Carol Diane Epstein

Comparison of methods of measurements of oxygen consumption in mechanically ventilated patients with multiple trauma: the Fick method versus indirect calorimetry.

Objective: The purpose of this study was to compare the measurements of whole body oxygen consumption determined by the Fick method and by indirect calorimetry in mechanically ventilated patients with multiple trauma. Design: A prospective, correlational, within‐subjects design. Setting: Surgical intensive care unit of a Level I trauma center. Patients: Thirty‐eight mechanically ventilated adults with multiple injuries who received a pulmonary artery catheter within 24 hrs of admission to the surgical intensive care unit. Measurements and Main Results: After the initial resuscitation, simultaneous measurements of oxygen consumption (&OV0312;O2) by the reverse Fick equation and by indirect calorimetry were performed every 6 hrs for 24 hrs in normothermic patients who were at rest for at least 30 mins. At each measurement period, the mean &OV0312;O2 values determined by indirect calorimetry were significantly greater than the mean &OV0312;O2 values determined by the Fick method (time 1: 172 ± 38 vs. 125 ± 47 mL/min/m2, p < .0001; time 2: 170 ± 31 vs. 130 ± 48 mL/min/m2, p < .0001; time 3: 170 ± 32 vs. 132 ± 53 mL/min/m2, p < .0001; time 4: 169 ± 29 vs. 130 ± 60 mL/min/m2, p < .0002). By using the Bland and Altman technique, the mean bias was 41 ± 3.95 mL/min/m2. Correlation coefficients of &OV0312;O2 values between methods of measurements were statistically significant (r2 = .32, p = .0001; r2 = .32, p = .0001; r2 = .33, p = .0001; r2 = .18, p = .0001). Conclusions: Indirect calorimetry should be the preferred standard for measurement of oxygen consumption in severely injured patients.

Oxygen consumption in the early postinjury period: use of continuous, on-line indirect calorimetry.

Objective: To determine the patterns of oxygen consumption (&OV0312;O2) using indirect calorimetry (IC) for the first 24 hrs after serious blunt traumatic injury. Design: Prospective, observational study. Setting: Surgical intensive care unit of a Level 1 trauma center. Patients: Sixty‐six mechanically ventilated patients with blunt traumatic injury and Injury Severity Score >15. Interventions: IC for 24 hrs postinjury. Patients were resuscitated to standard parameters of perfusion. Measurements and Main Results: Mean patient age was 50.1 ± 18.7 yrs with a mean Injury Severity Score 30.7 ± 11.3). Mean &OV0312;O2 for all patients for the 24‐hr study period was 168.5 ± 29.5 mL/min/m2. The level of &OV0312;O2 was not related to Injury Severity Score, the number or combination of organ systems injured, or to the use of vasoactive agents. Patients >65 yrs of age had significantly lower &OV0312;O2 (p = .0038) compared with patients ≤50 yrs. &OV0312;O2 did not change over time after resuscitation to normal parameters of perfusion. Mean &OV0312;O2 was 156.5 ± 63.2 mL/min/m2 in patients who developed multiple organ dysfunction, and 172.4 ± 33.3 mL/min/m2 in those who did not develop multiple organ dysfunction (p = .16). Conclusions: Seriously injured patients are hypermetabolic in the early postinjury period. The level of &OV0312;O2 is unrelated to injury severity or number of organ systems involved. Elderly patients can be expected to have lower levels of &OV0312;O2. &OV0312;O2 does not change significantly in response to resuscitation to normal parameters of perfusion. &OV0312;O2 measured by IC did not predict the development of multiple organ dysfunction.

Lights! Camera! Action!: video projects in the classroom.

We report on two classroom video projects intended to promote active student involvement in their classroom experience during a year-long medical-surgical nursing course. We implemented two types of projects, Nursing Grand Rounds and FPBTV. The projects are templates that can be applied to any nursing specialty and can be implemented without the use of video technology. During the course of several years, both projects have proven effective in encouraging students to promote pattern recognition of characteristic features of common illnesses, to develop teamwork strategies, and to practice their presentation skills in a safe environment among their peers. The projects appealed to students because they increased retention of information and immersed students in the experience of becoming experts about an illness or a family of medications. These projects have enabled students to become engaged and invested in their own learning in the classroom.

Changing interpretations of angina pectoris associated with transient myocardial ischemia.

Silent ischemia associated with transient myocardial ischemia is currently recognized in the medical literature as a critical physiologic event that may occur in the absence of angina pectoris. A changing view of the clinical significance of angina pectoris as a reliable marker of myocardial ischemia is presented as a phenomenon of concern to nursing that carries implications for patient assessment, nursing interventions, and effectiveness of the nursing care.

Adrenocortical Insufficiency in the Critically Ill Patient

The fluid and electrolyte imbalances associated with adrenocortical failure affect multiple physiologic systems in the critically ill patient. Because of its widespread effect, the objective signs of adrenocortical failure may escape recognition. In the context of shock states affecting the function of multiple organs that have been previously diagnosed, empirical evidence suggesting the presence of adrenal insufficiency may be attributed to the primary diagnosis and illness. However, it is most important that critical care nurses question whether adequate adrenal function is present. When effective patient assessment and management are standard components of care, adrenocortical dysfunction may be reversed, while failure to assess for signs of adrenal insufficiency may lead to irreversible patient outcomes. This paper describes phenomena of adrenocortical failure in critically ill patients and presents the problems of fluid and electrolyte imbalance that accompany them.

Fluid volume deficit for the adrenal crisis patient.

Recognition of fluid volume deficit as the critical nursing diagnosis for a trauma victim with primary adrenal insufficiency maximizes the patients chances for optimal recovery and prevents irreversible, life-threatening sequelae during adrenal crisis. The nurse is a key health care professional in the recognition, prevention, and treatment of this nursing diagnosis for patients with adrenal insufficiency. A case analysis demonstrates the defining characteristics of fluid volume deficit and the rationale for nursing interventions. The controversial use of military anti-shock trousers will also be discussed.