Clinical Voices February 2024

Feb 08, 2024

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In this issue, read articles on how ATTs may limit stroke and bleeding in trauma patients, a more aggressive therapy approach in AFib guidelines, refresher training to boost pediatric code skills, and more. Plus, read a new nurse Q&A on a values-based tool for prioritizing care.

Antithrombotics May Limit Stroke, Bleeding in Trauma Patients

The systematic review suggests that ATT timing is critical.

Antithrombotic therapies (ATTs) such as heparin and aspirin are effective for reducing the possibility of ischemic stroke in patients with blunt cerebrovascular injury (BCVI) and other trauma with a high risk of bleeding.

Efficacy of Antithrombotic Therapy and Risk of Hemorrhagic Complication in Blunt Cerebrovascular Injury Patients With Concomitant Injury: A Systematic Review,” in JACS: Journal of the American College of Surgeons, also finds that treatment with ATTs resulted in low rates of hemorrhage. The findings could help resolve a “therapeutic dilemma” for clinicians concerned about stroke and bleeding when treating patients with BCVI.

A search of medical databases uncovered 10 studies published from January 1996 through December 2021 that reported clinical outcomes after ATT for patients with BCVI who had a bleeding risk. “In the pooled data, among patients with BCVI and concomitant injury who received any form of antithrombotic therapy, the BCVI-related stroke rate was 7.6%. The subgroup of patients who did not receive therapy had an overall BCVI-related stroke rate of 34%. The total rate of hemorrhagic complications in the treated population was 3.4%.”

“Specifically, the reported risks that required surgical, endoscopic, or radiologic interventions were low,” the review adds. “Our findings suggest that clinicians may consider a more liberal approach to antithrombotics in this higher-risk population.”

Noting that most patients develop BCVI-related ischemic stroke within the first 72 hours, the review suggests that ATT timing is also critical. “In our review, the median time to therapy in most studies was within 48 hours, and the variability in timing to ATT initiation was at the discretion of treating clinicians.”

Citing limitations, the review acknowledges the lack of a consistent non-ATT comparison group across all studies. “High-quality prospective studies and ideally future randomized trials are needed with direct comparisons between those receiving and not receiving ATT, with reporting of ischemic stroke, hemorrhagic complications, and mortality for all patients stratified by treatment study.”

AFib Guidelines Take More Aggressive Approach to Therapy

New AFib guidelines include recommendations for catheter ablation and LAAO.

Catheter ablation can be a safe and effective first-line therapy rather than a secondary treatment option for certain patients with atrial fibrillation (AFib), including those who have heart failure with reduced ejection fraction.

The American College of Cardiology and American Heart Association’s new guidelines also strengthen the recommendation for use of left atrial appendage occlusion (LAAO) devices to reduce stroke risk in patients with long-term contraindications to anticoagulation, notes “New AFib Guidelines Include Higher Recommendations for Catheter Ablation, LAAO,” in Cardiovascular Business.

Lifestyle changes and risk factor modifications are pillars of AFib management, and the new guidelines call for more prescriptive recommendations to manage obesity, weight loss, physical activity, smoking cessation and other health factors, adds a related article in CHEST Physician.

“We should not only be telling patients they need to be healthy, which doesn’t mean much to a patient, we need to tell them precisely what they need to do,” says Jose Joglar, UT Southwestern Medical Center, co-chair of the guideline writing committee. “For example, how much exercise to do or how much weight to lose to have a benefit.”

Regarding catheter ablation, Joglar notes that recent studies favor it over medications for rhythm control in select patients. “There’s no need to try pharmacological therapies after a discussion between the patient and doctor and they decide that they want to proceed with the most effective intervention,” he adds in the related article.

Another important update involves a four-stage classification of AFib severity, with each stage requiring different strategies ranging from prevention to risk factor modification to therapy. The guidelines continue to endorse the CHA2DS2-VASc score for predicting stroke risk but also allow the flexibility for other variables to inform decisions.

The writing committee summarizes its recommendations in another related article with the top 10 take-home messages for the guidelines.

Non-Opioid Poses Increasing Overdose Threat

Although xylazine is a non-opioid, naloxone doesn’t reverse the effects.

When treating patients with suspected overdose, critical care nurses should recognize signs of xylazine, an emerging threat that poses an even greater risk than fentanyl on the illicit heroin market. “Infiltration of Xylazine in Illicit Fentanyl,” in American Nurse, warns that xylazine-laced heroin is highly dangerous, partly because the drug is a non-opioid, and the overdose antidote naloxone (Narcan) doesn’t reverse its effects. “The patient may remain unresponsive and in a state of stupor with continued respiratory depression, even after receiving naloxone,” the article adds.

Developed by Bayer Corp. in 1962, xylazine is a clonidine analog for sedating large animals. The powerful sedative isn’t approved for human use, and although a veterinarian license is required for legal purchases, xylazine can be bought on internet sites that aren’t associated with the profession.

Research cited in the article also reveals illicit xylazine, sometimes called “tranq,” has severely affected populations in Puerto Rico, Canada and the United States, with 38 states reporting the presence of xylazine in overdose cases. The DEA Joint Intelligence Report identified the drug in all U.S. regions.

Education can aid recognition, the article suggests, adding that xylazine should be suspected when patients don’t respond to naloxone. Nurses can also look for severe wound infections that are worse than those seen with other illicit drugs and can occur in parts of the body other than the injection site. Additional signs of xylazine toxicity include bradycardia, hypotension, hypothermia, respiratory distress, staggering, stupor and unresponsiveness.

