Gianfranco Sanson

Road traffic accidents with vehicular entrapment: incidence of major injuries and need for advanced life support.

Road traffic accidents (RTAs) with entrapment are perceived as a challenge to emergency systems because of the severity of the ensuing traumas and the inherent complexity of the rescue procedures. To clarify these two aspects this prospective cohort study enrolling 244 entrapped trauma patients was conducted by a Regional Medical Helicopter Service. Forty-six victims (18.9%) were found dead, 101 (51%) of the 198 patients who reached the hospital alive had an injury severity score (ISS) > or = 16. The use of seat belts was associated with lower trauma severity. Out of the 101 severely traumatized patients (ISS > or = 16), 46 (42.6%) were intubated at road side, 12 required decompression of a tension pneumothorax on the scene and in 15 cases a pneumothorax was drained during the early intrahospital phase. Thirty-six (34.7%) patients had the first systolic blood pressure (SBP) < or = 90 mmHg and were then aggressively infused: in 75% of these cases, the SBP on arrival at the emergency department increased. The first SBP was significantly correlated with mortality. There was no correlation of extrication time, total rescue time and mortality. Fourteen patients (13.9%) died during hospitalization. These data demonstrate that a high percentage of entrapped patients require advanced life support (ALS), including on scene intubation and chest decompression. Aggressive field resuscitation and immediate transport to a level 1 trauma centre is associated with a mortality lower than that predicted by TRISS in spite of the prolonged prehospital time.

Nursing diagnoses, outcomes and interventions as measures of patient complexity and nursing care requirement in Intensive Care Unit

AIMSnTo describe the nursing diagnoses, outcomes and interventions for patients admitted to intensive care units and to assess their possible relation with classical outcomes like length of stay and mortality.nnnBACKGROUNDnThe analysis of nursing diagnosis frequencies may help to estimate the patients complexity and the need for nursing interventions and can predict hospital outcomes. Nonetheless, few studies were conducted on critical patients.nnnDESIGNnProspective cohort observational study.nnnMETHODSnBetween 15 July-31 October 2013 we collected the above-described nursing parameters of 100 subjects throughout their stay in intensive care. We classified the parameters according to established taxonomies. The independent association between the number of nursing diagnoses and length of stay/mortality was investigated with multiple regressions.nnnRESULTSnWe found an average of 19 diagnoses, 24 outcomes and 60 interventions per patient. Most frequently, the plans of care involved support for self-care deficits or interrupted family processes. They also included strategies to prevent infection, disuse syndrome and impairment of skin integrity. Nineteen nursing diagnoses were significantly related with mortality or length of stay in bivariate analyses. In regression models, the number of such diagnoses explained 29·7% of the variance in length of stay and was an independent predictor of mortality.nnnCONCLUSIONnIn critically ill patients, the analysis of nursing diagnoses, outcomes and interventions confirmed an intense activity in response to a broad spectrum of patient needs. The number of nursing diagnoses allowed to predict patient outcomes.

Emergency medical service treated out-of-hospital cardiac arrest: Identification of weak links in the chain-of-survival through an epidemiological study

Background: In-depth analysis of emergency medical services (EMSs) performances in out-of-hospital cardiac arrest (OHCA) promotes quality improvement. Aims: The purpose of this study was to identify the improvable factors of the EMS response to OHCA through the description and analysis of OHCA incidence, characteristics, management and outcome. Methods: This was a retrospective cohort study on all OHCA patients treated by the EMSs of the district of Trieste, Italy (236,556 inhabitants) in 2011. Results: A total of 678 OHCAs occurred and 142 (20.1%) underwent cardiopulmonary resuscitation (CPR), with a respective incidence of 287/100,000/year and 60/100,000/year. The incidence of shockable rhythms in the CPR group was 13/100,000. OHCAs occurred mainly during daytime, though the proportion of patients receiving CPR was significantly higher by night-time (p=0.01). Thirty-four CPR patients (23.9%) restored spontaneous circulation on scene; 12 (8.5%) survived to hospital discharge (11 with good neurological recovery). Survival was not correlated with age, while was significantly higher for patients with shockable rhythms (32.3%; p<0.001). Mean response time was 8 min. Direct intervention of physician-staffed units did not improve the outcome when compared with two-tiered activation. Patients immediately identified as OHCA by dispatch nurses and those undergoing therapeutic hypothermia showed a non-significant trend towards improved survival (p=0.09 and 0.07, respectively). Conclusions: OHCA identification by dispatch nurses and reduction of response time were the factors most susceptible to improvement.

