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Schwartz RL, Hamlin SK, Vozzella GM, Randle LN, Klahn S, Maris GJ, Waterman AD. Utilizing Telenursing to Supplement Acute Care Nursing in an Era of Workforce Shortages: A Feasibility Pilot. Comput Inform Nurs 2024; 42:151-157. [PMID: 38252545 DOI: 10.1097/cin.0000000000001097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Hospitals are experiencing a nursing shortage crisis that is expected to worsen over the next decade. Acute care settings, which manage the care of very complex patients, need innovations that lessen nurses' workload burden while ensuring safe patient care and outcomes. Thus, a pilot study was conducted to evaluate the feasibility of implementing a large-scale acute care telenurse program, where a hospital-employed telenurse would complete admission and discharge processes for hospitalized patients virtually. In 3 months, almost 9000 (67%) of patient admissions and discharges were conducted by an acute care telenurse, saving the bedside nurse an average of 45 minutes for each admission and discharge. Preliminary benefits to the program included more uninterrupted time with patients, more complete hospital admission and discharge documentation, and positive patient and nurse feedback about the program.
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Affiliation(s)
- Roberta L Schwartz
- Author Affiliations: Administration (Drs Schwartz and Vozzella and Ms Maris); Center for Nursing Research, Education and Practice (Dr Hamlin); Virtual Medicine Department (Ms Randle and Mr Klahn); J. C. Walter Jr. Transplant Center and Department of Surgery (Dr Waterman), Houston Methodist, TX
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Hamlin SK, Fontenot NM, Hooker SJ, Chen HM. Systems-Based Physical Assessments: Earlier Detection of Clinical Deterioration and Reduced Mortality. Am J Crit Care 2023; 32:329-337. [PMID: 37652885 DOI: 10.4037/ajcc2023113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND Despite efforts to improve early detection of deterioration in a patient's condition, delays in activating the rapid response team remain common. OBJECTIVES To evaluate delays in activating the rapid response team and the occurrence of serious adverse events before and after implementation of a quality improvement initiative aimed at nurses' performing systems-based physical assessments. METHODS A retrospective observational cohort design was used to evaluate all patients who had a rapid response team activation during the study period. RESULTS A total of 1080 patients were included in the analysis: 536 patients before the quality improvement initiative and 544 patients after the quality improvement initiative. The delay in activating the rapid response team decreased from 11.7 hours in the before group to 9.6 hours in the after group (P < .001). In the after group, fewer patients were transferred to the intensive care unit (36% vs 41%, P = .02) and those who were transferred had 3.58 times greater odds of death than those who stayed at the same level of care. The after group had a 44% reduction in the odds of mortality compared with the before group. CONCLUSIONS When nurses focus on conducting a systems-based physical assessment early in their shift, delays in recognizing a patient's deteriorating condition are reduced, fewer patients are admitted to the intensive care unit, and mortality is significantly reduced.
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Affiliation(s)
- Shannan K Hamlin
- Shannan K. Hamlin is an associate professor of nursing, Houston Methodist Academic Institute, Houston Methodist Hospital, Houston, Texas
| | - Nicole M Fontenot
- Nicole M. Fontenot is an instructor of nursing, Houston Methodist Academic Institute, Houston Methodist Hospital, Houston, Texas
| | - Steven J Hooker
- Steven J. Hooker is an instructor of nursing, Houston Methodist Academic Institute, Houston Methodist Hospital, Houston, Texas
| | - Hsin-Mei Chen
- Hsin-Mei Chen is an assistant professor, Houston Methodist Academic Institute, Houston Methodist Hospital, Houston, Texas
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Fontenot NM, Hamlin SK, Hooker SJ, Vazquez T, Chen H. Physical assessment competencies for nurses: A quality improvement initiative. Nurs Forum 2022; 57:710-716. [PMID: 35434794 PMCID: PMC9545795 DOI: 10.1111/nuf.12725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/26/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022]
Abstract
As the only healthcare providers caring for hospitalized patients every hour of every day, nurses have a responsibility to keep patients safe. Physical assessment is a basic but essential nursing skill that fosters patient safety. Assessing a patient's current status enables nurses to recognize early patient deterioration. Contemporary nursing practice relies on vital signs and technology to aid in the detection of patient deterioration. The aim is to describe the Methodist Proficient Assessment Competency (MPAC©) quality improvement initiative. Surveys and directly observed patient assessment data were used to evaluate attitudes and practices. One hundred and seventy‐nine pre‐MPAC audits were conducted, followed by 1391 post‐MPAC audits. Pre‐ compared with post‐MPAC audits showed significant improvements in complete physical assessments (78% vs. 94%; p < .001), timeliness (within 4 h; 64% vs. 91%; p < .001) and accuracy (67% vs. 95%; p < .001) of documentation. In conclusion, nurses have a responsibility to quickly identify changes in a patient's condition and intervene to prevent serious adverse events. Taking the needed time to perform a full physical assessment at the beginning of the shift along with timely and accurate documentation, allows nurses to acquire the knowledge they need to establish a patient's current clinical status and usual behaviors, thereby facilitating early recognition of subtle changes that could indicate deterioration.
