American journal of critical care : an official publication, American Association of Critical-Care Nurses
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Review Case Reports
Cardiogenic oscillation and ventilator autotriggering in brain-dead patients: a case series.
Brain death is manifested by a flaccid, areflexic patient on assessment of brain function with fixed and dilated pupils at midpoint, loss of consciousness, no response to stimulation, loss of brainstem reflexes, and apnea. A lesion or clinical state responsible for the loss of consciousness must be found. An integral part of clinical evaluation of brain death is apnea testing, which indicates complete loss of brainstem function and respiratory drive. ⋯ Also, chest wall and precordial movements may mimic intrinsic respiratory drive. Ventilator autotriggering may delay determination of brain death, prolong the intensive care unit experience for patients and their families, increase costs, risk loss of donor organs, and confuse staff and family members. A detailed literature review and 3 cases of cardiogenic ventilator autotriggering are presented as examples of this phenomenon and highlight the value of close multidisciplinary clinical evaluation and examination of ventilator pressure and flow waveforms.
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Although enrolling a sufficient number of participants is a challenge for any multisite clinical trial, recruiting patients who are critically ill and receiving mechanical ventilatory support presents additional challenges because of the severity of the patients' illness and the impediments to their communication. Recruitment challenges related to the research sites, nursing staff, and research participants faced in the first 2 years of a 4-year multisite clinical trial of a patient-directed music intervention for managing anxiety in the intensive care unit were determined. Strategies to overcome these challenges, and thereby increase enrollment, were devised. ⋯ Other strategies, such as obtaining a waiver for a participant's signature, were instituted across all participating sites. Through implementation of these various strategies, the mean monthly enrollment of participants increased by 50%. Investigators are advised to plan well in advance of starting recruitment for a clinical trial based in an intensive care unit, anticipate peaks and valleys in recruitment, and be proactive in addressing issues creatively as the issues arise.
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Data on likely postdischarge outcomes are important for decision making about chronically critically ill patients. It seems reasonable to categorize outcomes into "better" or overall desirable states and "worse" or generally undesirable states. Survival, being at home, and being cognitively intact are commonly identified as important to quality of life and thus may be combined to describe composite outcome states. ⋯ Need for mechanical ventilatory support and persistent cognitive impairment at discharge were associated with worse outcomes 4 months after discharge.
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In August 2008, the American Association of Critical-Care Nurses' (AACN's) Evidence-Based Practice Resource Work Group met to review current AACN Practice Alerts and to identify new Practice Alerts to be created. The work group was also tasked with reassessment of the grading system used by AACN that evaluates evidence associated with the Practice Alerts and other AACN resources. This article details the effort of this national volunteer work group, specifically highlighting the development of the new AACN evidence-leveling hierarchy system.