TETRAPARESIS AND FAILURE OF PACEMAKER CAPTURE INDUCED BY SEVERE HYPERKALEMIA: CASE REPORT AND SYSTEMATIC REVIEW OF AVAILABLE LITERATURE

BACKGROUNDnIn severe hyperkalemia, neurologic symptoms are described more rarely than cardiac manifestations. We report a clinical case; present a systematic review of available literature on secondary hyperkalemic paralysis (SHP); and also discuss pathogenesis, clinical effects, and therapeutic options.nnnCASE REPORTnA 75-year-old woman presented to the emergency department complaining of tetraparesis. Her serum potassium level was 11.4 mEq/L. Electrocardiogram (ECG) showed a pacemaker (PMK)-induced rhythm, with loss of atrial capture and wide QRS complexes. After emergency treatment to restore cell membrane potential threshold and lower serum potassium, neurologic and ECG signs completely disappeared. An acute myocardial infarction subsequently occurred, possibly linked to tachycardia induced by salbutamol therapy. We reviewed 99 articles (119 patients). Mean serum potassium was 8.8 mEq/L. In most cases, ECG showed the presence of tall T waves; loss of PMK atrial capture was documented in 5 patients. In 94 patients, flaccid paralysis was described and in 25, severe muscular weakness; in 65 patients, these findings were associated with other symptoms. Concurrent renal failure was often documented. The most frequent treatments were dialysis and infusion of insulin and glucose. Eighty-seven percent of patients had complete resolution of symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Severe hyperkalemia is always a life-threatening medical emergency, as it can precipitate fatal dysrhythmias and paralysis. SHP should be considered in the differential diagnosis of neurologic signs and symptoms of uncertain etiology, especially in a subject with kidney failure or who is taking medications that may worsen renal function. The presence of a PMK does not necessarily impede hyperkalemic cardiac toxicity.

Identifying reliable predictors of protein-energy malnutrition in hospitalized frail older adults. A prospective longitudinal study

BACKGROUNDnDecreased food intake is a risk factor for relevant complications (e.g. infections, pressure ulcers), longer hospital stays, higher readmission rates, greater health care costs and increased patient mortality, particularly in frail hospitalized older adults who are malnourished or at risk of malnutrition. Nurses are called to improve this criticality, starting from accurately identifying malnourished patients at hospital admission and effectively monitoring their food intake.nnnOBJECTIVESnThe primary aim was to identify reliable predictive indicators of reduced food intake at hospital admission. The secondary aims were to assess the adequacy of daily energy and protein intake and the impact of nutrient intake on patient outcomes.nnnDESIGNnProspective observational longitudinal study.nnnSETTINGnInternal Medicine Ward of an Academic Teaching University Hospital.nnnPARTICIPANTSnAcute older adults who were malnourished or at risk of malnutrition (Nutritional Risk Score-2002u202f≥u202f3, middle-upper arm circumferenceu2009<23.5u202fcm or impaired self-feeding ability) at admission.nnnMETHODSnThe effective energy and protein intake was monitored during the first 5u202fdays of hospital stay by a photographic method and compared to the daily energy and protein requirement calculated by specific equations. Data on anthropometry, inflammation/malnutrition laboratory data and body composition (phaseu202fangle calculated using bioelectrical impedance analysis) were collected.nnnRESULTSnEighty-one subjects (age 81.5u202f±u202f11.5u202fyears) were enrolled. Mean energy intake was 669.0u202f±u202f573.9u202fkcal/day, and mean protein intake was 30.7u202f±u202f25.8u202fg/day. Over 60% of patients ingestedu2009≤50% of their calculated energy and protein requirements: these patients were older (pu202f=u202f0.026), had a lower middle-upper arm circumference (pu202f=u202f0.022) and total arm area (pu202f=u202f0.038), a higher C-reactive protein/albumin ratio and Instant Nutritional Assessment score (pu202f<u202f0.01), and experienced longer hospital stays (pu202f≤u202f0.04) and higher in-hospital and 30-day post-discharge mortality (pu202f<u202f0.001). In the multivariate analysis, lower middle-upper arm circumference, higher C-reactive protein/albumin ratio, and impaired self-feeding at admission were independently associated with critically reduced energy and protein intake.nnnCONCLUSIONSnMiddle-upper arm circumference, C-reactive protein/albumin ratio, and impaired self-feeding are easily obtainable indicators of impaired energy and protein intake and poor clinical outcomes. Such parameters should be adopted as screening criteria to assess the risk for critically reduced energy/protein intake in hospitalized older adults. These findings are relevant to improve clinical practice through the implementation of multidisciplinary strategies, given the adverse clinical outcomes related to hospital malnutrition.

