Download Spring 2014 newsletter - American Association of Critical

MVC-AACN Newsletter
SPRING/SUMMER 2014
AACN has had a busy year so far in
2014!
In April we had our New England
Horizons conference in Portland,
Maine. It was a well-attended event
where lots of learning and good
times took place! (See article and photos
in this newsletter for more details)
In May we had NTI in Denver,
Colorado. Our new AACN
President, Teri Lynn Kiss,
introduced her new theme for the
upcoming year – Focus the Flame!
INSIDE THIS ISSUE
1
Welcome, NTI update
2-9
Sepsis, PAD & ABCDE program review
9 -10
Horizons Conference Review
11-12
June Program – Hope to see you there!
13
Fundraising update, Chapter Board members
14-16
Photos
16
Horizons 2016 information
To learn more go to:
http://www.ntivoices.com/this-girl-is-on-fire/
Part of her theme included FIRE –
Fearlessness, Inquiry, Resilience and
Engagement – an element made up of
these four qualities, qualities that grow
our profession and contribute to our best
possible work.
Newsletter 1
Bundles, Guidelines &
PEARLs: Sepsis, PAD and
ABCDE
a review by Diane Meagher
On October 22, 2013 we held our fall
program, Bundles, Guidelines & PEARLs: Sepsis,
PAD & ABCDE, at the Westford Regency Inn &
Conference Center. The topics, as the title
indicates, focused on the latest guidelines for
sepsis and PAD (Pain, Agitation and Delirium),
as well as the ABCDE Bundle.
At last year’s NTI I had attended a session,
“Sepsis – The Next Core Measure,” presented
by Lisa Soltis, MSN, APRN, PCCN, CCRN-CSC,
CCNS, FCCM, Cardiovascular/Critical Care Clinical
Nurse Specialist at WakeMed Health and
Hospitals, Raleigh, NC. I thought she was a
phenomenal speaker so I contacted her to
speak for our chapter. She accepted and
presented an extended session, “Time is Tissue:
Early Recognition and Management of Sepsis.”
She began with an overview of the
inflammatory changes at the cellular level,
including the normal function of the immune
system and response to stress and infection.
Next she discussed the pathophysiology of
shock. Shock is the inability of the circulatory
system to deliver enough blood to meet the
oxygen and nutrient requirements of body
tissues.
Hypoperfusion, activation of the inflammatory
response, and hypercoagulability are universal
conditions with shock, regardless of the clinical
condition causing the cellular hypoperfusion.
“Timely reversal of the shock state prevents
development of multiple organ failure and
death, hence the phrase ‘time is tissue.’”
The Systemic Inflammatory Response
Syndrome (SIRS) is severe inflammation
caused by major insults. The SIRS diagnostic
criteria include 2 or more of the following:
Temperature > 38.0 C or < 36.0 C
Tachycardia (HR > 90)
Tachypnea (RR > 30 or pCO2 < 32
mmHg)
WBCs > 12K or < 4 K/mm3
Sepsis is SIRS caused by infection, severe sepsis
is associated with organ dysfunction, and
septic shock is associated with hypotension
and decreased end-organ perfusion.
Lisa shared the epidemiology of sepsis, AMI,
stroke and pneumonia to compare the
incidence vs mortality, demonstrating sepsis
had the highest rate of mortality at 29%. Sepsis
is the 6th most common reason for
hospitalization, the most costly, and the leading
cause of non-cardiac deaths in US. Common
causes of sepsis are pneumonia, central venous
line associated bacteremia, and urinary tract
infections. She posed the question, “why hasn’t
sepsis received the same (quality) focus as
other disease states?”
The Surviving Sepsis Campaign (SSC), an
initiative of the European Society of Intensive
Care Medicine, the International Sepsis Forum,
and the Society of Critical Care Medicine, was
developed to improve the management,
diagnosis, and treatment of sepsis. They issued
their third edition of "Surviving Sepsis
Campaign: International Guidelines for
Management of Severe Sepsis and Septic Shock:
2012.
The Surviving Sepsis Campaign Bundles are the
core of the sepsis improvement efforts. Using
"bundles" simplifies the complex processes of
the care of patients with severe sepsis. A
bundle is a selected set of elements of care
distilled from evidence-based practice
guidelines that, when implemented as a group,
have an effect on outcomes beyond
implementing the individual elements alone.
