Introduction. N-acetylcysteine (NAC) is the antidote for acetaminophen (Tylenol) toxicity from over ingestion leading to 56,000 emergency room visits yearly. This is worrisome due to the risk of hepatoxicity, especially in children and adolescents. Often, nausea and vomiting are associated with NAC use and is treated acutely by ondansetron (Zofran), a 5-HT3 receptor antagonist. Inconveniently, the NAC 21-hour intravenous (IV) infusion needs to be halted with IV flushing before ondansetron can be administered. Another IV flushing follows before NAC is resumed. This causes treatment interruption in a medical emergency; therefore, we are investigating the IV compatibility of NAC and ondansetron to reduce the steps in treating acute nausea/vomiting. Methods. A reverse phase high-performance liquid chromatography (RP-HPLC) method was utilized for NAC quantification. The analysis was conducted on an Agilent Eclpise XDB-C18 column (3.5 micron, 4.6 x 150 mm) with a mobile phase containing acetonitrile (ACN), water (10:90 v/v), and 0.1 % trifluoroacetic acid (TFA). The flow rate was set at 0.500 mL/min with an injection volume of 10 microliters and a temperature of 50oC. A UV wavelength of 212 nm was utilized for detection of NAC. A liquid chromatography mass spectrometry (LC – MS/MS) method was able to quantify levels of ondansetron. A Waters XBridge C18 column (3.5 micron, 4.6 x 150 mm) was used for separation of ondansetron. The mobile phase included ammonium formate buffer (pH 3.0, 5 mM) and acetonitrile (15:85, v/v) with the flow rate set at 0.500 mL/min. Electrospray ionization interface is set in the positive mode for measurement of ondansetron using a precursor ion of m/z 294.0200. Results. The HPLC-UV and LC-MS/MS methods for NAC and ondansetron, respectively, will be validated for linearity, precision and accuracy. Then the methods will be applied toward a chemical compatibility investigation of NAC and ondansetron through medical grade tubing and y-site. The ideal outcome would be to confidently assume NAC and ondansetron are IV compatible for y-site administration to avoid infusion interruption for treatment of acetaminophen toxicity. Conclusion. IV compatibility for NAC and ondansetron affords no infusion interruptions reducing unnecessary risk of acetaminophen toxicity. This also decreases risk of medical errors based on the multi-step process to administer ondansetron with receiving NAC. Overall, compatibility could create safer, more efficient protocols for treatment of acute nausea/vomiting from NAC administration.

Acute and chronic cardiovascular comorbidities are common among critically ill individuals. It is unclear if current critical care fellowship trainees feel adequately prepared to manage these conditions. Design: Prospective, cross-sectional survey. Patients or Subjects: Trainees enrolled in U.S. critical care training programs. Setting: Accredited pulmonary/critical care, surgery/critical care, anesthesiology/critical care, and stand-alone critical care training programs. Interventions: None. Measurements and Main Results: A 19-item survey assessing trainee confidence in the management of cardiac critical illness and the performance of cardiac-specific critical care interventions was constructed using Accreditation Council for Graduate Medical Education recommendations as a reference. After validation, the survey was electronically sent to all training programs for dissemination to their trainees. Confidence scores were measured on a Likert scale from 1 to 5. A total of 134 completed surveys were analyzed. Overall, respondents reported lower confidence in managing cardiovascular compared with noncardiovascular diseases in the ICU (4.0 vs 4.6 out of 5). Likewise, they reported lower perceived competence in performing cardiovascular procedures specific to the ICU (2.9 vs 4.5 out of 5). The majority (88%) of those surveyed felt that they would benefit from increased didactic and clinical experience in the management of cardiovascular critical illness. Conclusions: Current critical care fellows may be unprepared to deal with the increasing prevalence of cardiovascular illness in the ICU. This potential educational gap warrants timely attention to ensure that future graduates have the requisite skills necessary to manage these critically ill patients and presents a unique opportunity to develop multidisciplinary partnerships for enhancing training.

