Clinical Voices January 2023

Jan 03, 2023

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This issue, we cover topics on how AF and AFL should be managed as separate disorders, ECMO survivors and increased mental health diagnoses, half of study patients with OHCA developed PICS, and more. Plus, read a new nurse staffing solution story.

Therapy Improves Nonpermanent AF for Some Patients

The findings suggest that AF and AFL should be managed as separate disorders.

Intravenous potassium and magnesium given in the emergency department (ED) to patients with nonpermanent atrial fibrillation (AF) can improve spontaneous conversion to sinus rhythm (SCV).

"Association of Intravenous Potassium and Magnesium Administration With Spontaneous Conversion of Atrial Fibrillation and Atrial Flutter in the Emergency Department," in JAMA Network Open, notes that for patients with AF, the findings might reduce the need for antiarrhythmic therapy and the potential harms associated with it. However, the strategy is not effective for atrial flutter (AFL).

The cohort study involved 2,546 episodes of AF and 573 episodes of AFL in the ED of Medical University of Vienna, Austria, from February 2009 to February 2020. Intravenous potassium (24 mEq) and magnesium (145.8 mg) were administered for 1,763 episodes, or 56.5%.

Overall, the probability of SCV was 19.2% for patients with AF who received potassium and magnesium compared with 10.4% for those who did not. Patients fared best with baseline plasma potassium levels in a range of 3.50 to 3.99 mEq/L or lower. No association with SCV probability was noted for potassium and magnesium administration in patients with onset greater than or equal to 48 hours.

In contrast, among patients with AFL, overall rates of SCV were not significantly different regardless of whether they received potassium/magnesium (13.0% with administration vs. 12.5% without). "Our data suggest that AF and AFL should be handled as 2 distinct disorders from a mechanistic and a therapeutic perspective," the study notes.

"The results of our study have no direct implications for clinical practice in the management of care for patients with AF or AFL in the ED," the authors add. "The findings are purely exploratory and hypothesis-generating but could potentially provide a rationale for an appropriate prospective trial."

The study lists several limitations and suggests that a randomized clinical trial is warranted to determine the efficacy and safety of the potassium/magnesium strategy.

ECMO Survivors May Have Increased Mental Health Diagnoses

Additional research will help reveal the reasons for the study results.

Adult ICU patients who received extracorporeal membrane oxygenation (ECMO) had a 24% higher rate of new mental health diagnoses or social problems post-discharge than ICU survivors without ECMO.

In "Association of Extracorporeal Membrane Oxygenation With New Mental Health Diagnoses in Adult Survivors of Critical Illness," in JAMA: The Journal of the American Medical Association, a comparison of adults discharged from ICUs in Ontario, Canada, over 10 years finds an association between surviving ECMO and a future mental health diagnosis. "Further research is necessary to elucidate the potential mechanisms underlying this relationship," the study adds.

The retrospective study reviewed post-discharge diagnoses for 642 survivors who received ECMO compared with 3,820 matched survivors who did not. ECMO survivors had new mental health conditions at a rate of 22.1 per 100 person-years, compared with 14.5 for the control group.

"We already knew that ICU survivors can suffer mental health impacts from the trauma of invasive treatments, living with new physical limitations and dealing with long recovery times," says lead study author Shannon Fernando, University of Ottawa, Canada, in a related article in Medical XPress. "We suspected ECMO survivors would be at greater risk of mental health impacts because they are sedated and ventilated for longer and often face a more challenging recovery."

The study found no significant difference in substance misuse or deliberate self-harm, with suicide very rare in the entire cohort (five total cases). The primary outcomes used to assess a new mental health diagnosis were "a composite of mood disorders, anxiety disorders, posttraumatic stress disorder; schizophrenia, other psychotic disorders; other mental health disorders; and social problems."

"We really need more research and investment in the area of post-critical illness," Fernando adds in the article. "Patients will need help long after they leave the ICU."

Laryngeal Mask Airway: An Option for Neonatal RDS

The laryngeal mask airway can be an effective means of surfactant administration.

For premature infants with respiratory distress syndrome (RDS), surfactant administration with a laryngeal mask airway (LMA) reduces rates of early therapy failure with less risk of surfactant reflux compared with standard endotracheal intubation.

"Randomized Trial of Surfactant Therapy Via Laryngeal Mask Airway Versus Brief Tracheal Intubation in Neonates Born Preterm," in The Journal of Pediatrics, suggests that LMA limits early failures, possibly by avoiding the adverse effects of premedication, laryngoscopy and intubation. "These characteristics make LMA a desirable conduit for surfactant administration," the study notes.

Conducted at Albany Medical Center in New York from November 2014 to April 2020, the study involved 51 premature infants (27 to 36 weeks of gestation) receiving surfactant therapy via LMA and 42 infants with therapy delivered by an endotracheal tube (ETT). Failure of surfactant therapy to prevent the need for mechanical ventilation was the study's primary outcome.

For the ETT group, the failure rate was 29% versus 20% in the LMA group, the study reveals, adding that the difference was due to early failures (within one hour), which were 12.5% in the ETT group compared with 2% for the LMA group. Infants in the LMA group also had a lower rate of surfactant reflux during administration at 0% versus 9.7% for patients with ETTs, adds a related article in 2 Minute Medicine.

According to the article, lack of blinding to treatment type was one major limitation of the study since it could influence clinical decisions such as surfactant doses, intubation/extubation, respiratory management and settings, and premedication use.

"This study provides evidence that LMA administration of surfactant to infants with RDS is non-inferior to ETT administration," the article adds "Future studies are required to study the use of LMAs for surfactant administration in other cohorts to provide external validation."

