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Mera A, Argudo E, Martínez-Martínez M, Palmada C, Bonilla C, Pacheco A, Chiscano L, Marín G, Lozano B, Gallart E, Riera J. Extracorporeal membrane oxygenation in Jehovah's Witness patients: Case report, literature review, and summary of recommendations. Perfusion 2024; 39:60-65. [PMID: 34554022 DOI: 10.1177/02676591211047774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Extracorporeal Membrane Oxygenation (ECMO) is commonly associated with a high blood transfusion requirement. Jehovah's Witness patients present a particular challenge. The impossibility of transfusing blood cells and starting anticoagulation treatment are common contraindications for this supportive measure. Here we report the case of a Jehovah's Witness patient with refractory hypoxemia due to influenza A H1N1 pneumonia who required venovenous ECMO for 11 days. We describe the use of a bloodless approach to reduce the waste of blood, avoiding anticoagulation, and improving red blood cell production. We then summarize the current literature on the use of ECMO in Jehovah's Witness patients and, finally, we propose some recommendations for their management.
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Affiliation(s)
- Abrahán Mera
- Intensive Care Medicine Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Eduard Argudo
- Intensive Care Medicine Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María Martínez-Martínez
- Intensive Care Medicine Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Clara Palmada
- Intensive Care Medicine Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Camilo Bonilla
- Intensive Care Medicine Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Andrés Pacheco
- Intensive Care Medicine Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Luis Chiscano
- Intensive Care Medicine Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Gemma Marín
- Intensive Care Medicine Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Beatriz Lozano
- Intensive Care Medicine Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Elisabet Gallart
- Intensive Care Medicine Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jordi Riera
- Intensive Care Medicine Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Respiratorias. Instituto de Salud Carlos III, Madrid, Spain
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Moore LJ, Todd SR. Hemorrhage and Transfusions in the Surgical Patient. COMMON PROBLEMS IN ACUTE CARE SURGERY 2017. [PMCID: PMC7120919 DOI: 10.1007/978-3-319-42792-8_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hemorrhage remains the leading cause of intra-operative deaths and those in the first 24 h. Many cardiovascular and hepatobiliary procedures result in massive hemorrhage and postpartum hemorrhage events in labor and delivery place the patient at a high risk for mortality. Both upper and lower gastrointestinal bleeding (e.g., diverticulosis, esophageal and gastric varices, and peptic ulcer disease) can also result in significant blood loss requiring massive transfusion and resuscitation from hemorrhagic shock. Therefore, safe, timely, and effective transfusion of blood products is critical. The aim of this chapter is to provide clinicians with a discussion of the current literature on the various blood component products, their indications, and unique hemostatic conditions in the surgical patient. While the majority of data concerning optimal management of acquired coagulopathy and hemorrhagic shock resuscitation is based on trauma patients, many of the principles can and should be applied to the surgical patient (or likely any patient) with profound hemorrhage.
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Affiliation(s)
- Laura J. Moore
- Department of Surgery, The University of Texas McGovern Medical School - Houston, Houston, Texas USA
| | - S. Rob Todd
- General Surgery and Trauma Ben Taub Hospital, Houston, Texas USA
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Chalmers C, Tyson E, Walter E, Soon Y, Creagh-Brown B. Profound Anaemia in a Jehovah's Witness following Upper Gastrointestinal Haemorrhage: Intensive Care Management. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Management of the profoundly anaemic patient who competently refuses blood transfusion will always prove challenging. This article provides a review of treatment strategies based around a recent case of a patient presenting after major gastrointestinal haemorrhage. The main part of management involves providing supportive intensive care, paying particular attention to oxygen delivery and consumption, and minimising further blood loss. Specific treatments, such as pharmacotherapy to promote erythropoiesis, are based largely on indirect evidence or expert opinion. Virtually all aspects of care involve carefully balancing a shifting profile of risks and benefits; a team approach and close communication with the family are essential. This patient's successful outcome has extended our understanding of this area, which is discussed.