There is a 3-Hour Bundle and a 6-Hour Bundle.
To be completed within 3 hours:
1) Measure lactate level
2) Obtain blood cultures prior to
administration of antibiotics
(Cont……)
Newsletter 2
3) Administer broad-spectrum antibiotics
4) Administer 30 ml/kg crystalloid for
hypotension or lactate ≥4mmol/L
To be completed within 6 hours:
5) Apply vasopressors (for hypotension that
does not respond to initial fluid resuscitation)
to maintain a mean arterial pressure (MAP)
≥65 mm Hg
6) In the event of persistent arterial
hypotension despite volume resuscitation
(septic shock) or initial lactate ≥4 mmol/L (36
mg/dL):
- Measure central venous pressure
(CVP)*
- Measure central venous oxygen
saturation (ScvO2)*
7) Re-measure lactate if initial lactate was
elevated*
*Targets for quantitative resuscitation included
in the guidelines are CVP of ≥8 mm Hg; ScvO2 of
≥70%, and normalization of lactate.
We should all be performing routine screening
of potentially infected, seriously ill patients to
allow for early identification and
implementation of therapy. Cultures should be
obtained as clinically appropriate before
antibiotic therapy as long as it does not delay
the initiation of antibiotics. Imaging studies
should also be performed promptly to confirm
potential source of infection. Administration of
effective antimicrobials should begin within
the first hour of recognition of septic shock and
within 3 hours of severe sepsis without septic
shock. Each hour delay in antibiotics increases
mortality by 5%.
Crystalloids are recommended for initial fluid
resuscitation. Hydroxyethyl starches are not
recommended, however albumin may be
administered for severe sepsis when large
amounts of crystalloids have been
unsuccessful. Each hour of delay in
hemodynamic stability increases mortality by
7%. Vasopressors should be initiated for
persistent hypotension despite fluid
resuscitation with a target MAP of >65 mmHg.
Norepinephrine is the first choice vasopressor.
Epinephrine may be added to and potentially
substituted for norepinephrine when an
additional agent is needed to maintain
adequate blood pressure. Vasopressin 0.03
units/minute can be added to norepinephrine
with the intent of either raising MAP or
decreasing norepinephrine dosage. Low dose
vasopressin is not recommended as a single
agent. Dopamine may be used as an alternative
vasopressor agent to norepinephrine only in
highly selected patients (e.g., patients with low
risk of tachyarrhythmias and absolute or
relative bradycardia). Phenylephrine is not
recommended in the treatment of septic shock
except in circumstances where norepinephrine
is associated with serious arrhythmias, cardiac
output is known to be high and blood pressure
persistently low, or as salvage therapy when
combined inotrope/vasopressor drugs and low
dose vasopressin have failed to achieve MAP
target.
All patients requiring vasopressors should
have an arterial catheter placed as soon as
practical if resources are available. A trial of
dobutamine infusion up to 20 mcg/kg/min
may be administered or added to vasopressor
(if in use) in the presence of myocardial
dysfunction as suggested by elevated cardiac
filling pressures and low cardiac output, or
ongoing signs of hypoperfusion, despite
achieving adequate intravascular volume and
adequate MAP, but not using a strategy to
increase cardiac index to predetermined
supranormal levels. Corticosteroids are not
recommended if able to achieve hemodynamic
stability with fluid resuscitation and
vasopressor therapy. However, if
hemodynamic stability is not achievable,
intravenous hydrocortisone is recommended at
a dose of 200 mg per day, and then taper when
no longer required. ACTH stimulation testing
for adrenal insufficiency is not recommended.
The guidelines include recommendations for
other supportive therapies for severe sepsis.
