Factors that influence critical care nurses' management of sedation for ventilated patients in critical care: A qualitative study

BACKGROUND

Optimising sedation use is key to timely extubation. Whilst sedation protocols may be used to guide critical care nurses' management of sedation, sedation management and decision-making is complex, influenced by multiple factors related to patients' circumstances, intensive care unit design and the workforce.

AIM

To explore (i) critical care nurses' experiences managing sedation in mechanically ventilated patients and (ii) the factors that influence their sedation-related decision-making.

DESIGN

Qualitative descriptive study using semi-structured interviews. Data were analysed using Braun and Clarke's six-step thematic analysis.

SETTING AND PARTICIPANTS

This study was conducted in a 26-bed level 3 accredited ICU, in a private hospital in Melbourne, Australia. The majority of patients are admitted following elective surgery. Critical care nurses, who were permanently employed as a registered nurse, worked at least 16 h per week, and cared for ventilated patients, were invited to participate.

FINDINGS

Thirteen critical care nurses participated. Initially, participants suggested their experiences managing sedation were linked to local unit policy and learning. Further exploration revealed that experiences were synonymous with descriptors of factors influencing sedation decision-making according to three themes: (i) Learning from past experiences, (ii) Situational awareness and (iii) Prioritising safety. Nurses relied on their cumulative knowledge from prior experiences to guide decision-making. Situational awareness about other emergent priorities in the unit, staffing and skill-mix were important factors in guiding sedation decision-making. Safety of patients and staff was essential, at times overriding goals to reduce sedation.

CONCLUSION

Sedation decision making cannot be considered in isolation. Rather, sedation decision making must take into account outcomes of patient assessment, emergent priorities, unit and staffing factors and safety concerns.

IMPLICATIONS FOR CLINICAL PRACTICE

Opportunities for ongoing education are essential to promote nurses' situational awareness of other emergent unit priorities, staffing and skill-mix, in addition to evidence-based sedation management and decision making.

Pharmacokinetics, metabolism, excretion and plasma protein binding of 14C-levofloxacin after a single oral administration in the Rhesus monkey

Levofloxacin's metabolism, excretion, and in vitro plasma protein binding, together with its pharmacokinetics, were studied in the Rhesus monkey in support of an anthrax efficacy study in this species. Three males and three female Rhesus monkeys were dosed with a single oral dose of 14C-levofloxacin at 15 mg kg-1 (2 MBq kg-1). Following dose administration, blood samples were collected up to 48 h post-dose, and urine and faeces were quantitatively collected up to 168 h post-dose. Blood, plasma, urine, and faeces were analysed for total radioactivity. Metabolite profiling and identification was performed using radio-high-performance liquid chromatography (HPLC) and liquid chromatography coupled with tandem mass spectrometry detection (LC-MS/MS). Additionally, the plasma protein binding of levofloxacin was determined in vitro by means of equilibrium dialysis. Peak plasma levels of total radioactivity and levofloxacin were rapidly reached after oral administration with a total radioactivity blood: plasma ratio close to unity. The elimination half-life of levofloxacin was estimated at about 2 h. Total radioactivity was mainly excreted in urine (about 57-86% of the dose) with faecal excretion accounting for only a minor fraction of the total amount of excreted radioactivity (about 7.4-14.7%). In the plasma, the majority of total radioactivity was accounted for by levofloxacin. In addition, two minor metabolites, i.e. levofloxacin n-oxide and presumably a glucuronide conjugate of levofloxacin, were detected. In the urine, five components were found, with levofloxacin being the major component. Minor metabolites included desmethyl levofloxacin, levofloxacin n-oxide, and a glucuronide conjugate of levofloxacin. In the faeces, the major analyte was a polar metabolite, tentatively identified as a levofloxacin glucuronide. The in vitro plasma protein binding was low (on average 11.2%) and independent of concentration (1.0-10.0 microg ml-1). No sex differences were noted in any of the investigations. The present data indicated that the metabolism and excretion pattern, and also the in vitro plasma protein binding of levofloxacin in the Rhesus monkey, were comparable with those previously reported in man, hereby supporting the use of this animal species in the efficacy evaluation of levofloxacin against inhalation anthrax. The shorter half-life of levofloxacin in the Rhesus monkey relative to man (2 versus 7 h) prompted the development of an alternative dosing strategy for use in the efficacy study.

Surgical management of incompletely excised basal cell carcinomas of the head and neck

We made a retrospective audit of all basal cell carcinomas excised in the Maxillofacial Units at St. Richard's Hospital, Chichester and the Worthing and Southlands NHS Trust between 1990 and 1999. A total of 3795 BCCs were excised. Of these, 3560 were completely excised (93.8%) and 235 were incompletely excised (6.2%), which compares favourably with other series. Of these, 84 patients had further excision, 11 had radiotherapy, and 140 were kept under review. Residual tumour was present in 45% of the re-excised specimens. Of the 140 cases managed by observation, 21% recurred. Notably, 31% of patients in the observation cohort died of other causes without recurrence. Incomplete excision was significantly more likely (P < 0.001) if multiple lesions were excised at the time of operation. Involvement of multiple margins was not a significant risk factor for recurrence in the 'observed' cohort. This study shows that a flexible strategy, which balances observation, further excision and radiotherapy, is superior to any single approach.