Situation awareness and distributed situation awareness are important concepts in critical care, where large interdisciplinary teams must coordinate their activities through information sharing to provide lifesaving treatment to patients. Little is known, however, about how nurses contribute to distributed situation awareness in different types of intensive care settings. The purpose of this study was to explore information sharing by nurses in two intensive care units, with and without interdisciplinary rounds. The method of rapid qualitative inquiry was used, which emphasizes data triangulation and iterative data analysis. In each of two intensive care units studied, four RNs were observed for eight hours each, and the content and characteristics of information sharing were recorded. This was followed by chart reviews to determine the impact of information sharing by nurses on patient care. The results demonstrated that there was little difference in the type of information shared, the pattern of information sharing by nurses in the two units, and the impact that information sharing had on patient care. An important exception, however, was that nurses in the unit without interdisciplinary rounds contacted physicians twice as often as nurses in the unit with interdisciplinary rounds. The results were integrated into a revised model of distributed situation awareness. / Graduate

A thesis submitted to the Faculty of Commerce, Law and Management, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy. September 2018 / Intensive care is a small but complex system; context-specific and continually confronted by dynamic changes and challenges in the environment. Initiatives following the traditional reductionist approach to improve the delivery of intensive care has had limited success. The aim of this research was to develop a systemic framework for the improvement of intensive care delivery. The factors affecting the delivery of intensive care – in South Africa and internationally – were elucidated by a comprehensive review and analysis of intensive care literature. A further understanding of intensive care delivery in South Africa was obtained by “making sense of the mess” using a systems approach. Systemic intervention served as the meta-methodology and methods and techniques from interactive planning, critical systems heuristics, soft systems methodology and the viable system model were employed. Making sense of the mess emphasised the complexity of intensive care delivery, on both a situational and a cognitive level. It became clear that a single methodology would not suffice, but that a pluralist methodology was required to guide improvement in intensive care delivery. Based on this understanding, nine principles were formulated to guide the development of a framework for the improvement of intensive care delivery. Systemic intervention was used as the meta-methodology. Interactive planning was identified as the key methodology, incorporating methods and techniques from critical systems heuristics, soft system methodology and the viable system model to build a systemic framework for the improvement of intensive care delivery. Embedded in the proposed framework are matters relating to systemicity, complexity, flexibility, empowerment, and transformation of intensive care delivery. The proposed framework allows for multiple-perspectives, including that of marginalised stakeholders, the mitigation of multi-vested interests and power relationships. It is both flexible and adaptable to promote learning about the complex problems of intensive care delivery and it accommodates the strengths of various relevant approaches to complex problem solving. The proposed framework aims to facilitate sustainable improvement of intensive care delivery and to ensure the “just-use” of resources to foster distributive justice. It acknowledges the trajectory of intensive care delivery – the patient comes from the community and returns to the community and intensive care delivery functions on a continuum that ranges from basic to highly sophisticated. / E.K. 2019

Background: Delirium is common in critically ill trauma patients, yet there is no evidence-based standard of care sedation agent for this population. Objective: This thesis aims to expand knowledge around dexmedetomidine, a sedative that has demonstrated potential superiority in other clinical patient populations. Methods: We conducted a systematic review and network meta-analysis to compare the effectiveness of sedatives on delirium and associated patient outcomes. We conducted a health records review of sedated trauma patients at The Ottawa Hospital. We derived a simple mathematical model to demonstrate potential impact of dexmedetomidine on resources. Results: There was no statistical difference between sedatives in preventing delirium. Approximately 79% of critical trauma patients were sedated with propofol, 18% with propofol and dexmedetomidine, and 3 with dexmedetomidine. Increasing the proportion of patients receiving propofol with adjunct dexmedetomidine could improve the number of freed ICU bed-days. Conclusion: Dexmedetomidine could have potential benefits in improving outcomes for critically ill trauma patients.