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Affiliation(s)
| | - Emma Tyson
- Royal Surrey County Hospital, Guildford, Surrey
| | | | - Yuen Soon
- Royal Surrey County Hospital, Guildford, Surrey
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Hemorrhage and Transfusions in the Surgical Patient. COMMON PROBLEMS IN ACUTE CARE SURGERY 2013. [PMCID: PMC7121296 DOI: 10.1007/978-1-4614-6123-4_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Hemorrhage is the leading cause of intraoperative deaths. Many cardiovascular and hepatobiliary procedures result in massive hemorrhage and postpartum hemorrhage events in labor and delivery place the patient at a high risk for mortality. Gastrointestinal bleeding from diverticulosis, varices, and ulcer disease can result in significant blood loss requiring massive transfusion and resuscitation from hemorrhagic shock. Timely and effective transfusion of blood products is of critical in these scenarios. The frequency in which blood component products are transfused in surgical patients begs for a greater understanding of them. The aim of this chapter is to provide clinicians with a discussion of the current literature on the various blood component products, their indications, and unique hemostatic conditions in the surgical patient. While the majority of data concerning optimal management of acquired coagulopathy and hemorrhagic shock resuscitation is based on trauma patients, many of the principles can and should be applied to the surgical patient (or likely any patient) with profound hemorrhage.
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Abstract
OBJECTIVE Phlebotomy-induced blood loss in critically ill children is common, contributes to anemia, and may be avoidable. We aimed to identify factors associated with phlebotomy-induced blood loss. DESIGN Prospective observational study, single-center tertiary children's hospital. SETTING Pediatric intensive care unit. PATIENTS A total of 63 patients admitted to the pediatric intensive care unit for >48 hrs from 2004 to 2005. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Phlebotomy resulted in a mean blood volume loss of 2.5 ± 1.4 mL per draw, 7.1 ± 5.3 mL per day, and 34 ± 37 mL per pediatric intensive care unit stay, of which 1.4 ± 1.1 mL per draw, 3.8 ± 3.6 mL per day, and 23 ± 31 mL per pediatric intensive care unit stay were discarded as excess. This excess represents 210% ± 174% of the volume requested by the laboratory and a 110% overdraw. Blood drawn from central venous catheters had significantly greater overdraw volumes, 254% ± 112%, compared to those of arterial, 168% ± 44%, and peripheral intravenous catheters, 143% ± 39%, p < .001. Blood draws sent for one test had an associated overdraw of 278% ± 81%, compared to draws sent for two, 168% ± 48%, three 173% ± 4%, and four or greater tests 55% ± 5%, p < .001. Patients <10 kg had significantly greater mean volumes of blood loss/kg/day compared to patients ≥ 10 kg, p < .001. CONCLUSION Blood drawn in excess of phlebotomy requirements exceeds the blood volume loss drawn for phlebotomy by two fold. Using indwelling catheters for phlebotomy often requires a discard volume to be drawn before obtaining the laboratory sample. Consolidating phlebotomy tests and using a closed system may decrease the amount of blood overdrawn and minimize overall phlebotomy-induced blood loss.
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Collins TA. Packed red blood cell transfusions in critically ill patients. Crit Care Nurse 2011; 31:25-33; quiz 34. [PMID: 21285463 DOI: 10.4037/ccn2011200] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Anemia, which is prevalent in critically ill patients, often requires frequent blood transfusions. These blood transfusions are not without risks. A critical review of 6 studies shows an association between red blood cell transfusion and increased mortality. However, when disease state was adjusted for in 2 studies, researchers found that red blood cell transfusion correlated with decreased mortality. Thus further research, particularly on leukoreduction and age of stored blood, must be done before a change in practice can be implemented. It is vital that nurses stay current on this research in order to improve patients' outcomes.
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Affiliation(s)
- Tara Ann Collins
- Hospital of University of Pennsylvania, Rhoads 5 SICU, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Abstract
OBJECTIVE To review the pathophysiology of anemia, as well as transfusion-related complications and indications for red blood cell (RBC) transfusion, in critically ill children. Although allogeneic blood has become increasingly safer from infectious agents, mounting evidence indicates that RBC transfusions are associated with complications and unfavorable outcomes. As a result, there has been growing interest and efforts to limit RBC transfusion, and indications are being revisited and revamped. Although a so-called restrictive RBC transfusion strategy has been shown to improve morbidity and mortality in critically ill adults, there have been relatively few studies on RBC transfusion performed in critically ill children. DATA SOURCES Published literature on transfusion medicine and outcomes of RBC transfusion. STUDY SELECTION, DATA EXTRACTION, AND SYNTHESIS: After a brief overview of physiology of oxygen transportation, anemia compensation, and current transfusion guidelines based on available literature, risks and outcomes of transfusion in general and in critically ill children are summarized in conjunction with studies investigating the safety of restrictive transfusion strategies in this patient population. CONCLUSIONS The available evidence does not support the extensive use of RBC transfusions in general or critically ill patients. Transfusions are still associated with risks, and although their benefits are established in limited situations, the associated negative outcomes in many more patients must be closely addressed. Given the frequency of anemia and its proven negative outcomes, transfusion decisions in the critically ill children should be based on individual patient's characteristics rather than generalized triggers, with consideration of potential risks and benefits, and available blood conservation strategies that can reduce transfusion needs.