Red blood cell transfusion is only
recommended when hemoglobin concentration
decreases to <7.0 g/dL to target a hemoglobin
Newsletter 3
concentration of 7.0 –9.0 g/dL in adults, except
in extenuating circumstances such as
myocardial ischemia, severe hypoxemia, acute
hemorrhage, or ischemic heart disease. Fresh
frozen plasma is not recommended to correct
laboratory clotting abnormalities in the
absence of bleeding or planned invasive
procedures. Platelet transfusion is
recommended prophylactically when counts
are <10,000/mm3 (10 x 109/L) in the absence
of apparent bleeding, or when counts are <
20,000/mm3 (20 x 109/L) if the patient has a
significant risk of bleeding. Higher platelet
counts (≥50,000/mm3 [50 x 109/L]) are
advised for active bleeding, surgery, or invasive
procedure.
Blood glucose management should target an
upper blood glucose ≤180 mg/dL. Insulin
dosing should commence when 2 consecutive
blood glucose levels are >180 mg/dL, and
blood glucose values should be monitored
every 1–2 hrs until glucose values and insulin
infusion rates are stable and then every 4 hrs
thereafter. Glucose levels obtained with pointof-care testing of capillary blood should be
interpreted with caution, as such
measurements may not accurately estimate
arterial blood or plasma glucose values.
A combination of pharmacologic therapy and
intermittent pneumatic compression devices
for deep vein thrombosis prophylaxis are
recommended whenever possible unless
contraindicated. Stress ulcer prophylaxis using
H2 blocker or proton pump inhibitor is
recommended for patients who have bleeding
risk factors. When stress ulcer prophylaxis is
used, proton pump inhibitors are preferred.
Administer oral or enteral (if necessary)
feedings, as tolerated, rather than waiting 48
hours. Avoid mandatory full caloric feeding in
the first week but rather low dose feeding (e.g.,
up to 500 calories per day), advancing only as
tolerated. Use intravenous glucose and enteral
nutrition rather than total parenteral nutrition
(TPN) alone or parenteral nutrition in
conjunction with enteral feeding in the first 7
days. Goals of care and prognosis should be
discussed with patients and families as early as
feasible, but no later than within 72 hours of
ICU admission, and should be incorporated into
treatment and end-of-life care planning,
utilizing palliative care principles where
appropriate.
Next Lisa shared nursing considerations to
complement the guidelines. First and foremost
she discussed infection prevention through
education, accountability, surveillance of
nosocomial infections, hand hygiene, and
site/device specific considerations. Prevention
of respiratory infection includes head of bed
elevation greater than 30 degrees, regular oral
care including chlorhexidine gluconate, and
consideration of endotracheal tube (ETT) with
continuous subglottic suctioning, silver coated
ETT, and polyurethane ETT cuff.
Prevention of central line-associated
bloodstream infection (CLABSI) includes
central line bundles, maximal sterile barriers
during central line insertion, chlorhexidine for
skin prep, change IV sets every 96 hours, and
consideration of antibiotic impregnated central
venous catheters.
Prevention of surgical site infection (SSI)
includes antibiotic administration within 1
hour of incision, hair removal with clippers,
post-op glucose <200 on day 1, and
identification and treatment of remote
infections before elective surgery. Prevention
of catheter-associated urinary tract infection
(CAUTI) includes decrease duration of foley
catheter use, maintenance of sterile closed
drainage system, regular perineal hygiene, and
maintenance of unobstructed urine flow.
Sepsis screening tools should be utilized in all
areas of the hospital for early identification and
diagnosis of severe sepsis. Early warning
systems, e.g., Code Sepsis Teams, Rapid
Response Teams, and protocols should be used
to manage patients early. Nurses should be
empowered to implement resuscitation
bundles. Other supportive care includes
nutrition within 24-48 hours, eye care, and
pressure ulcer prevention.
(Cont…)
Newsletter 4
The last portion of Lisa’s presentation focused
on hemodynamic monitoring and tissue
oxygenation, and she stated, “we manage what
we monitor!” She made the case that pressure
(e.g., CVP) does not estimate volume because
compliance is dynamic and always changing.
Causes of decreased compliance include
ischemia, inotropes, increased afterload,
restrictive Cardiomyopathy, increased PEEP,
increased pericardial pressure, and increased
intra-abdominal pressure.
When metabolic oxygen demand is greater
than oxygen delivery, anaerobic metabolism
results in lactate production, metabolic
acidosis, and dysoxia (impaired tissue
oxygenation). The universal goal of critical care
is to maintain adequate tissue oxygenation.
