Vasopressin for the treatment of neonatal hypotension

Vasopressin (pitressin), also known as arginine vasopressin (AVP), is an antidiuretic hormone formed in the hypothalamus and secreted from the posterior pituitary gland. Various forms of exogenous vasopressin exist and have been used in neonates to treat conditions such as diabetes insipidus. Vasopressin has also been studied on a limited basis for use in the treatment of catecholamine-resistant hypotension in vasodilatory shock. Hypotension is a significant problem resulting in increased morbidity in preterm, septic, and postsurgical neonates. This article will discuss the role of vasopressin and its use as a therapeutic agent in the treatment of hypotension in the neonate.

How to ensure observations lead to prompt identification and management of hypotension

Hypotension is blood pressure that is abnormallylowand is a medical emergency, requiring rapid treatment and identification of the cause. Failure to manage this clinical sign can lead to a poor prognosis. This article describes the causes and management of hypotension.

How to ensure patient observations lead to effective management of bradycardia

Bradycardia can be a normal physiological sign in fit young adults. However, in acute illness it may indicate life threatening heart block or precede asystole. This article outlines the assessment and management of patients with this condition.

[Complications of the hemodialysis procedure in acute renal failure patients: nursing interventions]

This retrospective study has identified both the prevalence of complications during hemodialitic treatment in patients carrying acute renal failure (ARF) in an intensive care unit of a university hospital and the nursing conduct performed during those episodes. We have assessed sixty-five (282 sessions) records of ARF patients who underwent renal replacement therapy and presented complications during hemodialysis sessions. We have noticed that the most prevalent intradialitic complications were: arterial hypotension (35%), hypothermia (29%), and lack of flow in the vascular access (24.1%). The nursing interventions prioritized during episodes of clinical complications involved clinical assessment (66.8%) and evaluation of patients' consciousness level (59.9%). The search for nursing procedures that are suitable to different situations experienced by patients during hemodialysis, as well as the continuing education of the nursing team are actions that may minimize the intercurrence rate.

Clinical management of intradialytic hypotension: survey results

Intradialytic hypotension (IDH) is one of the most common complications of hemodialysis treatment. Incidence of IDH varies from 10% to 50% of hemodialysis treatments. Numerous publications address the pathophysiology, effect of frequent episodes, and clinical management of IDH, but no recent publication has studied how IDH is managed in dialysis clinics. Interviews and a mail survey were conducted to develop a better understanding of the clinical issues and concerns surrounding the management of hemodialysis patients who experience episodes of IDH. Results of the survey indicate that IDH is prevalent and that clinical management is protocol--driven and consistent with treatment recommendations in the literature.

An analysis of the increased demands placed on dialysis health care team members by functionally dependent hemodialysis patients

A team of health care providers is integral to the care of chronic hemodialysis patients and includes nephrologists, social workers, dietitians, and nurses. Increasingly, the chronic hemodialysis population is composed of older patients with multiple comorbid conditions and reduced functional independence. The demands placed on social workers, nurses, and dietitians caring for the increasingly fragile chronic hemodialysis population have not been examined. We compared the interventions required by social workers, dietitians, and nurses caring for two demographically matched chronic hemodialysis patient groups undergoing dialysis in two outpatient units over a 6-month period to examine the demands imposed by these functionally dependent patients. Patients underwent dialysis in either a step-down unit or an ambulatory unit. Patients undergoing dialysis in the step-down unit had more coronary artery disease (6 of 12 patients [50%] versus 1 of 12 patients; P < 0.025) and peripheral vascular disease (6 of 12 versus 0 patients; P < 0. 004). Mean urea reduction ratio, hematocrit, and serum albumin values, as well as number of hospitalizations and mean days hospitalized for the 6-month study period, were not different between the groups. Patients undergoing dialysis in the step-down unit were more likely to have lower scores on activities of daily living (11 +/- 5 versus 15 +/- 3; P < 0.02), live in a nursing home (58% versus 8%; P < 0.01), be nonambulatory (66% versus 0%; P < 0. 01), and have a catheter as permanent dialysis access (66% versus 9%; P < 0.004). Significantly more social worker and dietitian time in hours per week were provided to the patients in the step-down unit (social workers, 259 versus 201 h/wk; P < 0.001; dietitians, 115 versus 96 h/wk; P < 0.001). Similarly, dialysis treatments requiring nursing interventions (treatments with hypotension, 36% versus 13%; obtaining blood cultures, 7% versus 2%; administering intravenous medications, 9% versus 2%; communicating with other health care providers, 3% versus 0.1%; and non-dialysis-related interventions, 5% versus 0.5%; all P < 0.005) were more common in the patients in the step-down unit. We conclude that increased dialysis provider care is required by patients who are functionally dependent and have increased comorbid conditions. The increased demands this fragile patient population places on dialysis providers must be recognized, examined more closely, and reimbursed appropriately.