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Affiliation(s)
- Nicole M. Fontenot
- Department of Nursing, Center for Nursing Research, Education and Practice Houston Methodist Academic Institute Houston Texas USA
| | - Shannan K. Hamlin
- Department of Nursing, Center for Nursing Research, Education and Practice Houston Methodist Academic Institute Houston Texas USA
| | - Steven J. Hooker
- Department of Nursing, Center for Nursing Research, Education and Practice Houston Methodist Academic Institute Houston Texas USA
| | - Theresa Vazquez
- Department of Nursing, Center for Nursing Research, Education and Practice Houston Methodist Academic Institute Houston Texas USA
| | - Hsin‐Mei Chen
- Department of Nursing, Center for Nursing Research, Education and Practice Houston Methodist Academic Institute Houston Texas USA
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Abstract
Tumor lysis syndrome (TLS) is a life-threatening disorder that is an oncologic emergency. Risk factors for TLS are well-known, but the current literature shows case descriptions of unexpected acute TLS. Solid tumors and untreated hematologic tumors can lyse under various circumstances in children and adults. International guidelines and recommendations, including the early involvement of the critical care team, have been put forward to help clinicians properly manage the syndrome. Advanced practice nurses may be in the position of triaging and initiating treatment of patients with TLS, and need a thorough understanding of the syndrome and its treatment.
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Affiliation(s)
| | - Shannan K Hamlin
- Center for Professional Excellence, Institute for Academic Medicine, Houston Methodist Hospital, 6565 Fannin, MGJ 11-017, Houston, TX 77030, USA
| | - Johnny Dang
- Department of Acute and Continuing Care, University of Texas Health Science Center at Houston, 6901 Bertner Avenue SON 654, Houston, TX 77030, USA
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Abstract
Blood rheology, or hemorheology, involves the flow and deformation behavior of blood and its formed elements (ie, erythrocytes, leukocytes, platelets). The adequacy of blood flow to meet metabolic demands through large circulatory vessels depends highly on vascular control mechanisms. However, the extent to which rheologic properties of blood contribute to vascular flow resistance, particularly in the microcirculation, is becoming more appreciated. Current evidence suggests that microvascular blood flow is determined by local vessel resistance and hemorheologic factors such as blood viscosity, erythrocyte deformability, and erythrocyte aggregation. Such knowledge will aid clinicians caring for patients with hemodynamic alterations.
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Affiliation(s)
- Shannan K Hamlin
- Nursing Research and Evidence-Based Practice, Houston Methodist Hospital, 6565 Fannin, MGJ 11-017, Houston, TX 77030, USA.
| | - Penelope S Benedik
- UT Health School of Nursing, University of Texas Health Science Center at Houston, 6901 Bertner Street, Room 682, Houston, TX 77030, USA
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Abstract
Functional components of the microcirculation provide oxygen and nutrients and remove waste products from the tissue beds of the body's organs. Shock states overwhelmingly stress functional capacity of the microcirculation, resulting in microcirculatory failure. In septic shock, inflammatory mediators contribute to hemodynamic instability. In nonseptic shock states, the microcirculation is better able to compensate for alterations in vascular resistance, cardiac output, and blood pressure. Therefore, global hemodynamic and oxygen delivery parameters are appropriate for assessing, monitoring, and guiding therapy in hypovolemic and cardiogenic shock but, alone, are inadequate for septic shock.
