mitigate risks for preventable errors and patient harm associated with clinical handovers. OBJECTIVES: Adapt existing tools to standardise nursing handover from the intensive care unit (ICU) to the cardiac ward and assess patient safety risks before and after pilot implementation. METHODS: A three-stage, pre-post interrupted time-series design was used. Data were collected using naturalistic observations and audio-recording of 40 handovers and focus groups with 11 nurses. In Stage 1, examination of existing practice using observation of 20 handovers and a focus group interview provided baseline data. In Stage 2, existing tools for high-risk handovers were adapted to create tools specific to ICU-to-ward handovers. The adapted tools were introduced to staff using principles from evidence-based frameworks for practice change. In Stage 3, observation of 20 handovers and a focus group with five nurses were used to verify the design of tools to standardise handover by ICU nurses transferring care of cardiac surgical patients to ward nurses. RESULTS: Stage 1 data revealed variable and unsafe ICU-to-ward handover practices: incomplete ward preparation; failure to check patient identity; handover located away from patients; and information gaps. Analyses informed adaptation of process, content and checklist tools to standardise handover in Stage 2. Compared with baseline data, Stage 3 observations revealed nurses used the tools consistently, ward readiness to receive patients (10% vs 95%), checking patient identity (0% vs 100%), delivery of handover at the bedside (25% vs 100%) and communication of complete information (40% vs 100%) improved. CONCLUSION: Clinician adoption of tools to standardise ICU-to-ward handover of cardiac surgical patients reduced handover variability and patient safety risks. The study outcomes provide context-specific tools to guide handover processes and delivery of verbal content, a safety checklist, and a risk recognition matrix.

Sedation protocols to reduce duration of mechanical ventilation in the ICU: a Cochrane Systematic Review

AIMS: Assess the effects of protocol-directed sedation management on the duration of mechanical ventilation and other relevant patient outcomes in mechanically ventilated intensive care unit patients. BACKGROUND: Sedation is a core component of critical care. Sub-optimal sedation management incorporates both under- and over-sedation and has been linked to poorer patient outcomes. DESIGN: Cochrane systematic review of randomized controlled trials. DATA SOURCES: Cochrane Central Register of Controlled trials, MEDLINE, EMBASE, CINAHL, Database of Abstracts of Reviews of Effects, LILACS, Current Controlled Trials and US National Institutes of Health Clinical Research Studies (1990-November 2013) and reference lists of articles were used. REVIEW METHODS: Randomized controlled trials conducted in intensive care units comparing management with and without protocol-directed sedation were included. Two authors screened titles, abstracts and full-text reports. Potential risk of bias was assessed. Clinical, methodological and statistical heterogeneity were examined and the random-effects model used for meta-analysis where appropriate. Mean difference for duration of mechanical ventilation and risk ratio for mortality, with 95% confidence intervals, were calculated. RESULTS: Two eligible studies with 633 participants comparing protocol-directed sedation delivered by nurses vs. usual care were identified. There was no evidence of differences in duration of mechanical ventilation or hospital mortality. There was statistically significant heterogeneity between studies for duration of mechanical ventilation. CONCLUSIONS: There is insufficient evidence to evaluate the effectiveness of protocol-directed sedation as results from the two randomized controlled trials were conflicting.

Patients want to know about the 'cardiac blues'

BACKGROUND: Much attention has been given to identifying and supporting the minority of patients who develop severe clinical depression after a cardiac event. However, relatively little has been given to supporting the many patients who experience transient but significant emotional disturbance that we term the 'cardiac blues'. OBJECTIVE: The aim of this study was to investigate patients' preferences regarding information provision about cardiac blues. METHODS: One hundred and sixty consecutive cardiac patients admitted to two Victorian hospitals in Australia were interviewed three times over six months. They were asked about emotional issues, including information provision preferences. RESULTS: Four out of five (81%) patients would like to have received information about the cardiac blues, but only a minority received this information. CONCLUSION: Most patients want to know about cardiac blues. The development and evaluation of resources for health professionals and patients to support recovery through cardiac blues appears warranted.