Refractory hypotension in trauma: a case study

In the patient with blunt trauma, diagnosis of the cause of ongoing hypotension may be difficult. A number of causes may contribute to refractory hypotension, either alone or in combination. However, by following standard algorithms for the management of these patients, causes can be excluded or identified, then managed appropriately. The following case study highlights one of the diagnoses of exclusion for refractory hypotension in the blunt trauma victim. Ongoing considerations and implications for the nursing care of spinal injured patients are also discussed.

Semi-Fowler's positioning, lateral tilts, and their effects on nonstress tests

OBJECTIVE

To determine whether a lateral tilt for women in semi-Fowler's position for antepartum nonstress tests (NSTs) (a) promotes NST reactivity or (b) shortens testing time required to obtain a reactive tracing.

SETTING

An antepartum fetal assessment unit of a tertiary care facility in eastern Canada.

DESIGN

In this prospective, randomized study, a computer analysis of the NSTs was used to obtain an objective, standardized interpretation of fetal heart rate reactivity. Participants were randomly assigned to two experimental groups using semi-Fowler's position with a 45-degree tilt to either the left or right, or to a control group using semi-Fowler's position with no lateral tilt.

PARTICIPANTS

A convenience sample of 823 nonstress tests was obtained from women with singleton pregnancies, intact amniotic membranes, and gestations between 32 and 42 weeks. The final sample available for analysis totaled 738 nonstress tests from 573 pregnancies.

MAIN OUTCOME MEASURES

Percentage of reactive nonstress tests and the number of minutes required for tests to be reactive.

RESULTS

The rate of reactive NSTs and the time to achieve a reactive NST did not differ statistically for any of the three study groups. Likewise, NST outcomes were similar when the left-tilt group was compared with the right-tilt group. Although no significant differences were found between study groups, less than 2% of the women in the control group (semi-Fowler's position without a lateral tilt) experienced symptoms consistent with supine hypotensive syndrome.

CONCLUSIONS

No statistically or clinically significant differences were found in nonstress tests between the three groups. Lateral tilting did not shorten test time. Results do suggest that hemodynamic changes can occur in 3rd trimester women who are in semi-Fowler's position without a lateral tilt. Lateral tilting of gravidas in semi-Fowler's position during nonstress testing is thus supported to avoid hypotensive symptoms.

Hypotension

Advanced practice nurses are responsible for diagnosing and treating patients with acute onset hypotension. The potential diagnostic hypotheses for hypotension are related to a wide variety of pathophysiologic processes. These processes are represented by the acronym VINDICATE--Vascular (and cardiac), Inflammatory, Neoplastic, Degenerative, Intoxication/Iatrogenic, Congenital, Allergic/Autoimmune, Traumatic, Endocrine/Metabolic However, acute onset hypotension experienced by the adult patient in the hospital is likely to be caused by the vascular (and cardiac) processes of absolute hypovolemia, relative hypovolemia, and pump failure. Developing the differential diagnosis for acute onset hypotension involves making a series of clinical decisions in a stepwise manner. The clinician bases these decisions on information contained in a subjective and objective database and on recognizing patterns in the central findings. However, treatment of hypotension may be necessary before or during the diagnostic process, depending on the severity of the patient's symptoms.