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Affiliation(s)
- Shannan K Hamlin
- Nursing Research and Evidence-Based Practice, Houston Methodist Hospital, MGJ 11-017, Houston, TX 77030, USA.
| | - C Lee Parmley
- Vanderbilt University Hospital, 1211 21st Avenue South, S3408 MCN, Nashville, TN 37212, USA; Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, 1211 21st Avenue South, S3408 MCN, Nashville, TN 37212, USA
| | - Sandra K Hanneman
- Center for Nursing Research, University of Texas Health Science Center at Houston School of Nursing, Room #594, 6901 Bertner Avenue, Houston, TX 77030, USA
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Abstract
Erythrocytes are not just oxygen delivery devices but play an active metabolic role in modulating microvascular blood flow. Hemoglobin and red blood cell morphology change as local oxygen levels fall, eliciting the release of adenosine triphosphate and nitric oxide to initiate local vasodilation. Aged erythrocytes undergo physical and functional changes such that some of the red cell's most physiologically helpful attributes are diminished. This article reviews the functional anatomy and applied physiology of the erythrocyte and the microcirculation with an emphasis on how erythrocytes modulate microvascular function. The effects of cell storage on the metabolic functions of the erythrocyte are also briefly discussed.
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Affiliation(s)
- Penelope S Benedik
- Department of Acute and Continuing Care, School of Nursing, University of Texas Health Science Center at Houston, 6901 Bertner Street, SON 682, Houston, TX 77030, USA.
| | - Shannan K Hamlin
- Nursing Research and Evidence-Based Practice, Houston Methodist Hospital, 6565 Fannin, MGJ 11-017, Houston, TX 77030, USA
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Hamlin SK, Hanneman SK, Padhye NS, Lodato RF. Hemodynamic changes with manual and automated lateral turning in patients receiving mechanical ventilation. Am J Crit Care 2015; 24:131-40. [PMID: 25727273 DOI: 10.4037/ajcc2015782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Lateral turning of critical care patients receiving mechanical ventilation can adversely affect hemodynamic status. OBJECTIVE To study hemodynamic responses to lateral turning. METHOD A time-series design with automated signal processing and ensemble averaging was used to evaluate changes in heart rate, mean arterial pressure, and pulse pressure due to lateral turning in 13 adult medical-surgical critical care patients receiving mechanical ventilation. Patients were randomly assigned to the manual-turn or the automated-turn protocol for up to 7 consecutive days. Heart rate and arterial pressure were measured every 6 seconds for more than 24 hours, and pulse pressure was computed. RESULTS A total of 6 manual-turn patients and 7 automated-turn patients completed the study. Statistically significant changes in heart rate, mean arterial pressure, and pulse pressure occurred with the manual turn. Return of the hemodynamic variables to baseline values required up to 45 minutes in the manual-turn patients (expected recovery time ≤ 5 minutes). However, clinically important changes dissipated within 15 minutes of the lateral turn. The steady-state heart rate response on the right side was slightly greater (3 beats per minute) than that on the back (P = .003). Automated turning resulted in no clinically important changes in any of the 3 variables. CONCLUSIONS In medical-surgical critical care patients receiving mechanical ventilation, manual lateral turning was associated with changes in heart rate, mean arterial pressure, and pulse pressure that persisted up to 45 minutes.