Mixed venous (pulmonary artery) blood is a
good indicator of systemic oxygen delivery and
systemic oxygen uptake. Mixed venous oxygen
saturation (SvO2) is the percentage of Hgb
saturated with O2 in mixed venous blood.
Under normal circumstances, only about 25%
of oxygen is utilized by the cells (normal SvO2 =
75%). During sepsis, mitochondria can’t utilize
available oxygen and SvO2 is elevated >80%.
SvO2 <60 indicates impaired O2 delivery, SvO2
<50 indicates global tissue dysoxia. A decrease
in SvO2 is one of the earliest signs of problems
with tissue oxygenation, i.e., the oxygen
demand is exceeding oxygen consumption.
ScvO2 is a measurement of central venous
oxygenation, drawn from a central line and is
an acceptable alternative to SvO2 although can
differ from SvO2 by up to 10%. SvO2 may be
decreased due to increased O2 consumption
(e.g., hyperthermia, shivering, infection, pain),
decreased CO/CI (e.g., decreased
preload/increased afterload, hypovolemia,
sepsis (late), MODS), decreased O2 supply (e.g.,
respiratory failure, suctioning, increased work
of breathing, decreased alveolar/arterial
oxygenation), and nursing interventions (e.g.,
position changes, chest PT, bathing, visitors).
Causes of increased SvO2 include decrease in O2
demand (e.g., hypothermia, neuromuscular
blocking agents, sedation, sepsis), increased
CO/CI (e.g., positive inotropic agents, afterload
reduction, fluid administration), and increased
O2 supply (increased FiO2, increased SaO2,
increased PaO2). When O2 demand increases,
the body attempts to increase delivery. If
cardiac output increases, SvO2 may remain
unchanged. If delivery does not increase in
response to the increased demand, the tissues
will extract a larger amount of oxygen from the
available supply and will result in a decrease in
SvO2.
To improve tissue oxygenation, maximize the 3
major determinants of oxygen delivery: anemia
- consider transfusion if Hgb <7 g/dl (*Hgb in
banked blood >14 days old has decreased O2
carrying capacity); cardiac ouput – keep CI >2.4
L/min/m2; hypoxia – keep SaO2 >90%. Cardiac
output is equal to HR x SV (stroke volume).
Determinants of SV are preload (increased
preload = increased SV, decreased preload =
decreased SV), afterload (inversely
proportional to CO, i.e., high afterload = low CO,
low afterload = high CO), and contractility
(increased contractility = increased SV,
decreased contractility = decreased SV). Up to
50% of patients resuscitated from shock may
have continued global tissue hypoxia (i.e.,
increased lactate and decreased ScvO2 or SvO2)
even with the normalization of vital signs and
CVP.
PAD
The next speaker was Leanne Boehm, MSN, RN,
ACNS-BC, from the ICU Delirium and Cognitive
Impairment Study Group at Vanderbilt
University Medical Center, Nashville,
Tennessee. Her first presentation was, “Pain,
Agitation, and Delirium: New Guidelines for
Critically Ill Adults.” The new guidelines were
published in 2013 with recommendations as
MVC-AACN Newsletter 5
follows. Monitor pain routinely for all adult ICU
patients. For patients able to self-report use the
Numeric Rating Scale (0-10). For patients
unable to self-report use the Behavioral Pain
Scale (BPS) or Critical Care Pain Observation
Tool (CPOT).i,ii ,iii They do not suggest that vital
signs be used alone for pain assessment in
adult ICU patients but rather that vital signs
may be used as a cue to begin further
assessment of pain.iv
Assessing pain reduces sedative/ hypnotic use
and is associated with improved outcomes.v
Other pain management recommendations
include: preemptively treating chest tube
removal with either analgesics and/or
nonpharmacologic therapy; preemptively
treating other types of procedural pain with
analgesic and/or nonpharmacologic therapy;
using opioids as first-line therapy for treatment
of non-neuropathic pain; using non-opioid
analgesics in conjunction with opioids to
reduce opioid requirements and opioid related
side effects; using gabapentin or
carbamazepine, in addition to intravenous
opioids, for treatment of neuropathic pain;
using thoracic epidural for postoperative
analgesia in patients undergoing abdominal
aortic aneurysm surgery, and thoracic epidural
analgesia for patients with traumatic rib
fractures.vi
Recommendations for Agitation/Sedation
assessment include: depth and quality of
sedation should be routinely assessed in all ICU
patients; the RASS and SASS are the most valid
and reliable scales; they suggest using objective
measures of brain function to adjunctively
monitor sedation in patients receiving
neuromuscular blocking agents; use EEG
monitoring either to monitor non-convulsive
seizure activity in ICU patients at risk for
seizures, or to titrate electrosuppressive
medication to achieve burst suppression in ICU
patients with elevated intracranial pressure.
