Cheryl A. Lefaiver

Comparison of two pain scales for the assessment of pain in the ventilated adult patient.

The assessment of pain experienced by the patient requiring mechanical ventilation can be a challenge for critical care nurses. This study was conducted to assess the reliability and validity of two pain behavior assessment tools. Patients who met the inclusion criteria were enrolled from 13 critical care units and one long-term acute care unit within eight hospitals. A total of 200 patients were assessed over an 8-week period. The findings suggest that both tools have adequate reliability and validity. Use of a pain behavior tool is one strategy to improve assessment of pain experienced by the mechanically ventilated adult patient who is unable to provide a self-report.

Using evidence to improve care for the vulnerable neonatal population.

The facilitation of evidence-based practice (EBP) in the clinical setting is important to ensure patients receive the best care possible. This article highlights changes in open visitation and feeding readiness practices that occurred in a Magnet-designated facility neonatal ICU. The examples demonstrate ways to bring evidence to the bedside within an environment that supports EBP at all levels of nursing leadership.

Pilot study evaluates nutrition for patients receiving mechanical circulatory support in the intensive care unit.

Establishing a nutrition protocol with an accompanying algorithm allows a multidisciplinary team to make decisions to maintain or improve nutrition-related outcomes during the intensive care unit (ICU) stay. This descriptive pilot study included subjects (N = 11) recruited from a convenient sample of patients admitted for surgical implantation of a mechanical circulatory support device. Nutritional and strength measures were compared across 3 time intervals: preoperatively, postoperative day 3, and within 48 hours of transfer from ICU. The mean age of the sample was 60 ± 8 years. Overall, subjects maintained preoperative nutritional status demonstrated by a nonsignificant change in the nutritional and strength measures from the preoperative period compared to transfer from ICU. The nutrition protocol with algorithm provided a step-by-step approach to ensure a consistent nutritional plan of care. It also standardized nutritional care while ensuring safe practice.

Intermittent Versus Continuous and Intermittent Medications for Pain and Sedation After Pediatric Cardiothoracic Surgery; A Randomized Controlled Trial*

Objectives: Compare continuous infusions of morphine and midazolam in addition to intermittent doses with an intermittent only strategy for pain and sedation after pediatric cardiac surgery. Design: Randomized controlled trial. Setting: Advocate Children’s Hospital, Oak Lawn, IL. Patients: Sixty patients 3 months to 4 years old with early extubation after pediatric cardiac surgery. Interventions: Patients received a continuous infusion of morphine and midazolam or placebo for 24 hours. Both groups received intermittent morphine and midazolam doses as needed. Measurements and Main Results: Gender, age, bypass time, and surgical complexity were not different between groups. Scheduled ketorolac and acetaminophen were used in both groups and were not associated with adverse events. The mean, median, and maximum Faces, Legs, Activity, Cry, And Consolability score were not different between groups. There was no significant difference in number of intermittent doses received between groups. The total morphine dose was higher in the continuous/intermittent group (0.90 vs 0.23 mg/kg; p < 0.01). The total midazolam dose was also higher in the continuous/intermittent group (0.90 vs 0.18 mg/kg; p < 0.01). The hospital length of stay was longer in the continuous/intermittent group (8.4 vs 4.9 d; p = 0.04). Conclusions: Pain was not better controlled with the addition of continuous infusions of morphine and midazolam when compared with intermittent dosing only. Use of continuous infusions resulted in a significantly higher total dosage of these medications and a longer length of stay.

Tissue Motion Annular Displacement Predicts Mortality/Transplant After the Bidirectional Glenn:

Background: Quantifying right ventricular function in patients with a systemic right ventricle (RV) is difficult but important for prognosis. Tissue motion annular displacement tracks displacement of the tricuspid annulus toward the apex. We evaluated this measure alongside fractional area change (FAC) on patients with single, RV prior to the bidirectional Glenn procedure. We tested both measures for correlation with outcomes. Methods: Retrospective measurement of tissue motion annular displacement and FAC was performed on echocardiographic clips obtained prior to the bidirectional Glenn. A chart review included postoperative outcomes and midterm mortality/transplant. Bivariate correlations and Cox proportional hazards models were used for analyses. Results: Fifty-one patients with dominant RV underwent the bidirectional Glenn procedure and all had image quality that allowed analysis. The age ranged from 3 to 11 months (median 4 months). Neither tissue motion annular displacement nor FAC correlated with short-term postoperative outcomes. Tissue motion annular displacement was independently predictive of mortality/transplant (P = .03) in the Cox hazard model. The mean for survivors was 12.4% and for nonsurvivors/transplants was 10.0%. Tissue motion annular displacement intra-observer variability was 2.8% (1.2%-3.5%). Interobserver mean variability was 6.1% (3.3%-8.1%). Fractional area change was not predictive of mortality/transplant. Conclusion: Tissue motion annular displacement is an independent predictor of midterm mortality/transplant after the bidirectional Glenn procedure in patients with single, RV, in this study. It may outperform FAC in this regard and has good reproducibility. Tissue motion annular displacement may be a useful measure in identifying high-risk children in this population.