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Affiliation(s)
- Shannan K Hamlin
- Shannan K. Hamlin is director of the Department of Nursing Science, Houston Methodist Hospital and University of Texas Health Science Center at Houston School of Nursing, Houston, Texas. Sandra K. Hanneman is the Jerold B. Katz Distinguished Professor for Nursing Research and Nikhil S. Padhye is an associate professor of research, University of Texas Health Science Center at Houston School of Nursing. Robert F. Lodato is an associate professor in critical care medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Texas Health Science Center at Houston Medical School, Houston, Texas.
| | - Sandra K Hanneman
- Shannan K. Hamlin is director of the Department of Nursing Science, Houston Methodist Hospital and University of Texas Health Science Center at Houston School of Nursing, Houston, Texas. Sandra K. Hanneman is the Jerold B. Katz Distinguished Professor for Nursing Research and Nikhil S. Padhye is an associate professor of research, University of Texas Health Science Center at Houston School of Nursing. Robert F. Lodato is an associate professor in critical care medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Texas Health Science Center at Houston Medical School, Houston, Texas
| | - Nikhil S Padhye
- Shannan K. Hamlin is director of the Department of Nursing Science, Houston Methodist Hospital and University of Texas Health Science Center at Houston School of Nursing, Houston, Texas. Sandra K. Hanneman is the Jerold B. Katz Distinguished Professor for Nursing Research and Nikhil S. Padhye is an associate professor of research, University of Texas Health Science Center at Houston School of Nursing. Robert F. Lodato is an associate professor in critical care medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Texas Health Science Center at Houston Medical School, Houston, Texas
| | - Robert F Lodato
- Shannan K. Hamlin is director of the Department of Nursing Science, Houston Methodist Hospital and University of Texas Health Science Center at Houston School of Nursing, Houston, Texas. Sandra K. Hanneman is the Jerold B. Katz Distinguished Professor for Nursing Research and Nikhil S. Padhye is an associate professor of research, University of Texas Health Science Center at Houston School of Nursing. Robert F. Lodato is an associate professor in critical care medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Texas Health Science Center at Houston Medical School, Houston, Texas
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Hanneman SK, Gusick GM, Hamlin SK, Wachtel SJ, Cron SG, Jones DJ, Oldham SA. Manual vs automated lateral rotation to reduce preventable pulmonary complications in ventilator patients. Am J Crit Care 2015; 24:24-32. [PMID: 25554551 DOI: 10.4037/ajcc2015171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
PURPOSE To estimate effect sizes for a trial to compare preventable pulmonary complications (PPCs), turning-related adverse events, mechanical ventilation duration, intensive care unit (ICU) length of stay, and ICU mortality between patients randomized to 2-hourly manual or continuous automated lateral rotation. METHODS Randomized controlled trial pilot study with 15 patients selected randomly from eligible medical-surgical ICU patients from 2 tertiary hospitals and assigned randomly to the manual-turn or automated-turn protocol for up to 7 consecutive days. A radiologist blinded to group and site assessed serial chest radiographs for PPCs. Repeated-measures analysis with linear mixed models was used to estimate change in PPC score, and Wilcoxon rank sum or Fisher exact test was used to compare group differences in the secondary outcomes. RESULTS Of 16 patients enrolled, 12 (75%) completed the study. Data from 15 patients, 7 manual turn and 8 automated turn, were analyzed. Between-group differences in PPC incidence (67% overall), change in PPC score (β = 0.15, manual turn and β = -0.44, automated turn), and secondary outcomes were not significant (P > .05). Standardized effect sizes were small to moderate for the outcome variables. A sample size of 54 patients would be needed to detect statistically significant between-group differences in PPC over time. CONCLUSIONS The incidence of PPCs in adult patients receiving mechanical ventilation in a medical-surgical ICU was high. Automated turning decreased PPCs with time but had little effect on secondary outcomes. Safety outcomes were not substantially different between groups. A modest efficacy effect supported reduced PPCs with automated turning to the lateral position.