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Prittie JE. Controversies related to red blood cell transfusion in critically ill patients. J Vet Emerg Crit Care (San Antonio) 2010; 20:167-76. [PMID: 20487245 DOI: 10.1111/j.1476-4431.2010.00521.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To review the evolution of and controversies associated with allogenic blood transfusion in critically ill patients. DATA SOURCES Veterinary and human literature review. HUMAN DATA SYNTHESIS RBC transfusion practices for ICU patients have come under scrutiny in the last 2 decades. Human trials have demonstrated relative tolerance to severe, euvolemic anemia and a significant outcome advantage following implementation of more restricted transfusion therapy. Investigators question the ability of RBCs stored longer than 2 weeks to improve tissue oxygenation, and theorize that both age and proinflammatory or immunomodulating effects of transfused cells may limit efficacy and contribute to increased patient morbidity and mortality. Also controversial is the ability of pre- and post-storage leukoreduction of RBCs to mitigate adverse transfusion-related events. VETERINARY DATA SYNTHESIS While there are several studies evaluating the transfusion trigger, the RBC storage lesion and transfusion-related immunomodulation in experimental animal models, there is little research pertaining to clinical veterinary patients. CONCLUSIONS RBC transfusion is unequivocally indicated for treatment of anemic hypoxia. However, critical hemoglobin or Hct below which all critically ill patients require transfusion has not been established and there are inherent risks associated with allogenic blood transfusion. Clinical trials designed to evaluate the effects of RBC age and leukoreduction on veterinary patient outcome are warranted. Implementation of evidence-based transfusion guidelines and consideration of alternatives to allogenic blood transfusion are advisable.
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Affiliation(s)
- Jennifer E Prittie
- Department of Emergency and Critical Care, Animal Medical Center, New York, NY 10065, USA.
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9
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Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care*. Crit Care Med 2009; 37:3124-57. [DOI: 10.1097/ccm.0b013e3181b39f1b] [Citation(s) in RCA: 364] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Melmed GM, Hulsey ME, Newhouse M, Holmes HE, Mays EJ. Clinical strategies for supporting the untransfusable hemorrhaging patient. Proc (Bayl Univ Med Cent) 2009; 22:316-20. [PMID: 19865501 DOI: 10.1080/08998280.2009.11928545] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Hemorrhaging patients who cannot be transfused due to personal beliefs or the lack of compatible blood products provide a unique challenge for clinicians. Here we describe a 58-year-old African American man with a history of sickle cell-beta(+) thalassemia who had recently received a multiunit exchange transfusion and developed hematochezia followed by severe anemia. Due to the presence of multiple alloantibodies, no compatible packed red blood cell (pRBC) units could initially be located. The patient was managed with mechanical ventilation, colloid and crystalloid solutions, procoagulants, and recombinant erythropoietin. After an extensive search by our blood bank, enough compatible pRBC units were identified and the patient survived without significant clinical sequelae. Management of the untransfusable hemorrhaging patient requires a multidisciplined approach, with coordination between blood banks, hematologists, intensivists, and other specialists. Steps should be taken to avoid or limit blood loss, identify compatible pRBC units, control hypotension, maximize oxygen delivery, minimize metabolic demand, and stimulate erythropoiesis. In dire circumstances, use of experimental hemoglobin substitutes or transfusion of the least serologically incompatible pRBCs available may be considered.
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Affiliation(s)
- Gavin M Melmed
- Department of Oncology (Melmed, Holmes) and the Department of Pathology (Newhouse, Mays), Baylor University Medical Center and Baylor Sammons Cancer Center, Dallas, Texas, and the Department of Pathology, Midland Memorial Hospital, Midland, Texas (Hulsey). Dr. Melmed is now at Baylor Medical Center at Garland
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Pabla L, Watkins E, Doughty HA. A study of blood loss from phlebotomy in renal medical inpatients. Transfus Med 2009; 19:309-14. [PMID: 19735382 DOI: 10.1111/j.1365-3148.2009.00960.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The objective of the study was to assess phlebotomy loss in renal medical in-patients in order to minimise an iatrogenic cause of anaemia. Phlebotomy has been shown to be a significant cause of iatrogenic blood loss in critical care. However, there has been limited research in patients with renal disease, at risk from anaemia. A prospective observational study was conducted of 70 consecutive patients admitted to an acute renal medicine ward in a tertiary care hospital over a period of four months. Inclusion criteria included adult patients with acute or chronic renal failure. Patients actively bleeding were excluded. Blood loss due to phlebotomy was determined from the patient's computerised records. The mean patient age was 61.5 +/- 16.5 years; the mean length of hospital stay was 23.1 +/- 19.8 days. The mean admission Hb was 9.8 +/- 2.0 g dL(-1) and 9.5 +/- 1.5 g dL(-1) on discharge. The total mean blood loss from phlebotomy during hospitalisation was 215.8 +/- 166 mL with a mean weekly blood loss of 55.7 +/- 11.23 mL. Losses were highest in the first week (mean of 76.8 mL), declining in subsequent weeks. Samples were taken for biochemistry (38%), FBC (36%), transfusion (13%) and others (13%). 46% of patients were transfused (mean 4.8 +/- 3.6 units). Blood loss was lower than in previous studies conducted in intensive care and general medicine but clinical staff should be aware of the cumulative blood loss from phlebotomy. Losses should be managed by optimising the frequency and volume of blood drawn for diagnostic laboratory tests.
