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Clinical Rounds

doi: 10.1097/01.NURSE.0000527612.78204.e1
Department: CLINICAL ROUNDS
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CARDIOPULMONARY RESUSCITATION

AHA releases updated guidelines

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The American Heart Association (AHA) has published focused updates to its 2015 adult and pediatric guidelines for CPR and emergency cardiovascular care. New recommendations include the following:

  • When dispatchers' instructions are needed, dispatchers should provide chest compression-only CPR instructions to bystanders assisting adults with suspected out-of-hospital cardiac arrest.
  • In children under age 18, CPR with chest compressions and rescue breaths is recommended over chest compression-only CPR. Studies showed worse 30-day outcomes or no difference in outcomes for children who received chest compression-only CPR over CPR with rescue breaths. However, if bystanders can't or won't deliver rescue breaths to infants or children, they should be instructed to provide chest compressions.

Sources: Kleinman ME, Goldberger ZD, Rea T, et al. 2017 American Heart Association Focused Update on Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. [e-pub Nov. 6, 2017]. Atkins DL, de Caen AR, Berger S, et al. 2017 American Heart Association Focused Update on Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. [e-pub Nov. 6, 2017].

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CARDIOLOGY

PCI doesn't promote exercise tolerance

Percutaneous coronary intervention (PCI) is commonly used for symptomatic relief in patients with stable angina, but its efficacy for this indication hasn't been established. Now, a blinded, placebo-controlled randomized trial comparing PCI with placebo for angina relief has called PCI's efficacy for symptom relief into question. The study involved 200 patients with ischemic symptoms and severe (≥70%) single-vessel coronary artery stenosis at five different sites in the United Kingdom. All patients received 6 weeks of medication optimization before completing cardiopulmonary exercise testing, symptom questionnaires, and dobutamine stress echocardiography. Patients were then randomly assigned to undergo PCI (N = 105) or placebo procedure (N = 95). The previously completed assessments were repeated 6 weeks after PCI or placebo procedures took place. The primary end point was the difference in exercise increment between the two groups.

Study results showed no significant difference in the exercise time increment between the PCI and placebo groups. Researchers concluded that PCI didn't increase a patient's exercise time by more than the effect of a placebo procedure.

Because PCI is an invasive procedure that can cause serious complications and even death, study authors recommend revising guidelines to reserve PCI for patients who are experiencing a myocardial infarction.

Source: Al-Lamee R, Thompson D, Dehbi HM, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet. [e-pub Nov. 1, 2017].

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OPIOID EPIDEMIC

Protection from fentanyl exposure

Because of the current opioid epidemic, first responders face risks from potential exposure to fentanyl. Issued by a Federal Interagency Working Group coordinated by the White House National Security Council, Fentanyl Safety Recommendations for First Responders includes evidence-based instructions for law enforcement, fire, rescue, and emergency medical services personnel, and other first responders. For example, personal protective equipment is recommended as effective protection from exposure to fentanyl and fentanyl analogues by inhalation or incidental skin contact. If incidental skin exposure occurs, first responders are advised to promptly wash the skin with cool water and soap, if available, but warned against using a hand sanitizer, which may enhance skin absorption. First responders should suspect fentanyl intoxication if they or a colleague experiences hypoventilation or apnea, drowsiness or unresponsiveness, and constricted or pinpoint pupils, and administer naloxone as per department and basic life support protocols as indicated.

The recommendations are provided in an easy-to-read format that can be posted in appropriate areas for quick reference.

Source: Fentanyl Safety Recommendations for First Responders. https://www.whitehouse.gov/ondcp/key-issues/fentanyl.

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PATIENT TURNING

Wireless monitoring improves compliance

Modern devices designed to help clinicians remember when to turn patients, such as turn clocks and timers, haven't resulted in high turning compliance and don't account for patients' self-turns. A new wireless sensor system may help clinicians significantly increase the frequency of patient turns, reducing the risk of pressure injuries.

In a pilot study, researchers sought to determine if continual patient position monitoring, taking into account self-turns and clinician-assisted turns, would increase the percentage of time a patient's position changed at least every 2 hours. They collected data from a 39-bed medical unit in a community hospital from May 2013 to February 2014 (N = 7,854 hours of monitoring). Patient turning data, including self-turns, were recorded via a small disposable sensor attached to the patient's chest. Patient position information was wirelessly displayed on computer monitors in the nurses' station, telling nursing staff when a patient needed to be turned.

Results of this study showed a significant increase in patients being turned every 2 hours. Before the study, 64% of patients were being turned appropriately; after this intervention, 98% of patients were turned every 2 hours. Eighty-seven percent of the nursing staff said they found the patient monitoring system helpful in a poststudy questionnaire.

