Clinical Voices March 2024

Mar 15, 2024

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In this issue, read articles on an AHA cardiovascular life support update, toothbrushing to reduce pneumonia in the ICU, dangers of unsecured firearms in the home, and more. Plus, view a new nurse Q&A video on two nurses who each attended their first NTI 50 years apart.

Update on Cardiovascular Life Support

The update addresses calcium administration, body temperature control and other concerns.

The American Heart Association advises against routine administration of calcium for patients in cardiac arrest, while emphasizing that hospitals should develop deliberate strategies for body temperature control during postarrest care.

2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,” in Circulation, summarizes the latest research on these and other topics, including percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation and seizure management.

Controlled temperature is a key factor for patients who don’t respond after return of spontaneous circulation. The update recommends that clinicians aim for a constant body temperature between 32 C and 37.5 C. Patients should not be rewarmed faster than 0.5 C per hour.

“If the local protocol is we keep the patient at a temperature of 37 °C and the patient arrives at 35.5 °C, you’re not going to go from 35.5 °C to 37 °C in 1 hour,” says Jon Rittenberger, University of Pittsburgh, and chair of the update writing group, in a related article in Medscape.

Along with calcium, the update lists “no benefit” to routine administration of sodium bicarbonate or magnesium for patients in cardiac arrest. “Calcium has slowly been downgraded over the last couple of guidelines,” Rittenberger adds. “For the average cardiac arrest patient, calcium does not improve outcomes.”

Among other key messages in the update:

  • Extracorporeal cardiopulmonary resuscitation is reasonable for select patients if hospital staff is adequately trained and equipped.
  • Coronary angiography should be performed immediately for patients with cardiac arrest who have ST-segment elevation.
  • Prompt diagnosis and treatment of clinically apparent seizures in survivors of cardiac arrest is recommended.
  • Organ donation should be considered for resuscitated patients who meet the neurological criteria for death.
  • Researchers should recruit patients from diverse backgrounds for cardiac arrest studies.

Brushing Away Pneumonia in the ICU

Twice-daily toothbrushing is recommended, especially for ICU patients receiving invasive mechanical ventilation.

Daily toothbrushing for ICU patients, particularly among those on invasive mechanical ventilation, can significantly lower rates of hospital-acquired pneumonia (HAP), mortality and length of ICU stay.

Association Between Daily Toothbrushing and Hospital-Acquired Pneumonia: A Systematic Review and Meta-Analysis,” in JAMA Internal Medicine, finds that toothbrushing can also limit the duration of mechanical ventilation, noting that “policies and programs encouraging more widespread and consistent toothbrushing are warranted.”

A search of medical databases identified 15 randomized clinical trials with 10,742 patients (2,033 in the ICU and 8,709 in non-ICU departments), comparing outcomes for those who received daily oral care and those who did not. However, the review’s effective population size was reduced to 2,786 to account for one cluster randomized trial of non-ICU patients.

Overall, toothbrushing was associated with a much lower risk of HAP (risk ratio [RR], 0.67) and ICU mortality (RR, 0.81). The reduction in pneumonia cases was significant among patients receiving invasive mechanical ventilation (RR, 0.68) but not among non-ventilated patients (RR, 0.32).

Toothbrushing was linked to a mean of 1.24 fewer days of mechanical ventilation and 1.78 fewer days in the ICU, the review adds, noting that “brushing twice per day vs more frequent intervals was associated with similar effect estimates.” Toothbrushing was not associated with non-ICU hospital length of stay or the need for antibiotics.

Commenting in a related article in HCPLive, the review authors add, “Other questions we were unable to answer due to lack of pertinent studies include whether the type of toothpaste or choice of toothbrushing fluid affects outcomes, whether including tongue cleaning in the procedure increases the effect, and whether there is an interaction between toothbrushing and selective digestive tract decontamination.”

Reducing Risk of Ventilator-Associated Pneumonia

The clinical trial randomly assigned 847 patients in France to receive amikacin or a placebo.

For critically ill patients receiving mechanical ventilation, a three-day course of inhaled amikacin reduced the risk of developing ventilator-associated pneumonia (VAP) after 28 days.

Inhaled Amikacin to Prevent Ventilator-Associated Pneumonia,” in The New England Journal of Medicine, notes that “ventilator-associated pneumonia is a disease with an attributable mortality of up to 13% and contributes to increased systemic antibiotic consumption, duration of mechanical ventilation and ICU lengths of stay, and costs.”

The clinical trial randomly assigned 847 patients in France to receive the antibiotic amikacin at 20 mg/kg of ideal body weight or a placebo once daily for three days. All patients were already on ventilation for at least 72 hours.

In the amikacin group, 337 patients (81%) completed the course compared with 355 patients (83%) in the placebo group. After 28 days, 62 patients (15%) in the amikacin group and 95 patients (22%) in the placebo group developed VAP.

“The enrollment of patients after at least 3 days of invasive mechanical ventilation may have enabled amikacin to act sufficiently early to control the tracheobronchial spread of bacteria before pneumonia occurred, with a majority of patients being extubated a few days after the end of the intervention and thus no longer at risk for ventilator-associated pneumonia.”

Development of infection-related ventilator-associated complications also favored amikacin for 18% of patients compared with 26% in the placebo group. However, seven patients (1.7%) in the amikacin group experienced trial-related serious adverse effects compared with four (0.9%) in the placebo group.

A related article in U.S. Pharmacist adds that efforts to control VAP – including tracheal tube cuff management, patients’ positioning, oral care, and reduced sedation and weaning protocols – have been ongoing for decades.

