Clinical Voices July 2021

Jul 01, 2021

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In July we explore extending infusion sets, non-drug therapies for dementia and depression, and hypertonic saline for ICP reduction, and more. Plus: Beth Wathen’s first President’s Column and an eye-opening Q&A on human trafficking. 

Extending Infusion Sets

The trial also revealed no significant differences in secondary outcomes.

Use of infusions for patients with central venous access devices (CVADs) or peripheral arterial catheters (PACs) can be extended safely from four days to seven — a finding that could decrease hospital costs and nursing workload.

"Effect of Infusion Set Replacement Intervals on Catheter-Related Bloodstream Infections (RSVP): A Randomised, Controlled, Equivalence (Central Venous Access Device)-Non-Inferiority (Peripheral Arterial Catheter) Trial," in The Lancet, reveals that infection rates do not differ that much when infusion sets were replaced at four days or at seven days.

Conducted at 10 Australian hospitals from May 2011 to December 2016, the trial involved adults and children requiring a CVAD or PAC. In total, 1,463 patients were assigned to a seven-day (intervention) group and 1,481 patients to a four-day (control) group for infusion set replacement.

For both devices, the trial revealed similar rates of catheter-related bloodstream infection (CRBSI), the primary outcome. Findings for the two patient groups revealed the following:

  • CVAD: 1.78% CRBSI rate in the seven-day group vs. 1.46% in the four-day group
  • PAC: 0.28% CRBSI rate in the seven-day group vs. no one in the four-day group

A related article in 2 Minute Medicine reports that the trial also revealed no significant differences in secondary outcomes, including catheter tip colonization, mortality, all-cause bloodstream infection and central line-associated bloodstream infection.

Relative to the four-day group, median nursing time saved by waiting seven days for infusion set replacement was 174 minutes (CVAD) and seven minutes (PAC), the article notes. In addition, the seven-day group had a mean cost savings of AU$483 (CVAD) and AU$43 (PAC). In U.S. currency, those savings amount to about $372 and $33, respectively.

Some Studies Favor Hypertonic Saline for ICP Reduction

The review recommends additional research in a large multicenter clinical trial.

A review finds that nurse practitioners and other providers should consider hypertonic saline (HTS) as well as mannitol to reduce intracranial pressure (ICP) in patients with traumatic brain injury.

According to "Hypertonic Saline Versus Mannitol for the Treatment of Increased Intracranial Pressure in Traumatic Brain Injury" in Journal of the American Association of Nurse Practitioners, research suggests that both alternatives could be effective. “Providers should consider the properties of each agent, adverse effects, and potential benefits when selecting a hyperosmotic agent,” the review notes.

Based on data from eight eligible studies (four single studies and four meta-analyses) involving 770 patients, the review finds that five studies “revealed HTS had superior efficacy compared with mannitol, although only three could determine its superiority to be statistically significant.”

Studies establishing the efficacy of HTS include one that measured outcomes by cumulative and daily ICP burden, and one that controlled for assorted therapies and physiological responses. The dosage of HTS varied across the studies, in part because of shifting treatment threshold guidelines over the study period. There were also variations in when ICP was measured in the studies, so the peak effects of mannitol at its normal half-life range were not included consistently.

Data limitations include varying populations being studied, sample size and the criteria for including patients (some included patients did not have traumatic brain injury), leaving insufficient evidence for a clear recommendation.

The review recommends “further research in a large multicenter clinical trial to compare these two agents for superiority in the management of increased ICP.”

Dementia and Depression: Non-Drug Therapy

More research is needed on non-drug interventions, particularly for older people.

Non-drug interventions may be more effective than drug therapies to reduce symptoms of depression in people who have dementia without a major depressive disorder.

Comparative Efficacy of Interventions for Reducing Symptoms of Depression in People With Dementia: Systematic Review and Network Meta-Analysis,” in BMJ, examines 213 randomized controlled trials of drug and non-drug interventions. In all, 25,177 people with dementia (mean age at least 70) were involved in the trials, and the Cornell scale for depression in dementia was the most prevalent outcome measure.

The review identifies the following non-drug interventions as “more efficacious than usual care”:

  • Animal therapy
  • Cognitive stimulation
  • Exercise
  • Massage and touch therapy
  • Reminiscence therapy
  • Multidisciplinary care
  • Occupational therapy
  • Cognitive stimulation and a cholinesterase inhibitor
  • Exercise combined with social interaction and cognitive stimulation
  • Psychotherapy combined with reminiscence therapy and environmental modification

“Intervention rankings suggest that non-drug interventions either alone or in combination with drug interventions are the best interventions for reducing symptoms of depression in people with dementia without a diagnosis of a major depressive disorder,” the review notes.

To put the findings into practice, everyone from patients to policymakers has a role, the review suggests, adding that “policy makers can support people with dementia, care givers, and clinicians in choosing non-drug interventions by developing health services, systems, and policies that enable implementation.”