Right Ventricular Longitudinal Shortening Before and After Stage I Surgical Palliation Correlates with Outcomes

Quantification of right ventricular function is difficult, but important, in patients with single ventricles. Tissue motion annular displacement (TMAD) is an echocardiographic tool that measures displacement of the tricuspid valve relative to the apex. We evaluated TMAD, lateral annular displacement (LAD), and fractional area change (FAC) for correlation with outcomes. We measured TMAD, LAD, FAC, and other variables that may affect prognosis in patients with single right ventricle physiology pre- and post-Stage I palliation and correlated them with outcomes up to the Glenn procedure. Intra- and inter-observer variability for TMAD measurements were 2.7% (1.2–3.5%) and 6.1% (3.3–8.1%), respectively. Sixty-six subjects met the inclusion criteria. Pre-Stage I TMAD was 13.7% (SD 3.9%). TMAD had a linear relationship with FAC (r2 = 0.76). There was a correlation between TMAD and hospital stay (p = 0.044) and ECMO/arrest (p = 0.024). LAD correlated with ECMO/arrest (p = 0.045) and mortality/transplant (p = 0.049). FAC correlated with in-hospital mortality (p = 0.028). Post-Stage I TMAD was 11.8% (SD 3.7%). TMAD, LAD, and FAC all correlated with in-hospital mortality and mortality/transplant. In multivariate models, TMAD was independently predictive of weight for age Z score pre-Glenn. TMAD, FAC, and LAD correlate with clinically significant outcomes after the first-stage palliation. TMAD correlated with more outcomes than FAC and was the only measure that was independently predictive of any outcome. TMAD is a reproducible measure of RV function in this population. TMAD has prognostic value before and after first-stage palliation and may outperform more traditional measures.

Immunologist’s Perspectives on Assessment and Management of Lung Disease in CVID: a Survey of the Membership of the Clinical Immunology Society and the European Society for Immunodeficiencies

Over 350 primary immunodeficiency diseases are currently recognized. Other than selective IgA deficiency, common variable immunodeficiency (CVID) is the most common primary immunodeficiency disease [1]. The prevalence of CVID is estimated to be one in 25,000, but this is at best an educated guess. An International Consensus Document (ICON) [2] has proposed a revised definition for CVID and compared it with the previously published criteria suggested by Ameratunga et al. [3]. The usual practice is to use simpler criteria proposed by the European Society of Immune Deficiency Disorders (ESID) and Pan-American Group for Immunodeficiency (PAGID) [4]. Recurrent bacterial infections are a hallmark of CVID, the most common of which are sino-pulmonary infections. These may result in a chronic and progressive bronchiectasis. Patients with CVID are also prone to developing interstitial lung disease (ILD) (some with non-caseating granulomas) or ILD, and bronchiectasis may be present in the same patient [1]. According to the 2012 Immune Deficiency Foundation’s (IDF) National Patient Survey, [5] 27% of patients with CVID reported a permanent loss of lung function. It is likely that the loss of lung function plays an important part in the health of patients with CVID. Whereas 90% of all respondents to the 2011 U.S. Population National Health Interview Survey assessed their health status as Bgood or better,^ only 52% of the patients with lung disease and CVID in the 2012 IDF survey reported their health as good or better (p < 0.01) [6]. Currently, there exist no guidelines or best practices related to the assessment and management of lung disease in patients with CVID. However, pulmonary experts have established recommendations for managing non-cystic fibrosis (CF) bronchiectasis [7]. These recommendations may be applicable to CVID patients with bronchiectasis. Similarly, there are broad guidelines for managing idiopathic ILD and sarcoidosis with non-caseating granulomas as their hallmark [8, 9]. However, the medications currently recommended for these conditions may not be appropriate for ILD with or without non-caseating granulomas seen in CVID. The objective of this study was to characterize physicians’ practices related to the management of lung disease in CVID and to describe usual practices for follow up labs and medical visits. An examination of current practices related to the management of lung disease in patients with CVID is an important first step in the creation of guidelines that will aid the clinician in optimizing health outcomes for these patients. This may lead to evidence and experienced based guidelines for the management of lung disease in patients with CVID.