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Affiliation(s)
- Sandra K Hanneman
- Sandra K. Hanneman is the Jerold B. Katz Distinguished Professor for Nursing Research at University of Texas Health Science Center at Houston School of Nursing. Gary M. Gusick is a clinical nurse specialist in cardiovascular and transplant nursing at St Luke's Episcopal Hospital, Houston, Texas. Shannan K. Hamlin is program director of nursing research and evidence-based practice at Houston Methodist Texas Medical Center. Sheryln J. Wachtel is director of innovation and research at CHRISTUS Spohn Health System, Corpus Christi, Texas. Stanley G. Cron is a research instructor and statistician and Deborah J. Jones is an assistant professor and assistant dean for undergraduate programs at University of Texas Health Science Center at Houston School of Nursing. Sandra A. Oldham is a professor of radiology at University of Texas Health Science Center at Houston Medical School.
| | - Gary M Gusick
- Sandra K. Hanneman is the Jerold B. Katz Distinguished Professor for Nursing Research at University of Texas Health Science Center at Houston School of Nursing. Gary M. Gusick is a clinical nurse specialist in cardiovascular and transplant nursing at St Luke's Episcopal Hospital, Houston, Texas. Shannan K. Hamlin is program director of nursing research and evidence-based practice at Houston Methodist Texas Medical Center. Sheryln J. Wachtel is director of innovation and research at CHRISTUS Spohn Health System, Corpus Christi, Texas. Stanley G. Cron is a research instructor and statistician and Deborah J. Jones is an assistant professor and assistant dean for undergraduate programs at University of Texas Health Science Center at Houston School of Nursing. Sandra A. Oldham is a professor of radiology at University of Texas Health Science Center at Houston Medical School
| | - Shannan K Hamlin
- Sandra K. Hanneman is the Jerold B. Katz Distinguished Professor for Nursing Research at University of Texas Health Science Center at Houston School of Nursing. Gary M. Gusick is a clinical nurse specialist in cardiovascular and transplant nursing at St Luke's Episcopal Hospital, Houston, Texas. Shannan K. Hamlin is program director of nursing research and evidence-based practice at Houston Methodist Texas Medical Center. Sheryln J. Wachtel is director of innovation and research at CHRISTUS Spohn Health System, Corpus Christi, Texas. Stanley G. Cron is a research instructor and statistician and Deborah J. Jones is an assistant professor and assistant dean for undergraduate programs at University of Texas Health Science Center at Houston School of Nursing. Sandra A. Oldham is a professor of radiology at University of Texas Health Science Center at Houston Medical School
| | - Sheryln J Wachtel
- Sandra K. Hanneman is the Jerold B. Katz Distinguished Professor for Nursing Research at University of Texas Health Science Center at Houston School of Nursing. Gary M. Gusick is a clinical nurse specialist in cardiovascular and transplant nursing at St Luke's Episcopal Hospital, Houston, Texas. Shannan K. Hamlin is program director of nursing research and evidence-based practice at Houston Methodist Texas Medical Center. Sheryln J. Wachtel is director of innovation and research at CHRISTUS Spohn Health System, Corpus Christi, Texas. Stanley G. Cron is a research instructor and statistician and Deborah J. Jones is an assistant professor and assistant dean for undergraduate programs at University of Texas Health Science Center at Houston School of Nursing. Sandra A. Oldham is a professor of radiology at University of Texas Health Science Center at Houston Medical School
| | - Stanley G Cron
- Sandra K. Hanneman is the Jerold B. Katz Distinguished Professor for Nursing Research at University of Texas Health Science Center at Houston School of Nursing. Gary M. Gusick is a clinical nurse specialist in cardiovascular and transplant nursing at St Luke's Episcopal Hospital, Houston, Texas. Shannan K. Hamlin is program director of nursing research and evidence-based practice at Houston Methodist Texas Medical Center. Sheryln J. Wachtel is director of innovation and research at CHRISTUS Spohn Health System, Corpus Christi, Texas. Stanley G. Cron is a research instructor and statistician and Deborah J. Jones is an assistant professor and assistant dean for undergraduate programs at University of Texas Health Science Center at Houston School of Nursing. Sandra A. Oldham is a professor of radiology at University of Texas Health Science Center at Houston Medical School