Use of the Trendelenburg position by critical care nurses: Trendelenburg survey

BACKGROUND

Little evidence indicates that changing a patient's body position to the Trendelenburg (head lower than feet) or the modified Trendelenburg (only the legs elevated) position significantly improves blood pressure or low cardiac output. This intervention is still used and is often the first measure implemented for treatment of hypotension.

OBJECTIVES

The purpose of this research was to assess the degree of use of Trendelenburg positions by critical care nurses, the clinical uses of these positions, and the sources of knowledge and beliefs of nurses about the efficacy of the positions.

METHOD

A survey was mailed to 1000 nurses whose names were randomly selected from the membership list of the American Association of Critical-Care Nurses.

RESULTS

The return rate was 49.4%. Ninety-nine percent of the respondents had used the Trendelenburg position, and 80% had used the modified Trendelenburg position, mostly for treatment of hypotension. Most used this intervention as an independent nursing action, and most learned about these positions from their nursing education, nurse colleagues, supervisors, and physicians. The Trendelenburg position was used for many nonemergent reasons; the most frequent use was for insertion of central IV catheters. Although 80% of the respondents believed that use of the Trendelenburg position improves hypotension almost always or sometimes, many respondents recognized several adverse effects associated with use of this position.

DISCUSSION AND CONCLUSIONS

The results provide evidence that tradition-based therapy still underlies some interventions used in the care of critically ill patients and that some nurses may be relying on an outdated knowledge base that is not supported by the current literature.

Cardiovascular emergencies in the post anesthesia care unit

Optimizing the cardiac function of the postanesthesia patient is dependent on identifying the possible causes of dysfunction. The causes of alterations in cardiac function are varied and complex. The PACU nurse must possess a knowledge of cardiac physiology, an intricate understanding of the cardiovascular effects of various anesthetic agents, and astute assessment skills.

Variables associated with hypotension in postoperative total knee arthroplasty patients receiving epidural analgesia

The purpose of the study was to identify variables that may place the total knee arthroplasty patient receiving epidural analgesia at risk for hypotension postoperatively. A review of medical records of this convenience sample of 99 subjects was conducted in this retrospective, descriptive, correlational study. Variables predictive of postoperative hypotension using stepwise multiple regression included low postoperative systolic BP on the nursing unit the day of surgery (R2 = .26, p less than .001), low diastolic BP in postanesthesia room (R2 = .31, p less than or equal to .01), low hemoglobin the third postoperative day (R2 = .37, p less than or equal to .01), use of diuretics preoperatively (R2 = .40, p less than or equal to .05), and total fluid intake first day postoperatively (R2 = .43, p less than or equal to .05). These variables accounted for 43% of the variability in the occurrence of hypotension. Identification of variables predictive of hypotension should provide direction for future care givers and researchers.

Clinical management of the organ donor

Critical care nurses play a vital role in the clinical management of potential organ donors. Knowledge of the physiologic traits a donor will exhibit and the clinical interventions necessary to prevent circulatory collapse are essential in providing care to the organ donor. Maintaining hemodynamic stability in the donor optimizes organ function and improves the chances of successful results in transplant recipients.

Hypotensive crises: identifying the high-risk patient on hemodialysis

Hypotensive crises in patients on hemodialysis remains a substantial problem for both patient and nurse. Awareness of its causes, research-develop assessment tools, and their application in the field may minimize this problem. Nurses play a prominent role in a patient's hypotensive crisis by administering, monitoring, and evaluating the effectiveness of intervention measures used to reverse this hemodynamic state. This study has provided a nursing assessment tool that will enable nurses to predict systolic risk levels and aid them in deciding when to initiate intervention measures.