Sources: Schutt SC, Tarver C, Pezzani M. Pilot study: assessing the effect of continual position monitoring technology on compliance with patient turning protocols. Nursing Open. [e-pub Oct. 26, 2017]. Wireless system prompts turning patients at risk for bedsores. MDLinx. Nov. 10, 2017.

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C. DIFFICILE INFECTION

FMT found to be safe for older adults

Although fecal microbiota transplantation (FMT) is being prescribed to treat recurrent Clostridium difficile infection (CDI), its safety and efficacy in older adults and seriously ill patients with multiple comorbidities hasn't been well studied. To compare FMT with conventional therapy, researchers studied two groups of patients with recurrent CDI at two Israeli medical centers between 2012 and 2016. Eleven patients were treated with FMT and 23 received conventional therapy. The mean age of patients was 82. All patients had a high comorbidity index. The primary end points were CDI recurrence, length of hospitalization, and short-term survival.

Ten of 11 (90%) patients in the FMT group showed clinical improvement after treatment, compared with 9 of 23 (39%) in the control group. Survival at 2 months was about the same in the two groups, but mean survival was higher in the FMT group.

Notably, two patients in the FMT group experienced significant adverse reactions related to suspected aspiration occurring during gastroscopy administration. The researchers concluded, “FMT is effective for elderly and very ill patients. Safety is a concern, but is rare even in patients with much comorbidity. Colonoscopy may be the preferred route of FMT infusion.”

Source: Freidman-Korn T, Livosky DM, Maharshak N, et al. Fecal transplantation for treatment of Clostridium difficile infection in elderly and debilitated patients. Dig Dis Sci. [e-pub Nov. 13, 2017].

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In January, celebrate

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ORGAN DONATION

Older lungs work well in younger patients

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Transplanting more lungs from older donors into younger recipients would expand the donor transplant pool, but prior research on survival rates for younger patients receiving older lungs has had mixed results. In a large retrospective study, researchers evaluated the use of “advanced age” donors (age 60 or older) and single versus double lung transplantation on posttransplant survival. Using a United Network for Organ Sharing database, they examined 14,222 lung transplants performed between January 2005 and June 2014. Patients were stratified by recipient ages 18 to 50, donor age 60 or older, and single versus double lung transplantation. They found that the 5-year survival rate for patients receiving older lungs was similar to the survival rate for patients receiving younger lungs. However, younger patients receiving older lungs had better outcomes when they received a double lung transplant versus a single lung transplant. Examining outcomes for all recipients of a double transplant, researchers found that the donor's age had no significant impact on survival.

The researchers concluded, “Reasonable posttransplant outcomes can be achieved with use of advanced age donors in all recipient groups,” but they recommend that patients age 50 or younger who are receiving advanced age lungs should undergo a double transplant.

Source: Whited WM, Henley P, Schumer EM, Trivedi JR, van Berkel VH, Fox MP. Does donor age and double versus single lung transplant affect survival of young recipients? Ann Thorac Surg. [e-pub Oct. 30, 2017].

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DIABETES TREATMENT

Hyperbaric oxygen therapy is effective alternative

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New research shows that hyperbaric oxygen therapy (HBOT) is comparable to standard diabetic foot ulcer therapy in many variables (healed ulcer rate, amputation risk, adverse events) and results in a greater reduction in wound area.

HBOT has been used for decades as an alternative treatment for chronic diabetic foot ulcers, but previous small clinical trials have left its efficacy and advantages in doubt. Standard therapies for diabetic foot ulcers are pressure reduction, necrotic tissue debridement, moist dressings, and antibiotics. By delivering more oxygen to the wound, HBOT may enhance therapy by reducing ischemia, stimulating wound repair, triggering release of bone marrow stem cells, and enhancing host antimicrobial responses.

Researchers conducted a meta-analysis of nine randomized clinical trials involving a total of 526 patients who received either HBOT or standard therapy. While no large difference was found between the treatment types regarding healed ulcers, amputations, or adverse events, HBOT was associated with a greater reduction in the ulcer wound area compared with standard therapy. Study authors say this means HBOT should be considered as a therapy option for patients with diabetic foot ulcers, although more study is needed.

Sources: Zhao D, Luo S, Xu W, Hu J, Lin S, Wang N. Efficacy and safety of hyperbaric oxygen therapy used in patients with diabetic foot: a meta-analysis of randomized clinical trials. Clin Ther. 2017;39(10):2088-2094.e2. Hyperbaric oxygen therapy is as effective as standard care for diabetic foot ulcers. MDLinx. Oct. 27, 2017.

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