Like your average morning alarm, hospital alarms are specifically designed to elicit cognitive distress via auditory stimulation. They sound continuously, beckoning hospital staff to investigate the source of their call, day and night. As a result, caregivers become desensitized and begin to ignore the seemingly constant stimulus. However, ignoring these pleas for help can lead to adverse patient outcomes as the true alarms are indistinguishable from the false. In this study, we will review literature from the last five years to examine how alarm fatigue in nurses leads to detrimental patient outcomes and how we can begin to reduce the incidence of alarm fatigue. For example, when telemetry leads are improperly applied or lose their adherence, they are more sensitive to patient movements and can cause alterations on the recorded cardiac strips, creating the illusion that a patient is having an arrhythmia when, in reality, the patient is fine. This phenomenon causes alarms to chime, requiring the nurse to rush into the room to check on the patient and turn off the alarm. This can occur multiple times a shift, causing the nurse to become overwhelmed, to ignore the alarm, or to become distracted from their other duties due to the constant alarm response. This situation can easily be avoided by proper preparation of skin at the attachment site and the replacement of leads and pulse oximeters with disposable versions that can be changed daily. The aim of this study is to provide a multifaceted approach to identify ways to reduce the amount of alarm fatigue in an acute care setting in order to improve patient outcomes and consequently increase both patient and nurse satisfaction.

Introduction — Hyperkalemia, defined as serum potassium >6.0mmol/L, affects ±6% of people with kidney disease and is a contraindication to surgery due to the perioperative risk of potentially fatal cardiac dysrhythmia (1,2,3). When emergency surgery cannot be avoided, hyperkalemia must be managed perioperatively using a variety of traditional practice patterns which vary in efficacy (3,4,5). We present a case report of successful rapid correction of hyperkalemia in a 67-year- old man with a history of chronic kidney disease who presented to the emergency department for acute compartment syndrome in need of emergent fasciotomy to prevent loss of limb. Methods — Since emergent treatment of hyperkalemia is often managed through a combination of medications with multiple mechanisms of action, we reviewed available related literature in PubMed in order to present this educational case report. Patient Presentation — At the time of presentation, our patient’s serum potassium was 7.7mmol/L, creatinine kinase was 33,160U/L, and an ECG revealed a first-degree AV node block with slight ST depression. Following intubation, as a team of surgeons started extensive fasciotomy of his arm, our anesthesia team gave several medications in tandem—calcium gluconate to stabilize cardiac myocytes and prevent ventricular arrythmia, coadministration of dextrose and insulin to induce an intracellular shift of potassium, sodium bicarbonate to induce cellular hydrogen/potassium exchange, and albuterol to increase cellular uptake of potassium via β2 adrenergic receptors (1,6). The patient’s hyperkalemia improved from 7.7 to 3.7 (normal 3.5 – 5.1mmol/L) over 4 hours. Discussion and Conclusion — Our review of available literature identified several methods of treatment of hyperkalemia, some with limitations to use which we believe support our team’s approach to treatment in this case report (6). Calcium salts are integral to the treatment of hyperkalemia by stabilizing cardiac myocytes, however they do not directly influence serum or total body potassium levels. Our report adds to a growing pool of existing case reports and small studies documenting safe, efficacious emergent treatment of hyperkalemia. It also describes the utility of the anesthesiologist in providing safe, effective perioperative medical care.