Ultrasound-guided deep-arm veins insertion of long peripheral catheters in patients with difficult venous access after cardiac surgery

Objectives To analyze success rate, dwell‐time, and complications of long peripheral venous catheters (L‐PVCs) inserted under ultrasound guidance. Background In difficult venous access (DVA) patients, L‐PVC can represent an alternative to central or midline catheters. Methods Prospective observational study. L‐PVCs were positioned in DVA patients. The outcome of the cannulation procedure and the times and reasons for catheters removal were analyzed. Results A 100% placement success rate was documented. The catheter dwell‐time was 14.7 ± 11.1 days. Most catheters were removed at end‐use in the absence of complications. The rate of catheters appropriately or inappropriately removed before completing the intravenous therapies was 27.7/1000 catheter‐days. Two thrombophlebitis (1.91/1000 catheter‐days) and 1 catheter‐related bloodstream infection (0.96/1000 catheter‐days) occurred. Conclusions L‐PVC could be a viable solution in DVA patients, as it may reduce the need for multiple vein punctures, patients discomfort, and nursing workload. A better adherence to catheter management recommendations should further reduce complications.

Longitudinal Responses to Weighing and Bathing Procedures in Preterm Infants

Knowledge of the effects of nursing-induced stress on short-term outcomes in preterm infants is limited. Effects of 2 standard nursing procedures—weighing and bathing—on autonomic and motor stability of preterm infants were studied during their hospitalization. Outcomes were evaluated during and after the procedures. Eleven preterm infants were observed between 32 and 35 weeks postmenstrual age (PMA) (postnatal days range: 4–63). Neonatal responses were assessed according to the Synactive Theory of Development and nursing was performed taking into account Newborn Individualized Developmental Care and Assessment Program (NIDCAP) principles. Effects of the studied nursing procedures on infants stability during and after their execution were evaluated by nonparametric statistics. During monitored procedures, stress responses in autonomic and motor systems were observed at all PMAs. However, after 32 weeks PMA, preterm infants also showed an autonomic and motor stability recovery 5 minutes after procedure completion. Contrary to our hypothesis, preterm infants showed to be stressed by weighing and bathing procedures up to 35 weeks PMA. However, if facilitated and supported after nursing conclusion by interventions such as swaddling and nesting, according to NIDCAP principles, they recovered autonomic and motor stability by 5 minutes after ending procedures.