A related article in 2 Minute Medicine notes that while the findings are “important for clinical consideration,” more research is needed regarding non-Alzheimer’s dementia as well as the risks and feasibility of non-drug interventions, particularly for older people. Many of them “have difficulties with ambulation, hearing, and/or vision, which may impact their ability to utilize social interventions.”

High-Flow Nasal Oxygen for Respiratory Failure

The recommendations are based on a systematic review of data from 29 randomized controlled trials.

High-flow nasal oxygen (HFNO) should be provided to hospitalized adults for initial or postextubation management of acute respiratory failure, according to a clinical guideline.

"Appropriate Use of High-Flow Nasal Oxygen in Hospitalized Patients for Initial or Postextubation Management of Acute Respiratory Failure: A Clinical Guideline From the American College of Physicians," in Annals of Internal Medicine, recommends HFNO rather than conventional oxygen therapy (COT) for patients with postextubation acute hypoxemic respiratory failure, and rather than noninvasive ventilation (NIV) for patients with acute hypoxemic respiratory failure.

Lead author Amir Qaseem and his colleagues from the American College of Physicians, Philadelphia, developed the recommendations after a systematic review of data from 29 randomized controlled trials. They evaluated a variety of patient-centered health outcomes, such as all-cause mortality, days of intubation or reintubation, ICU admission, 30-day hospital readmissions and hospital length of stay. The recommendations were “developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.”

The guideline suggests that further research is necessary to determine which patients may benefit most from HFNO.

Caring for Patients With Acute Ischemic Stroke

Updated guidance is available for nurses working in stroke care settings.

An updated scientific statement on the care of patients with acute ischemic stroke (AIS) is available for nurses who work in ICUs, emergency departments (EDs), emergency settings or stroke care units.

According to "Care of the Patient With Acute Ischemic Stroke (Prehospital and Acute Phase of Care): Update to the 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association [AHA]," in Stroke, facilitating time-sensitive care for patients with stroke is essential to prevent possible irreversible damage to brain tissue. Ischemic stroke is the fifth leading cause of death in the United States, according to a related news release from AHA..

The guidance outlines the D’s of Stroke Care, which are the significant steps for diagnosis and treatment of patients with AIS:

  • Detection – “Rapid recognition of stroke symptoms”
  • Dispatch – Early activation and dispatch of emergency medical services (EMS) by calling 911
  • Delivery – “Rapid EMS identification, management, and transport”
  • Door – “Appropriate triage to stroke center”
  • Data – “Rapid triage, evaluation, and management within the ED”
  • Decision – “Stroke expertise and therapy selection”
  • Drug/Device – “Fibrinolytic therapy, intra-arterial strategies”
  • Disposition – “Rapid admission to stroke unit, critical care unit”

The AHA statement adds that “stroke care is increasingly complex in the new reperfusion era, requiring nurses to participate in continuing education while attaining levels of competency in both the acute and recovery care process.”

Medication to Lower BP Beneficial Regardless of Risk Factors

Consider antihypertensives as a tool to reduce cardiovascular risk.

A large-scale review of clinical trial data shows that blood pressure (BP)-lowering medication reduces the risk of cardiovascular events regardless of the patient’s baseline level or risk factors for heart disease.

According to "Pharmacological Blood Pressure Lowering for Primary and Secondary Prevention of Cardiovascular Disease Across Different Levels of Blood Pressure: an Individual Participant-level Data Meta-Analysis," in The Lancet, “a 5 mm Hg reduction of systolic blood pressure reduced the risk of major cardiovascular events by about 10%, irrespective of previous diagnoses of cardiovascular disease, and even at normal or high-normal blood pressure values.” The review adds that clinicians should emphasize to patients that pharmacological treatment can be beneficial even with low initial BP levels.

The review of 48 randomized trials with nearly 345,000 patients used a primary outcome of a major cardiovascular event — fatal or non-fatal stroke, fatal or non-fatal myocardial infarction, ischemic heart disease or heart failure — with death from all causes or from heart-related causes secondarily. With a 5 mm Hg reduction, “the corresponding proportional risk reductions for stroke, heart failure, ischaemic heart disease, and cardiovascular death were 13%, 13%, 8%, and 5%, respectively.”

The review suggests revising guidelines that require a minimum threshold of high BP to qualify patients for medication treatment or that include a floor for BP reduction levels. “By considering antihypertensives as a tool for reducing cardiovascular risk, rather than simply reducing blood pressure, clinicians are no longer required to make decisions according to an arbitrary and confusing classification of hypertension.”

President’s Column: Rooted in Strength

Today, nurses are at a threshold of a new and different world. In her inaugural column, AACN President Beth Wathen likens this pandemic to a wildfire. “Beauty and life can rise from destruction. Through adversity, through challenges, we grow stronger.”

Read Her Story

Nurse Story: Invisible Patients: Human Trafficking Victims

Without knowing it, you’ve probably treated a victim of human trafficking. Two Texas nurses founded a nonprofit to provide training and resources to help healthcare professionals recognize and report human trafficking.

Read Their Story

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