American Journal of Critical Care. 2007;16: 535
Copyright © 2007 by the American Association of Critical-Care Nurses.
Clinical Pearls
By
Mary Jo Grap, RN, PhD, ACNP, Section Editor.
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Animals and Heart Failure Patients
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Animal lovers probably don’t need to be told about the benefits of pet ownership, but Cole and colleagues show that even a short (12-minute) interaction with a dog can reduce cardiopulmonary pressures, neurohormones, and anxiety in patients with advanced heart failure. Do you allow pets in your ICU? Do you have a pet protocol? Consider the following:
- Animal therapy can reduce patients’ blood pressure, heart rate, and fear of procedures.
- In several clinical studies, animal therapy programs did not increase patients’ infection rates.
- A recent article describes the habits of Oscar the Cat in identifying the end of life and providing companionship to those who would otherwise have died alone (
Dosa DM. A day in the life of Oscar the cat. N Engl J Med. 2007;357[4]:328–329)[Free Full Text]
.
See Article, pp 575–588
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Insulin Protocols and Tight Glycemic Control
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Hyperglycemia in the critically ill results in adverse outcomes, so tight glycemic control protocols are regularly used to maintain patients’ blood glucose at optimum levels. Although "tight" glucose control (80–110 mg/dL) reduces morbidity and mortality in the critically ill, consistent achievement of this target may be difficult, time consuming, and increase the frequency of hypoglycemia.
Malesker and colleagues and Oeyen and colleagues evaluated insulin protocols. Here’s what they found:
- Malesker et al evaluated efficiency of a tight insulin protocol showing that treatment delay was due to time spent calculating new insulin doses. Nurses reported increased workload.
- Although Oeyen et al were able to show appropriate insulin adjustments 71% of the time, patients were in the target glucose range only 42% of the time using a tight control protocol.
See Article, pp 589–598; 599–608
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Oral Hygiene Practices in the ICU
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What is the oral care practice in your unit? Is there great variation in products or procedures used? The CDC recommends implementation of an ICU oral hygiene program, but does not specify its characteristics. Berry and colleagues offer a systematic review of oral care practices. The August 2006 AACN Practice Alert on oral care for the critically ill (available at www.aacn.org) suggests the following:
- Brush patients’ teeth, gums, and tongue at least twice a day using a soft pediatric or adult toothbrush.
- In addition to brushing, provide oral moisturizing to oral mucosa and lips every 2 to 4 hours.
- Use an oral chlorhexidine gluconate (0.12%) rinse twice a day during the perioperative period for adult patients who undergo cardiac surgery. No evidence to support routine use of this rinse in other ICU populations is available at this time.
See Article, pp 552–563
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CPR and Hypothermia After Cardiac Arrest
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Are you using the latest evidence for CPR in your unit? Bader and colleagues describe a case in which rapid and effective implementation of the American Heart Association guidelines (http://circ.ahajournals.org/content/vol112/24_suppl) including use of hypothermia had a dramatic effect on one patient’s recovery. Consider the following points for your own CPR protocol:
- Hypothermia should begin as soon as spontaneous circulation is restored, should last 18 hours, and should have a goal temperature of 33°C.
- A written protocol outlining the process including monitoring (ECG, blood pressure, urine output, neurologic status) and clinical interventions for the cooling phase is essential.
- Shivering should be eliminated by sedatives, narcotics, or paralytic medications.
- Constant attention is required to maintain low body temperature and to help avoid adverse effects.
- See Article, pp 636, 632–635
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Assessing Gastric Tube Placement
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How do you test for enteral tube placement in your unit? What is the best method? Elpern and colleagues evaluated capnometry as a verification method, but found limited support for its use. The May 2005 AACN Practice Alert (available at www.aacn.org) on verification of feeding tube placement suggests the following:
- There is no single best method for verification of enteral tube placement.
- Do not rely on the ausculatory method; it may give you false assurance that the tube is properly placed.
- Measuring aspirate pH to differentiate between gastric and respiratory placement is helpful in fasting patients and those not receiving medications that alter the pH.
- Radiographic confirmation is the only reliable method to confirm enteral tube placement.
See Article, pp 544–550
Clinical Pearls is designed to help implement evidence-based care at the bedside by summarizing some of the most clinically useful material from select articles in each issue. Readers are encouraged to photocopy this ready-to-post page and share it with colleagues. Please be advised, however, that any substantive change in patient care protocols should be carefully reviewed and approved by the policy-setting authorities at your institution.
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Animals and Heart Failure...
Insulin Protocols and Tight...
