Clinical Voices January 2021

Jan 05, 2021

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Link Between Influenza, Cardiovascular Events

Clinicians can encourage flu vaccination, especially in patients with underlying conditions.

About 12% of adults hospitalized with flu had acute cardiovascular events, and those with key risk factors had significantly higher chances.

"Acute Cardiovascular Events Associated With Influenza in Hospitalized Adults: A Cross-sectional Study," in Annals of Internal Medicine, notes that acute heart failure or acute ischemic heart disease occurred in 11.9% of 80,261 patients with flu confirmed by a lab from the 2010-2011 through 2017-2018 seasons. "Clinicians should ensure high rates of influenza vaccination, especially in those with underlying chronic conditions, to protect against acute cardiovascular events associated with influenza," the study notes.

A related article in JAMA Network Open adds that risk factors associated with higher rates of acute cardiovascular events included tobacco use, older age, obesity, diabetes, heart disease and kidney disease. Seasonal flu affects more than the respiratory system and also has been associated with diagnoses of pneumonia, sepsis and acute kidney injury.

In a related article in Healthline, lead study author Eric Chow, University of Washington School of Medicine, says the flu season combined with COVID-19 could lead to a spike in heart conditions. "I am concerned about the possibility of having both influenza and SARS-CoV-2 circulating in the community as both can result in severe complications, especially in those with underlying medical conditions," he notes.

The risk factors did not necessarily predict cardiovascular events, because 5% of those acute cardiovascular events didn't have any key risk factors. "This study is key because it truly highlights how common it can be to experience serious heart complications after getting the flu — including in some people that did not have any prior chronic health conditions," Natasha Bhuyan, a Phoenix-based physician, adds in Healthline.

Angiotensin II Shows Promise Against Refractory Shock

Angiotensin II was associated with increased hemodynamic stability.

A study of 270 patients with vasopressor-refractory shock reveals that 67% demonstrated a favorable hemodynamic response after angiotensin II infusion, and a reduced likelihood of 30-day mortality.

"Angiotensin II Infusion for Shock: A Multicenter Study of Postmarketing Use," in Chest, also notes that "patients with lower lactate concentrations and those receiving vasopressin were more likely to respond to angiotensin II."

The multicenter, retrospective study at five U.S. tertiary medical centers was designed to test the safety and effectiveness of synthetic angiotensin II, a potent vasoconstrictor, and identify variables associated with favorable hemodynamic responsiveness. The study defines a favorable response as attaining a mean arterial pressure (MAP) of ≥ 65 mm Hg with stable or reduced total vasopressor dosage three hours after initiating the medication.

Of the 270 patients (mean age 60) receiving angiotensin II, 181 (67%) “showed a greater increase in MAP (+10.3 mm Hg vs +1.6 mm Hg, P < .001) and reduction in vasopressor dosage (-0.20 μg/kg/min vs +0.04 μg/kg/min; P < .001) compared with nonresponders at 3 h,” the study reports.

A related article in 2 Minute Medicine notes that hemodynamic responsiveness was associated with increased 30-day survival (41% vs. 25%). "The most common adverse effects noted among patients were transaminitis and thrombocytopenia," the article adds.

"In all, this study showed that angiotensin II was associated with increased hemodynamic stability and decreased total vasopressor requirement among patients with refractory shock," the article notes. "More work is needed, however, to delineate optimal dosages and timing of administration in order to maximize patient outcomes."

LMWH Associated With Improved Outcomes for Some Patients

Overall, patients treated with LMWH fared better than those who received UFH.

For patients with trauma, ages 10 to 17, treatment with low molecular weight heparin (LMWH) is associated with improved survival and decreased risk of deep vein thrombosis (DVT) compared to treatment with unfractionated heparin (UFH).

"The Survival Benefit of Low Molecular Weight Heparin Over Unfractionated Heparin in Pediatric Trauma Patients," in Journal of Pediatric Surgery, also associates LMWH with shorter hospital stays for patients 10 to 17 years old. The two-year (2015-2016) retrospective analysis of the Pediatrics American College of Surgeons Trauma Quality Improvement Program database involved patients with trauma, ages 0 to 17, who received thromboprophylaxis with LMWH or UFH. The 1,678 patients were in three age groups, and outcome measures included mortality and venous thromboembolism (VTE) events, such as DVT and pulmonary embolism (PE), along with hospital and ICU lengths of stay (LOS).

Overall, patients treated with LMWH fared better than those who received UFH, the analysis reports, noting that a "significant difference in survival, DVT events, and in-hospital LOS was seen in the age groups above 9 years." However, the analysis finds "no significant difference in the ICU LOS among survivors and the incidence of PE between the two groups."