Parotid neoplasms in children: experience of diagnosis and management in a district general hospital

Parotid neoplasms are uncommon in children and the available literature is predominantly from specialized centres. This paper highlights our experience at a district general hospital, in the diagnosis and management of parotid neoplasms in children. The case records of all parotidectomies performed in a 26-year period between 1974-1999 were scrutinized and patients aged 18 years and below identified. The demographic data, histology, presentation, investigations, treatment, outcomes and complications were analysed. 545 parotidectomies were performed in 536 patients, in whom 569 neoplasms were diagnosed. Only 12 patients aged 18 and under were identified (2.2%). The relative frequency of individual tumours differed markedly from that in adults. 75% of the tumours were benign. Pleomorphic adenoma and mucoepidermoid carcinoma were the most common tumours. A painless mass was the most frequent clinical presentation and CT sialogram was the most common investigation. Parotidectomy with preservation of the facial nerve was performed in all cases, and adjuvant radiotherapy employed in the case of malignant tumours. All patients were alive and well at the time of last follow up. Transient facial nerve palsy and hypertrophic scars were the most common complications.

Surgical management of cutaneous squamous cell carcinoma of the head and neck

A retrospective audit was made of histological records and hospital case notes of patients who had cutaneous squamous cell carcinomas excised from the head and neck region at the Maxillofacial Units at St Richard's Hospital, Chichester and Southlands Hospital, Shoreham-By-Sea, UK. A total of 227 lesions were excised from 183 patients over a 5-year period between 1990 and 1995. The local recurrence rate was 4% (9/227) and 12 (7%) of the patients presented with or developed regional nodal metastases. Of the 183 patients, 177 (97%) were cured. These rates compare favourably with those of other published series of cutaneous squamous cell carcinoma managed by surgical techniques that did not follow the micrographical technique of Mohs. Certain characteristics may aid in the prediction of those cancers that may be more aggressive. It is important to evaluate each case in terms of histological grade and site and to design management plans to deal with each lesion in the most appropriate way.

High incidence of breast and endometrial neoplasia resembling human Cowden syndrome in pten+/- mice

PTEN is one of the most commonly mutated tumor suppressor genes in human cancer. PTEN mutations have been implicated in the development of a variety of human neoplasia, including high-grade glioblastoma, prostate, breast, endometrial, and thyroid carcinoma. Germ-line mutations of PTEN cause Cowden's syndrome (CS), a multiple hamartoma condition resulting in increased susceptibility for the development of cancer. When more than 6 months old, pten+/- mice develop a range of tumors, partially resembling the spectrum of neoplasia observed in CS patients. One-half (32 of 65) of pten+/- females developed breast tumors, whereas all (65 of 65) of the females had endometrial hyperplasia, and there was a high incidence (14 of 65) of endometrial cancer. Hamartoamous tumors of the gastrointestinal tract, as well as prostate and adrenal neoplasia, were also frequently observed. Significantly, the spectrum of neoplasia observed in pten+/- mice partially overlaps with the types of tumors frequently detected in CS patients. The majority of tumors in pten+/- mice exhibit loss of heterozygosity at the pten locus, which indicates the importance for loss of PTEN function in tumor formation. Consistent with the role of PTEN in negative regulation of PKB/Akt phosphorylation and activity, pten loss of heterozygosity is accompanied by hyperphosphorylation of PKB/Akt in tumors. Taken together, our results establish pten+/- mice as an excellent animal model system for the investigation of PTEN-related hamartoma syndromes, as well as the role of PTEN in breast and endometrial carcinogenesis.

The Chichester diagnostic peritoneal lavage simulator

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Medical audit and quality of care--a new English initiative

In 1989 the Government in the UK announced a fundamental review of the financing of the National Health Service (NHS). Before the review, health authorities were responsible for both establishing need and providing services. Health Authorities are now allocated resources with which they commission services from managerially independent provider units. In the discussion that preceded the review concern was expressed about standards of clinical care given by doctors. It was recognised that these were professional issues which could not be directly addressed through the commissioning process, therefore within its NHS review proposals, the Government made clear its expectation that all doctors working in the NHS should participate in medical audit. This was defined as a systematic peer review of their work, including procedures used for diagnosis and treatment, the use of resources and the resulting outcome for patients. Managers should be provided with regular general reports of audit activity. These proposals for medical audit have been well received by the medical profession, who are now working closely with the Government to put them into practice.