| | - Deborah J Jones
- Sandra K. Hanneman is the Jerold B. Katz Distinguished Professor for Nursing Research at University of Texas Health Science Center at Houston School of Nursing. Gary M. Gusick is a clinical nurse specialist in cardiovascular and transplant nursing at St Luke's Episcopal Hospital, Houston, Texas. Shannan K. Hamlin is program director of nursing research and evidence-based practice at Houston Methodist Texas Medical Center. Sheryln J. Wachtel is director of innovation and research at CHRISTUS Spohn Health System, Corpus Christi, Texas. Stanley G. Cron is a research instructor and statistician and Deborah J. Jones is an assistant professor and assistant dean for undergraduate programs at University of Texas Health Science Center at Houston School of Nursing. Sandra A. Oldham is a professor of radiology at University of Texas Health Science Center at Houston Medical School
| | - Sandra A Oldham
- Sandra K. Hanneman is the Jerold B. Katz Distinguished Professor for Nursing Research at University of Texas Health Science Center at Houston School of Nursing. Gary M. Gusick is a clinical nurse specialist in cardiovascular and transplant nursing at St Luke's Episcopal Hospital, Houston, Texas. Shannan K. Hamlin is program director of nursing research and evidence-based practice at Houston Methodist Texas Medical Center. Sheryln J. Wachtel is director of innovation and research at CHRISTUS Spohn Health System, Corpus Christi, Texas. Stanley G. Cron is a research instructor and statistician and Deborah J. Jones is an assistant professor and assistant dean for undergraduate programs at University of Texas Health Science Center at Houston School of Nursing. Sandra A. Oldham is a professor of radiology at University of Texas Health Science Center at Houston Medical School
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Hamlin SK, Parmley CL. Monitoring tissue perfusion and oxygenation. Crit Care Nurs Clin North Am 2014; 26:ix-x. [PMID: 25169694 DOI: 10.1016/j.ccell.2014.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | - C Lee Parmley
- Vanderbilt University Hospital, 1211 21st Avenue South, S3408 MCN, Nashville, TN 37212, USA.
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Abstract
The cardiovascular system (macrocirculation) circulates blood throughout the body, but the microcirculation is responsible for modifying tissue perfusion and adapting it to metabolic demand. Hemodynamic assessment and monitoring of the critically ill patient is typically focused on global measures of oxygen transport and utilization, which do not evaluate the status of the microcirculation. Despite achievement and maintenance of global hemodynamic and oxygenation goals, patients may develop microcirculatory dysfunction with associated organ failure. A thorough understanding of the microcirculatory system under physiologic conditions will assist the clinician in early recognition of microcirculatory dysfunction in impending and actual disease states.
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Affiliation(s)
- Shannan K Hamlin
- Nursing Research and Evidence-Based Practice, Houston Methodist Hospital, MGJ 11-017, Houston, TX 77030, USA.
| | - C Lee Parmley
- Vanderbilt University Hospital, 1211 21st Avenue South, S3408 MCN, Nashville, TN 37212, USA; Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, 1211 21st Avenue South, S3408 MCN, Nashville, TN 37212, USA
| | - Sandra K Hanneman
- University of Texas Health Science Center at Houston School of Nursing, Center for Nursing Research, Room #594, 6901 Bertner Avenue, Houston, TX 77030, USA
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Abstract
In this article, we illustrate a new method for random selection and random assignment that we developed in a pilot study for a randomized clinical trial. The randomization database is supported by a commonly available spreadsheet. Formulas were written for randomizing participants and for creating a "shadow" system to verify integrity of the randomization. Advantages of this method are that it is easy to use, effective, and portable, allowing it to be shared among multiple investigators at multiple study sites. Clinical researchers may find the method useful for research projects that are pilot studies or conducted with limited funding.