Spirituality Can Benefit Patients With Terminal Cancer

The findings may inform the kinds of support that can help these patients.

A review of studies of patients with terminal cancer shows that spirituality can provide enhanced quality at the end of life.

"A Qualitative Meta-synthesis Examining Spirituality as Experienced by Individuals Living With Terminal Cancer," in Health Psychology Open, addresses the four main themes of "making sense of dying, living with dying, feeling connected and being reflective."

These themes demonstrate the range of spiritual challenges that patients with terminal cancer face and how an enhanced spiritual experience can have a positive effect. "The findings also suggest the potentially transformative impact of self-reflection on ones' outlook on life and on dying; specifically, these aspects of spirituality were reported by participants as being beneficial in living while dying, to help in overcoming suffering, finding a deeper understanding of self and meaning in life, gaining acceptance of illness and death, and achieving inner peace," the review adds.

The systematic literature review includes 37 articles screened for inclusion criteria, encompassing 18 different countries and a total of 1,046 participants. Four studies included patients at end of life, 13 included patients with terminal cancer, and 20 included those with advanced cancer and a prognosis of less than one year to live.

The research identifies "relationships with the self, family, society, nature, and a higher power" as primary pathways to find meaning on spiritual journeys while strengthening those bonds and resolving unfinished issues. The review demonstrates the importance of a "requirement for basic spiritual care training for all palliative care staff with more advanced levels of spiritual care to be offered by more highly skilled professionals."

Half of Study Patients With OHCA Developed PICS

AACN's website offers a wide range of resources on this syndrome.

About half of patients admitted to critical care because of an out-of-hospital cardiac arrest (OHCA) exhibited signs of post-intensive care syndrome (PICS) up to a year after discharge.

"Post-Intensive Care Syndrome in Out-of-Hospital Cardiac Arrest Patients: A Prospective Observational Cohort Study," in PLOS One, which followed up at three and 12 months, revealed comparable long-term health impairments for nearly half of the patient cohort. "With a growing number of patients surviving their ICU stay after an OHCA and nearly half of all OHCA survivors displaying evidence of PICS up to one year after ICU admission, appropriate screening and management is necessary to minimize the risk for PICS and to meet the increased need for its treatment," the study adds.

The ongoing study involves a single hospital in Basel, Switzerland, starting in October 2012 and continuing through October 2025. It includes adult patients with OHCA who participated in one or both follow-up assessments, with 156 completing at least one of the interviews (59.6% completed both). Eleven patients (7.1%) died between the three- and 12-month assessments.

At three months, 49.6% of patients showed some PICS signs, with 36.7% physically impacted, 25.2% cognitively and 12.9% psychologically. At 12 months, 47.3% showed some PICS signs, 36.7% physically, 22.2% cognitively and 12.7% psychologically.

Clinical implications include a need for rehabilitation and prolonged rehabilitation, an area that could benefit from additional research. "Screening for PICS could help identify high-risk patients needing medical and psychological support, which in turn may reduce their risk in the long term."

The study also notes that much of the cognitive impairment could be the result of baseline issues identified at discharge that had not improved, so screening could be predictive.

AACN's website offers a wide range of additional resources related to PICS from a clinical perspective, including articles on nurses' roles and PICS during COVID-19.

Paxlovid Interactions With Some Heart Medications

Medication reconciliation is essential.

Before prescribing the COVID-19 medication nirmatrelvir-ritonavir (NMVr or Paxlovid) for patients with heart disease, clinicians should consider potential adverse interactions with some commonly used cardiovascular medications, notes a media release.

A review in JACC: Journal of the American College of Cardiology examines possible drug-drug interactions (DDIs) involving Paxlovid and some potential alternatives for treating heart patients with COVID-19. According to the review, the DDIs of Paxlovid with five common cardiovascular medications are as follows:

Antiarrhythmic agents: When co-administered with Paxlovid, antiarrhythmic agents for managing patients with abnormal heart rhythms can metabolize and increase plasma levels. Alternative COVID-19 therapies should be considered.

Antiplatelet agents and anticoagulants: Aspirin and prasugrel are safe with Paxlovid, but the risk of blood clots increases when Paxlovid is given with clopidogrel, and bleeding risk rises with ticagrelor. These agents should be switched to prasugrel if possible. Warfarin and other anticoagulants may be co-administered with Paxlovid, but they require close monitoring of the clotting factors in bloodwork.

Certain statins: Simvastatin or lovastatin should be stopped before initiating Paxlovid due to an increased risk of muscle weakness (myopathy) and rhabdomyolysis. Reduce the dose of atorvastatin and rosuvastatin if co-administering with NMVr.

Ranolazine: Temporary discontinuation of ranolazine, for treating patients with angina, is advised if prescribing Paxlovid, because it can increase arrhythmia risk.

Immunosuppressive agents: Plasma levels of immunosuppressive agents prescribed after a heart transplant can rise to toxic levels when combined with Paxlovid. Alternative COVID-19 therapies should be considered.

Awareness is key to avoiding serious DDIs, and the "importance of medication reconciliation" cannot be overemphasized, the review's authors note in an article in Cardiovascular Business. "If co-administration of NMVr with certain cardiovascular medications is not advisable or if their temporary discontinuation is impractical, NMVr should be avoided, and other treatments used," they add.

Nurse Story: Flexible Service Line Staffing

Retention of talented staff is a top priority. In this nurse staffing story, members of the Duke Heart Services team discuss how they use a multipronged approach to appropriately staff their units and implement a healthy work environment.

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