Bryan Boling

Safety of Nurse-Led Ambulation for Patients on Venovenous Extracorporeal Membrane Oxygenation

Purpose: Venovenous extracorporeal membrane oxygenation (VV ECMO) is an effective therapy in patients with acute lung injury and end-stage lung disease. Although immobility increases the risk of complications, ambulation of patients on VV ECMO is not the standard of care in many institutions. Staff concerns for patient safety remain a barrier to ambulation. In this case series, we present our experience utilizing a nurse-driven ambulatory VV ECMO process to safely rehabilitate patients. Methods: We retrospectively reviewed all VV ECMO cases at our institution between January 1, 2011, and November 1, 2013. Inclusion criteria for this study required patients to be cannulated in the right internal jugular vein and ambulated while on VV ECMO. Results: During the period from January 1, 2011, to November 1, 2013, 18 patients (mean age 49 ± 15 years, 12 male) were ambulated while on ECMO. Eight received a transplant and survived to discharge. Of the remaining patients, 4 were successfully weaned from VV ECMO and 6 died following decisions by the family to withdraw care. The mean duration of VV ECMO support was 18 ± 16 days with the maximum duration being 61 days. All patients received physical therapy, range of motion at the bedside, and ambulated in the hospital. There were no patient falls, decannulations, or any other complications related to ambulation. Conclusion: The adoption of a nurse-driven program to ambulate patients on VV ECMO is safe and may reduce other complications associated with immobility.

Renal Issues in Older Adults in Critical Care

Renal issues are among the most commonly encountered complications in the intensive care unit, increasing mortality, morbidity, and health care costs. Older adult patients face an increased risk because of several factors, including the normal effects of aging and a higher rate of comorbid conditions that may affect kidney function. This article describes the classification of renal dysfunction, the effects of aging on kidney function, as well as additional risk factors, management strategies, and outcomes in the older adult population.

Harlequin Syndrome as a Complication of Epidural Anesthesia

Harlequin syndrome is a rare neurological condition that results in unilateral facial flushing and sweating. Although the syndrome is generally a benign condition with complete resolution if appropriate treatment is initiated, unilateral facial flushing can be a sign of several serious conditions and should be thoroughly investigated. Sudden onset of facial flushing related to harlequin syndrome developed in a patient who had bilateral lung transplant with postoperative epidural anesthesia for pain control. Differential diagnosis includes neurovascular disease (acute stroke), malignant neoplasm of brain or lung, Horner syndrome, idiopathic hyperhidrosis, and Frey syndrome. Harlequin syndrome is often easily treated by discontinuing the anesthetic or adjusting placement of the epidural catheter.

Evaluation of a High-Fidelity Simulation Training Program for New Cardiothoracic Intensive Care Unit Nurses

The objective of this article is to evaluate the effect of a high-fidelity simulation training program on knowledge and confidence as part of a nursing internship in the cardiothoracic intensive care unit. Ten nurse interns each completed a simulation scenario involving common postoperative complications followed by a group debriefing session. Knowledge and confidence were assessed using a multiple-choice test and modified self-efficacy scale, respectively. Both were administered precourse and postcourse and again 2 weeks later. The simulation effectiveness tool, a 0-2 scale with higher scores indicating higher degree of perceived effectiveness, was used to evaluate participants׳ perceptions of the program. Paired t-tests compared precourse and postcourse scores as well as postcourse and follow-up scores for both knowledge and confidence. Spearman rho compared subjective with objective assessment of learning and improvement in learning with improvement in confidence. Mean knowledge scores improved from 48.18% (standard deviation [SD] = 14.7) to 60.9% (SD = 22.6; P < 0.05) and confidence scores improved from 20.8 (SD = 5.17) to 25.9 (SD = 3.3; P < 0.05), both with insignificant changes 2 weeks later. The simulation effectiveness tool mean score was 1.64 (SD = 0.56). There was no correlation between the objective and subjective learning assessments or between the improvement in learning and improvement in confidence. The inclusion of a high-fidelity simulation course showed improvement in both learning and confidence among the new graduate nurses; however, objective assessment of learning is needed. It is also important to note that an improvement in confidence may not indicate an improvement in actual ability.

Acute Ischemic Stroke

&NA; Acute ischemic stroke is a major cause of mortality and morbidity in the United States and worldwide. Despite the development of specialized stroke centers, mortality and morbidity as a result of acute ischemic strokes can and do happen anywhere. These strokes are emergency situations requiring immediate intervention. This article covers the fundamentals of care involved in treating patients with acute ischemic stroke, including essentials for the initial evaluation, basic neuroimaging, reperfusion therapies, critical care management, and palliative care, as well as current controversies. National guidelines and current research are presented, along with recommendations for implementation.