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Affiliation(s)
- Nikhil S Padhye
- University of Texas Health Science Center at Houston School of Nursing, 6901 Bertner Avenue, Suite 592, Houston, TX 77030, USA
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Abstract
Left ventricular diastolic dysfunction plays an important role in congestive heart failure. Although once thought to be lower, the mortality of diastolic heart failure may be as high as that of systolic heart failure. Diastolic heart failure is a clinical syndrome characterized by signs and symptoms of heart failure with preserved ejection fraction (0.50) and abnormal diastolic function. One of the earliest indications of diastolic heart failure is exercise intolerance followed by fatigue and, possibly, chest pain. Other clinical signs may include distended neck veins, atrial arrhythmias, and the presence of third and fourth heart sounds. Diastolic dysfunction is difficult to differentiate from systolic dysfunction on the basis of history, physical examination, and electrocardiographic and chest radiographic findings. Therefore, objective diagnostic testing with cardiac catheterization, Doppler echocardiography, and possibly measurement of serum levels of B-type natriuretic peptide is often required. Three stages of diastolic dysfunction are recognized. Stage I is characterized by reduced left ventricular filling in early diastole with normal left ventricular and left atrial pressures and normal compliance. Stage II or pseudonormalization is characterized by a normal Doppler echocardiographic transmitral flow pattern because of an opposing increase in left atrial pressures. This normalization pattern is a concern because marked diastolic dysfunction can easily be missed. Stage III, the final, most severe stage, is characterized by severe restrictive diastolic filling with a marked decrease in left ventricular compliance. Pharmacological therapy is tailored to the cause and type of diastolic dysfunction.
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Affiliation(s)
- Shannan K. Hamlin
- University of Texas Health Science Center at Houston (SKH, PSV, JTK) and Department of Critical Care Medicine, University of Texas M.D. Anderson Cancer Center (SKH, ADS), Houston, Tex
| | - Penelope S. Villars
- University of Texas Health Science Center at Houston (SKH, PSV, JTK) and Department of Critical Care Medicine, University of Texas M.D. Anderson Cancer Center (SKH, ADS), Houston, Tex
| | - Joseph T. Kanusky
- University of Texas Health Science Center at Houston (SKH, PSV, JTK) and Department of Critical Care Medicine, University of Texas M.D. Anderson Cancer Center (SKH, ADS), Houston, Tex
| | - Andrew D. Shaw
- University of Texas Health Science Center at Houston (SKH, PSV, JTK) and Department of Critical Care Medicine, University of Texas M.D. Anderson Cancer Center (SKH, ADS), Houston, Tex
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Hamlin SK, Villars PS, Kanusky JT, Shaw AD. Role of diastole in left ventricular function, II: diagnosis and treatment. Am J Crit Care 2004; 13:453-66; quiz 467-8. [PMID: 15568651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Left ventricular diastolic dysfunction plays an important role in congestive heart failure. Although once thought to be lower, the mortality of diastolic heart failure may be as high as that of systolic heart failure. Diastolic heart failure is a clinical syndrome characterized by signs and symptoms of heart failure with preserved ejection fraction (0.50) and abnormal diastolic function. One of the earliest indications of diastolic heart failure is exercise intolerance followed by fatigue and, possibly, chest pain. Other clinical signs may include distended neck veins, atrial arrhythmias, and the presence of third and fourth heart sounds. Diastolic dysfunction is difficult to differentiate from systolic dysfunction on the basis of history, physical examination, and electrocardiographic and chest radiographic findings. Therefore, objective diagnostic testing with cardiac catheterization, Doppler echocardiography, and possibly measurement of serum levels of B-type natriuretic peptide is often required. Three stages of diastolic dysfunction are recognized. Stage I is characterized by reduced left ventricular filling in early diastole with normal left ventricular and left atrial pressures and normal compliance. Stage II or pseudonormalization is characterized by a normal Doppler echocardiographic transmitral flow pattern because of an opposing increase in left atrial pressures. This normalization pattern is a concern because marked diastolic dysfunction can easily be missed. Stage III, the final, most severe stage, is characterized by severe restrictive diastolic filling with a marked decrease in left ventricular compliance. Pharmacological therapy is tailored to the cause and type of diastolic dysfunction.