Tunnelling a midline catheter: When the traffic light shifts from yellow to green:

Introduction: A safe, largely used practice for difficult venous access patients is positioning a catheter in deeper veins under ultrasound guide. However, the risk of complications is increased when there is a high catheter-to-vein ratio or when the insertion site is in a zone with particular anatomical/physiological characteristics. Case description: A 60-year-old woman admitted to a post-operative intensive care unit after cardiac surgery had a complicated post-operative course. After the removal of a central venous catheter, it was necessary to insert a midline catheter. A complete ultrasound evaluation showed that only the axillary vein was suitable for direct cannulation. To avoid creating an exit site in the axillary cavity, the decision was made to tunnel the catheter to locate an exit site in a safer position. A guidewire was introduced through a needle in the axillary vein. A tunnel was created using a subcutaneous injection of lidocaine. A 14u2009G/13.3u2009cm peripheral venous catheter was inserted in the subcutaneous tract. A 4u2009Fr/20u2009cm catheter was introduced through the peripheral venous catheter and moved to the axillary vein through the previously inserted sheath. No acute complications occurred. The catheter was accessed several times a day during the period following its insertion to infuse drugs and take blood samples. It was removed 50u2009days after its placement because it was no longer needed. No symptomatic thrombosis or infections occurred. Conclusion: The placement of the tunnelled midline catheter is shown to be a safe and effective way to ensure vascular access for almost 2u2009months.

Prevalence, Defining Characteristics, and Related Factors of the Nursing Diagnosis of Anxiety in Hospitalized Medical‐Surgical Patients

PURPOSEnTo document the prevalence of the nursing diagnosis of anxiety in hospital patients, based on its level of severity, defining characteristics (DCs), and other related factors, and to identify the key DCs that serve as predictors of clinically significant anxiety (CSA).nnnDESIGNnCross-sectional study. We enrolled 116 consecutive adult patients hospitalized from October 10 to 16, 2016, in medical-surgical wards within the first 48 hr of admission.nnnMETHODSnThe potential DCs and related factors of anxiety were collected based on the NANDA International terminology. Anxiety was considered clinically significant when presenting at moderate, severe, or panic level. The differences in DC prevalence among patients having or not having CSA were analyzed by unpaired students t-test. Multivariate analysis was used to examine the independent association between the DCs and CSA.nnnFINDINGSnThe prevalence of CSA was 36.2% and was significantly higher in patients who were older, female, and taking anxiolytic drugs, and among those who had cancer. The most frequent related factor for CSA was major change in health status. In the logistic regression, the presence of the DCs helplessness, altered attention or concentration, and anguish independently increased the odds of having CSA, whereas subjects presenting with Diminished ability to problem-solve had about a 96% reduction in the likelihood to suffer from such a condition.nnnCONCLUSIONSnA high prevalence of CSA among medical-surgical patients was shown. Furthermore, a critical cluster of DCs useful to identify CSA was found.nnnCLINICAL RELEVANCEnThe ability to accurately diagnose CSA should help prescribe and deliver the appropriate nursing interventions.

Delirium after cardiac surgery. Incidence, phenotypes, predisposing and precipitating risk factors, and effects

Background: In cardiac surgical patients little is known about different phenotypes of delirium and how the symptoms fluctuate over time. Objectives: Evaluate risk factors, incidence, fluctuations, phenotypic characteristics and impact on patients outcomes of delirium. Methods: Prospective longitudinal study. In postoperative intensive care unit 199 patient were assessed three‐times a day through an adapted versions of the Intensive Care Delirium Screening Checklist. Results: Delirium and subsyndromal delirium incidence were 30.7% and 31.2%, respectively. Delirium manifested mostly in the hypoactive form and showed a fluctuating trend for several days. Atrial fibrillation, benzodiazepine/opioids dosages, hearing impairment, extracorporeal circulation length, SAPS‐II and mean arterial pressure were independent predictors for delirium. Delirium was a statistically significant predictor of chemical/physical restraint use and hospital length of stay. Conclusions: Given the fluctuating and phenotypic characteristics, delirium screening should be a systematic/intentional activity. Multidisciplinary prevention strategies should be implemented to identify and treat the modifiable risk factors.