“People don’t know about xylazine,” says co-author Kathleen Neville, Seton Hall University College of Nursing, in a related video. “It was in the news frequently, and now it’s not so much in the news. But nurses in every clinical setting are going to see it.”

Veterans’ Potential Toxic Exposures

The article lists many resources for clinicians.

Since military veterans recently became eligible for new benefits due to toxic exposure during their service, clinicians who treat them outside Veterans Administration (VA) facilities need to be informed about potential concerns.

Military Environmental Exposures,” in AJN: American Journal of Nursing, notes that providers should learn about potential exposures for which their patients may require screening. “Making a conscious effort to learn about military culture and environmental exposures is a pivotal and responsible first step to providing valuable, informed care and services to veterans and their families,” the article adds.

The PACT Act, signed into law in 2022, significantly expands benefits to veterans from Vietnam, the Gulf War and post-9/11 Middle East conflicts, as well as to soldiers and family members who might have been exposed at military bases. Because estimates show more than half of veterans receive their healthcare outside the VA system, nurses need to understand the health risks that patients and families may face.

Clinicians need to inquire about a patient’s specialty. “Knowing the veteran’s daily jobs during military service will provide additional insight into any environmental exposures.”

“Whether from explosions, radiation, airborne hazards, or contaminated water supplies, these exposures have, in some cases, resulted in a toxic effect, impacting the health of both veterans and their families,” adds the article in AJN.

“Veterans may carry visible or invisible wounds, and many attribute symptoms and long-term conditions to varying occupational and environmental exposures.” The article notes the differences in potential exposures and the commonly associated diseases and conditions based on location and era of service – for example, Agent Orange from Vietnam or burn pits in the Gulf region.

Resources for clinicians, including nonprofit organizations and agencies, registry programs, specialized services and a crisis line, are also included in the article in AJN.

Weaning Protocol Can Reduce Ventilator-Associated Events

VAEs occurred in three times as many cases that did not use the protocol.

Use of a ventilator weaning protocol for patients with acute respiratory distress syndrome was associated with a reduced likelihood of all types of ventilator-associated events (VAEs).

Association Between Ventilator-Associated Events and Implementation of Acute Respiratory Distress Syndrome (ARDS) Ventilator Weaning Protocol,” in AJIC: American Journal of Infection Control, notes that a work group developed a protocol for a sliding scale method for oxygenation-based positive end-expiratory pressure (PEEP) with optimized individual patient management. VAEs occurred in three times as many cases that did not use the protocol.

“Protocol implementation as a part of a multidisciplinary process can assist patients in recovering their ability to breathe on their own while lowering the chance of consequences related to ventilation such as pneumonia, infections, and other respiratory issues,” the study notes.

The study included 1,233 ventilator periods of at least four days from April to December 2022, and the protocol was followed in 813 cases. ICUs included in the study involved cardiovascular, medical, neurosurgical and trauma units covering 173 beds, with the highest VAE rates in cardiovascular (17.75 per 1,000 vent days), burn (12.76) and step-down cardiac (9.22) units.

There were VAEs in 49 of the protocol cases (6%), compared with 76 of the 420 non-protocol cases (18%), with VAEs including infection-related ventilator-associated complications (IVACs), possible ventilator-associated pneumonia (PVAP) and ventilator-associated conditions (VACs). When using the protocol, VACs developed in 44.6% fewer periods, PVAP in 28.6% fewer, and IVAC in 18.2% fewer periods.

The protocol included a process to reduce PEEP by 2 cm H2O per 24 hours to improve gas exchange and lung function. “FiO2 levels can be reduced more aggressively when weaning high PEEP levels because the lung integrity is maintained by functional residual capacity which is already sustained by the PEEP.”

Refresher Training Boosts ED Nurses’ Pediatric Code Skills

First-attempt success rates and overall success improved with subsequent training.

Emergency department (ED) nurses who have regular refresher training on pediatric code-cart skills, which are infrequently used in practice, maintained skill levels and improved their overall training scores at six-month intervals.

Emergency Department Pediatric Code Cart In Situ Rolling Refresher Training Program,” in Clinical Simulation in Nursing, describes how a rural, tertiary care center devised ongoing training to ensure ED nurses retained low-frequency, high-risk skills in the rare event of a pediatric emergency. First-attempt success rates and overall success improved with subsequent training. “This training program can also serve as a model for obtaining initial emergency skill levels in a cohort of nurses and a sustainable means to foster skill retention and maintenance,” the study adds.

The study included 56 nurses, with 38 receiving both a first and second training six months later, 26 receiving a third training and 12 receiving a fourth. The mean training score rose from 79% at the first training to 92% at the second and 94% at the third, with statistically significant improvement in first-attempt success in “obtaining supplies for placing an IV and for intraosseous needle placement, delivering a weight-based appropriate fluid bolus via a push-pull methodology, preparation and delivery of a weight-based epinephrine infusion, preparation and delivery of weight-based dose of adenosine, and a weight-based appropriate [resuscitation] dose of epinephrine.”

Nurses trained in their work environment with the equipment required in a live event. They underwent four simulation scenarios that included 17 code-cart skills for pediatric advanced life support with expected time limits and accuracy defined for each task.

The training could not account for skill use during a real emergency or whether nurses used any of the skills between simulations. “Further work is needed to determine how this skill retention applies in real pediatric code situations as well as how teams affect individual performance.”

Nurse Story: Anticipating Surges With a Values-Based Approach to Prioritizing Care

With limited resources and possible winter surges in admissions, how can nurses prepare? Two nurses discuss the bedside, values-based tool they developed to help prioritize care. “Work had to be done to get everybody aligned with their values. Those values are unit values. Using this tool, everybody is on the same page.”

Read the Q&A