The burden of VAP remains “unacceptably high,” but since the progression to overt pneumonia takes many days with the peak occurring seven days after ventilation, a therapeutic window of opportunity may hinder the process early on.

Cardiovascular-Kidney-Metabolic Syndrome Risks, Therapies

The statement explores the evidence for recommended approaches and therapies.

The care considerations for patients with a combination of risk factors stemming from obesity, diabetes and other causes led to the concept of CKM syndrome.

A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association,” in Circulation, notes that the American Heart Association launched an initiative to explore the evidence and focus on holistic care.

“Many of the key considerations for CKM syndrome care moving forward relate to where, when, and how to deploy an increasing array of cardioprotective therapies with multisystem effects,” the statement adds.

Developed by an interdisciplinary group that included nurses, doctors and scientists, the statement describes the burden on patients with cardiovascular disease, chronic kidney disease and risk factors. It focuses on the impacts of social determinants of health that tend to be associated with CKM syndrome, including societal, community, relationship, behavior and individual predisposition factors.

The statement defines five stages ranging from no risk factors (0) to clinical cardiovascular disease along with metabolic syndrome and/or potential kidney failure (4). Screening starting in early childhood may help reduce cardiac issues later in life.

“For those individuals who are in stages 1, 2, and 3, with substantial lifestyle change and weight loss, there’s the potential to actually regress and go back in staging,” says lead statement author Chiadi Ndumele, Johns Hopkins University, in a related article in Pharmacy Times.

“Holistic approaches to both prevention and management are needed to fully and equitably address the population impact of CKM syndrome, with the goal of advancing cardiovascular health for all,” the statement adds.

Dangers of Unsecured Firearms in Homes

Children exposed to firearm violence might experience poor mental health outcomes.

Loaded and unlocked firearms in homes contribute to a high number of unintentional injury deaths of U.S. children; secure storage could lower the risk significantly.

Unintentional Firearm Injury Deaths Among Children and Adolescents Aged 0-17 Years – National Violent Death Reporting System, United States, 2003-2021,” in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, shows that about three-fourths of these deaths come from unsecured weapons, mostly taken from sleeping areas and nightstands.

“Secure firearm storage practices (e.g., firearm stored locked, unloaded, and separate from ammunition) have been identified as protective factors against unintentional and intentional (i.e., suicides) firearm injuries and deaths of children, highlighting the important role of policymakers, health care professionals and others in partnering with parents, caregivers, and firearm owners to promote secure firearm storage,” the article adds.

A review of data from 2003-2021 indicates 1,262 unintentional firearm deaths among those aged 0-17 across 49 states, plus Washington, D.C. and Puerto Rico. A significant majority were boys (83.1%), involved handguns (74%) and occurred at houses or apartments (85.5%), with 55.6% in their own homes.

Once the storage status was identified, it was determined that 73.8% of firearms were loaded and 76.2% were unlocked. The most common circumstances include a shooter playing with or showing the weapon to another person (66.6%) or unintentionally pulling the trigger (21.3%). Over 10% of children mistook the gun for a toy, including about one-fourth of children ages 5 and younger.

A friend, sibling or acquaintance was responsible in three-fourths of shootings, and about one-third of cases involved other children witnessing the event. “Studies show that children exposed to firearm violence might experience poor mental health outcomes (e.g., anxiety), further underscoring the importance of preventing unintentional firearm injury deaths among children and providing support for those involved in these incidents when they do occur.”

Benefits of Cooler Body Temperature Uncertain for Some Patients With OHCA

Additional trials may be needed to prove the value of cooling as a treatment.

Comatose patients who were resuscitated after an out-of-hospital cardiac arrest (OHCA) with initial nonshockable rhythm fared equally well whether their body temperature was kept intentionally cool or within a normal range.

In “Hypothermia vs Normothermia in Patients With Cardiac Arrest and Nonshockable Rhythm: A Meta-Analysis,” in JAMA Neurology, an analysis of two randomized clinical trials shows that keeping patients with hypothermia at 33 C (about 91 F) resulted in similar all-cause mortality at three months and unfavorable functional outcomes at three to six months, compared with those kept at normal temperatures (36.5 C to 37.7 C).

“In this individual patient data meta-analysis, including unconscious survivors from OHCA with an initial nonshockable rhythm, hypothermia at 33 ⁰C did not significantly improve survival or functional outcome,” the analysis notes.

The analysis included 912 patients, of whom 442 were assigned to the cooling groups in the TTM2 (Targeted Temperature Management) and HYPERION trials. Three-month mortality was 80.1% for patients with hypothermia (354 of 442) and 82.1% for patients with normothermia (386 of 470). Functional outcome unfavorability was 90.0% for patients with hypothermia vs. 89.2%, with all subgroups performing consistently.

Without effective evidence supporting cooling as a treatment measure, additional trials may be needed to prove its value. Only about a quarter of patients in the TTM2 trial had initial nonshockable rhythms, “which limits the generalizability of the trial’s findings to those patients,” adds a related article in ICU Reach.

Some upcoming trials will focus on fever management as well as sedation’s critical impact on longer-term neurological outcomes after cardiac arrest. “Most deaths post-cardiac arrest are due to withdrawal of life-sustaining treatment (WLST) based on perceived poor neurologic recovery prospects,” the article adds.

Nurse Story Video: NTI at 50: Connecting Generations

In 1974, Diane Ogren attended AACN’s inaugural National Teaching Institute & Critical Care Exposition (NTI). In 2023, Maddi Flanagan attended her first in-person NTI. Now, these two critical care nurses meet and reflect on how their shared passion, care and dedication transcend generations.

Watch the Interview