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Affiliation(s)
- L Pabla
- University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
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12
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Skarda DE, Mulier KE, Myers DE, Taylor JH, Beilman GJ. DYNAMIC NEAR-INFRARED SPECTROSCOPY MEASUREMENTS IN PATIENTS WITH SEVERE SEPSIS. Shock 2007; 27:348-53. [PMID: 17414414 DOI: 10.1097/01.shk.0000239779.25775.e4] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study evaluated near-infrared spectroscopy (NIRS)-derived measurements in hemodynamically stable patients with severe sepsis, as compared with similar measurements in healthy age-matched volunteers. Prospective, preliminary, observational study in a surgical intensive care unit and clinical research center at a university health center. We enrolled 10 patients with severe sepsis and 9 healthy age-matched volunteers. For patients with severe sepsis, we obtained pulmonary artery catheter and laboratory values three times daily for 3 days and oxygen consumption values via metabolic cart once daily for 3 days. For healthy volunteers, we obtained all noninvasive measurements during a single session. We found lower values in patients with severe sepsis (versus healthy volunteers), in tissue oxygen saturation (StO2), in the StO2 recovery slope, in the tissue hemoglobin index, and in the total tissue hemoglobin increase on venous occlusion. Patients with severe sepsis had longer StO2 recovery times and lower NIRS-derived local oxygen consumption values versus healthy volunteers. In our preliminary study, NIRS provides a noninvasive continuous method to evaluate peripheral tissue oxygen metabolism in hemodynamically stable patients with severe sepsis. Further research is needed to demonstrate whether these values apply to broader populations of patients with systemic inflammatory response syndrome, sepsis, severe sepsis, and septic shock.
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Affiliation(s)
- David E Skarda
- Department of Surgery, University of Minnesota, Minneapolis, USA
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Affiliation(s)
- David M Rogers
- Department of Pathology, University of New Mexico, United Blood Services of New Mexico, Albuquerque, New Mexico 87131, USA
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14
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Picard KM, O’Donoghue SC, Young-Kershaw DA, Russell KJ. Development and Implementation of a Multidisciplinary Sepsis Protocol. Crit Care Nurse 2006. [DOI: 10.4037/ccn2006.26.3.43] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Kathy M. Picard
- Kathy Picard is the clinical nurse specialist, Sharon O’Donoghue is a clinical nurse educator, and Kristin Russell is a nurse manager in the medical intensive care units and Duane Young-Kershaw is the clinical nurse educator in the emergency department at Beth Israel Deaconess Medical Center, Boston, Mass
| | - Sharon C. O’Donoghue
- Kathy Picard is the clinical nurse specialist, Sharon O’Donoghue is a clinical nurse educator, and Kristin Russell is a nurse manager in the medical intensive care units and Duane Young-Kershaw is the clinical nurse educator in the emergency department at Beth Israel Deaconess Medical Center, Boston, Mass
| | - Duane A. Young-Kershaw
- Kathy Picard is the clinical nurse specialist, Sharon O’Donoghue is a clinical nurse educator, and Kristin Russell is a nurse manager in the medical intensive care units and Duane Young-Kershaw is the clinical nurse educator in the emergency department at Beth Israel Deaconess Medical Center, Boston, Mass
| | - Kristin J. Russell
- Kathy Picard is the clinical nurse specialist, Sharon O’Donoghue is a clinical nurse educator, and Kristin Russell is a nurse manager in the medical intensive care units and Duane Young-Kershaw is the clinical nurse educator in the emergency department at Beth Israel Deaconess Medical Center, Boston, Mass
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