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Affiliation(s)
- Shannan K Hamlin
- University of Texas Health Science Center at Houston, University of Texas M.D. Anderson Cancer Center, Houston, Tex., USA
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15
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Abstract
Left ventricular diastolic function plays an important role in cardiac physiology. Lusitropy, the ability of the cardiac myocytes to relax, is affected by both biochemical events within the myocyte and biomechanical events in the left ventricle. β-Adrenergic stimulation alters diastole by enhancing the phosphorylation of phospholamban, a substrate within the myocyte that increases the uptake of calcium ions into the sarcoplasmic reticulum, increasing the rate of relaxation. Troponin I, a regulatory protein involved in the coupling of excitation to contraction, is vital to maintaining the diastolic state; depletion of troponin I can produce diastolic dysfunction. Other biochemical events, such as defects in the voltage-sensitive release mechanism or in inositol triphosphate calcium release channels, have also been implicated in altering diastolic tone. Extracellular collagen determines myocardial stiffness; impaired glucose tolerance can induce an increase in collagen cross-linking and lead to higher end-diastolic pressures. The passive properties of the left ventricle are most accurately measured during the diastasis and atrial contraction phases of diastole. These phases of the cardiac cycle are the least affected by volume status, afterload, inherent viscoelasticity, and the inotropic state of the myocardium. Diastolic abnormalities can be conceptualized by using pressure-volume loops that illustrate myocardial work and both diastolic and systolic pressure-volume relationships. The pressure-volume model is an educational tool that can be used to demonstrate isolated changes in preload, afterload, inotropy, and lusitropy and their interaction.
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Affiliation(s)
- Penelope S. Villars
- University of Texas Health Science Center at Houston (PSV, SKH, JTK) and Department of Critical Care Medicine, University of Texas M.D. Anderson Cancer Center (SKH, ADS), Houston, Tex
| | - Shannan K. Hamlin
- University of Texas Health Science Center at Houston (PSV, SKH, JTK) and Department of Critical Care Medicine, University of Texas M.D. Anderson Cancer Center (SKH, ADS), Houston, Tex
| | - Andrew D. Shaw
- University of Texas Health Science Center at Houston (PSV, SKH, JTK) and Department of Critical Care Medicine, University of Texas M.D. Anderson Cancer Center (SKH, ADS), Houston, Tex
| | - Joseph T. Kanusky
- University of Texas Health Science Center at Houston (PSV, SKH, JTK) and Department of Critical Care Medicine, University of Texas M.D. Anderson Cancer Center (SKH, ADS), Houston, Tex
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Villars PS, Hamlin SK, Shaw AD, Kanusky JT. Role of diastole in left ventricular function, I: Biochemical and biomechanical events. Am J Crit Care 2004; 13:394-403; quiz 404-5. [PMID: 15470855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Left ventricular diastolic function plays an important role in cardiac physiology. Lusitropy, the ability of the cardiac myocytes to relax, is affected by both biochemical events within the myocyte and biomechanical events in the left ventricle. Beta-adrenergic stimulation alters diastole by enhancing the phosphorylation of phospholamban, a substrate within the myocyte that increases the uptake of calcium ions into the sarcoplasmic reticulum, increasing the rate of relaxation. Troponin I, a regulatory protein involved in the coupling of excitation to contraction, is vital to maintaining the diastolic state; depletion of troponin I can produce diastolic dysfunction. Other biochemical events, such as defects in the voltage-sensitive release mechanism or in inositol triphosphate calcium release channels, have also been implicated in altering diastolic tone. Extracellular collagen determines myocardial stiffness; impaired glucose tolerance can induce an increase in collagen cross-linking and lead to higher end-diastolic pressures. The passive properties of the left ventricle are most accurately measured during the diastasis and atrial contraction phases of diastole. These phases of the cardiac cycle are the least affected by volume status, afterload, inherent viscoelasticity, and the inotropic state of the myocardium. Diastolic abnormalities can be conceptualized by using pressure-volume loops that illustrate myocardial work and both diastolic and systolic pressure-volume relationships. The pressure-volume model is an educational tool that can be used to demonstrate isolated changes in preload, afterload, inotropy, and lusitropy and their interaction.
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