Purpose: Education of the novice critical care nurse has traditionally been conducted by critical care educators in face-to-face classes in an orientation or internship. A shortage of qualified educators and growth in electronic modes of course delivery has led organizations to explore electronic learning (e-learning) to provide orientation to critical care nursing concepts. Equivalence of e-learning versus traditional critical care orientation has not been studied. The primary aim of this study was to examine the equivalency of knowledge attainment in the cardiovascular module of the Essentials of Critical Care Orientation (ECCO) e-learning program to traditional face-to-face critical care orientation classes covering the same content. Additional aims were to determine if learning style is associated with a preference for type of learning method, and to determine any difference in learning satisfaction between the two modalities. Methods: The study was conducted using a two-group pretest-posttest experimental design. Forty-one practicing volunteer nurses with no current critical care experience living in southwest Florida were randomly assigned to either the ECCO (n=19) or face-to-face (n=22) group. Those in the face-to-face group attended 20 hours of classroom instruction taught by an expert educator. Those in the ECCO group completed the lessons on line and had an optional 2 hour face-to-face discussion component. Pre-test measures included the Basic Knowledge Assessment Test (BKAT-7), modified ECCO Cardiovascular (CV) Examination, and Kolb Learning Style Inventory (LSI). Post-tests included the BKAT-7, modified CV Examination, and Affective Measures Survey. Results: The majority of subjects were female, married, and educated at the associate degree level. Their mean age was 39.5 + 12 years, and they averaged 9.9 + 11.7 years of nursing experience. The diverging learning style was assessed in 37% of subjects. Classroom instruction was preferred by 61% of participants. No statistical differences were noted between groups on any demographic variables or baseline knowledge. Learning outcomes were compared by repeated measures analysis of variance. Mean scores of subjects in both groups increased statistically on both the BKAT-7 and modified CV Examination (p= < .01); however, no significant differences (p > .05) were found between groups. Preference for online versus classroom instruction was not associated with learning style (X2 = 3.39, p = .34). Satisfaction with learning modality was significantly greater for those in the classroom group (t=4.25, p=.000). Discussion/Implications: This is the first study to evaluate the ECCO orientation program and contributes to the growing body of knowledge exploring e-learning versus traditional education. The results of this study provide evidence that the ECCO critical care education produces learning outcomes at least equivalent to traditional classroom instruction, regardless of the learning style of the student. As participant satisfaction was more favorable toward the classroom learning modality, consideration should be given to providing blended learning if using computer-based orientation programs. Replication of this study with a variety of instructors in varied geographic locations, expanded populations, larger samples, and different subject matter is recommended.

No description available.

Critical illness can lead to profound physical morbidity that persists for years post-intensive care unit (ICU) discharge. Rehabilitation started in ICU can mitigate morbidity and improve outcomes, however, there are gaps in existing research. This thesis includes manuscripts addressing three areas: primary research reporting, patient-reported outcome measures (PROM), and research intervention implementation. The first manuscript was a scoping review of ICU rehabilitation interventions. Previous systematic reviews assessed the effectiveness of ICU rehabilitation to improve functional outcomes, and identified conflicting results and deficiencies in study reporting. I conducted a scoping review to describe the types, amounts, and reporting of rehabilitation interventions in ICU studies. I identified 117 prospective ICU rehabilitation studies from database inception to 2016 and assessed the completeness of study and intervention reporting using standardized reporting guidelines. Results identified adequate overall study reporting, however important reporting deficiencies in intervention and control groups, limiting future trial development and clinical implementation. The second manuscript evaluated the psychometrics of the Patient-Reported Functional Scale-ICU (PRFS-ICU) – a new PROM for ICU survivors in acute care. I demonstrated the PRFS-ICU was feasible, reliable, responsive, and valid in medical-surgical ICU patients able to follow commands. Results suggest the PRFS-ICU warrants future research and may be useful to assess and monitor patient perceptions of their functioning over time. The final manuscript was a self-administered electronic survey of frontline therapists, assessing barriers and facilitators to implementing a novel rehabilitation intervention in the context of research. Respondents implementing CYCLE, a trial of in-bed cycling with mechanically ventilated patients, identified two primary barriers to implementing the protocol: time required to conduct the protocol and concerns for provision of equitable service to all patients on their caseload. Together these manuscripts provide an important foundation to guide development, implementation, and evaluation of future ICU rehabilitation trials. / Thesis / Doctor of Philosophy (PhD) / Critical illness requiring intensive care unit (ICU) admission can lead to physical disability lasting years post-ICU. Exercises started in ICU can reduce disability. However there are important gaps in the research addressed by my thesis: 1) Summaries of studies found different results on the effects of exercise on disability, and details of exercises were sparse. I reviewed over 3 decades of exercise research for ICU patients and determined reporting must improve; 2) ICU patients had no standard way to report their own level of movement in hospital. I evaluated a measure, which may be useful to assess how patients think they are functioning; 3) ICU therapists reported challenges delivering exercises to patients in research studies. I conducted a survey and learned therapists needed more time to provide these exercises. My findings can inform future ICU exercise studies, assess how patients feel they are functioning, and optimize exercise delivery.