A related article in 2 Minute Medicine notes the findings were not as favorable for younger children. Among patients ages 0 to 9 who received either LMWH or UFH, the analysis revealed no significant differences in incidence of DVT, PE or mortality.

"These findings suggest that LMWH is a more favorable choice for VTE prophylaxis among pediatric trauma patients aged 10 to 17," the article adds. "Additional, prospective studies should be done to further elucidate this possible benefit."

Statement Recommends Year-Round Standard Time

A study finds an 18.7% increase in healthcare errors the week after the time change in spring.

A position statement recommends a national, year-round standard time, noting the negative effects of daylight saving time (DST) on circadian cycles and other health risks.

"Daylight Saving Time: an American Academy of Sleep Medicine [AASM] Position Statement," in JCSM: Journal of Clinical Sleep Medicine, cites study findings on increased cardiovascular events, mood disorders and fatal car accidents after the spring time change. "A change to permanent standard time is best aligned with human circadian biology and has the potential to produce beneficial effects for public health and safety," the statement notes.

A related study in MedPage Today reports on an AASM and Sleep Research Society meeting that found human errors caused an 18.7% increase in safety-related healthcare incidents the week after returning to DST in the spring. The observational study over eight years in a multistate system found human errors led to only a 4.9% increase in adverse events the week after returning to standard time in the fall.

The AASM statement describes the biological causes of the spring shift's effect, noting that "early morning darkness and light in the evening have a similar effect on [the] circadian phase, causing the endogenous rhythm to shift to later in the day. There is evidence that the body clock does not adjust to DST even after several months."

The statement adds that permanent DST "could result in permanent phase delay ... as well as chronic sleep loss due to early morning social demands that truncate the opportunity to sleep." Circadian misalignment is "associated with an increased risk of obesity, metabolic syndrome, cardiovascular disease, and depression." Further research is needed.

Hospital Operational Rhythms and Medication Times

The analysis identifies a potential operational barrier to optimal care.

Operational rhythms in hospitals may lead to medication orders and dosing that conflict with ideal times for patients and reduce efficacy.

According to "A Large-Scale Study Reveals 24-h Operational Rhythms in Hospital Treatment," in PNAS: Proceedings of the National Academy of Sciences, many clinical decisions stem from considerations besides optimal patient care, including time of physician availability. As a result, patterns of medication orders and treatment come from a "systemic bias in the timing of medicine" and "reveal a potential operational barrier to best clinical care," adds the retrospective, population-level analysis.

Referencing medication distribution at Cincinnati Children's Hospital Medical Center from 2010 to 2017, the analysis finds that about one-third of orders were placed between 8 a.m. and noon based on rounding times, with the first doses averaging about two hours later due to an ordering bottleneck. Optimal time of day for administering medication did not seem to play a role in the process, and the morning bottleneck occurred regardless of a patient's condition, medication or unit.

In a related article in The Atlantic, Michael Smolensky, University of Texas at Austin, observes that delivering treatment at less optimal times can alter the expected outcomes and even worsen the patient's condition. "A lot of the times the schedules that are in place have nothing to do with the biological requirements of the patient that may be driven by circadian rhythms," he notes.

The analysis adds that "future multicenter, prospective trials may further elucidate the importance of drug timing on individual patient outcome measures. In sum, time of day in hospital operations deserves further consideration."

Recruiting and Retaining Volunteers

Volunteers can help your chapter or your organization plan and implement its activities.

Joining a nursing organization can enhance your bold voice about issues that matter, including healthcare, the profession and networking.

Nursing organizations are "dedicated to advancing the profession and committed to the personal and professional development of their members. When nurses unite, they have a stronger voice on issues that affect healthcare and the profession," says nurse educator Lynn Orser, author of "How to Recruit and Retain Volunteers for Your Professional Organization," in American Nurse.

Volunteers can help plan and implement your organization's activities. AACN's six standards for a healthy work environment — authentic leadership, skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition — "can help engage and retain volunteers," the article notes.

Use social media platforms, email and word of mouth to announce your request for volunteers. "Recruit people who want to be part of your team; don't just fill seats," Orser adds.

You also need to develop and periodically review the job descriptions for volunteer roles, set clear goals and time commitments, and create policies and how-to guides for their reference. Once they join your team, choose the best means of communication (email, text, phone). You also might have mentors work with them.

"Organizations need to secure a network of volunteers to plan and execute activities. Recruiting and retaining volunteers requires good communication, pairing the right person with the right job, providing training and onboarding, respecting volunteers' time, and acknowledging their efforts," Orser concludes.

And be sure to give specific recognition that is meaningful to each volunteer.

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