Maintaining light levels of sedation in adult ICU
patients is associated with improved clinical
outcomes (e.g., shorter duration of mechanical
ventilation (MV) and a shorter ICU length of
stay (LOS)).
Maintaining light levels of sedation increases
the physiologic stress response, but is not
associated with an increased incidence of
myocardial ischemia. The association between
depth of sedation and psychological stress in
these patients remains unclear. They
recommend that sedative medications be
titrated to maintain a light rather than a deep
level of sedation in adult ICU patients, unless
clinically contraindicated. They recommend
either daily sedation interruption or a light
target level of sedation be routinely used in
mechanically ventilated adult ICU patients.vii
Early deep sedation is associated with longer
MV and reduced 6-month survival.viii Research
demonstrates a trend towards more PTSD
symptoms with deep sedation, and no
difference in anxiety or depression scores.
Light sedation patients averaged 1 day shorter
on MV and 1.5 days shorter LOS.ix Daily
sedation interruption decreases duration of
MV. The process is to hold sedation infusion
until patient awakens and then restart at 50%
of the prior dose.
“Awake” is defined as any 3 of the following:
open eyes in response to voice, use eyes to
follow investigator on request, squeeze hand
on request, and/or stick out tongue on request.
Additional outcomes include fewer diagnostic
tests to assess changes in mental status, no
increase in rate of agitated-related
complications or episodes of patient-initiated
device removal, and no increase in PTSD or
cardiac ischemia.x,xi They suggest that
analgesia-first sedation be used in
mechanically ventilated adult ICU patients; that
sedation strategies using nonbenzodiazepine
sedatives (either propofol or
dexmedetomidine) may be preferred over
sedation with benzodiazepines (either
midazolam or lorazepam) to improve clinical
MVC-AACN Newsletter 6
outcomes in mechanically ventilated adult ICU
patients; that in adult ICU patients with
delirium unrelated to alcohol or
benzodiazepine withdrawal, continuous IV
infusions of dexmedetomidine rather than
benzodiazepine infusions be administered for
sedation to reduce the duration of delirium in
these patients.xii
ICU delirium develops in ~2/3 of critically ill
patients, hypoactive or mixed forms are most
common, and it goes undiagnosed in up to 72%
of cases. The following are associated with an
increased risk of delirium: benzodiazepines,
extended ventilation, immobility, coma and
dementia.xiii Sequelae of delirium include
increased mortality, longer intubation time, an
average of 10 additional days in the hospital,
higher costs of care, development of dementia,
long-term cognitive impairment, requirement
for care in chronic care facility, and decreased
functional status at 6 months.xiv,xv ,xvi ,xvii ,xviii
Each day of delirium in the ICU increases the
hazard of mortality by 10%.xix Duration of
delirium was an independent predictor of
cognitive impairment - an increase from 1 day
of delirium to 5 days was associated with
nearly a 5-point decline in cognitive battery
scores. A patient’s testimony,
“One quite literally loses one’s grip on what is
true and what is false because the true and the
false are mixed together in a mess of
experience.”xx,xxi
They recommend routine monitoring of
delirium in adult ICU patients - the CAM-ICU
and the ICDSC are the most valid and reliable
delirium monitoring tools.xxii There is no
published evidence that treatment with
haloperidol reduces the duration of delirium in
adult ICU patients. Atypical antipsychotics (e.g.,
quetiapine, ziprasidone) may reduce the
duration of delirium in adult ICU patients (must
monitor QT interval). They recommend
performing early mobilization of adult ICU
patients whenever feasible to reduce the
incidence and duration of delirium.xxiii
ABCDE
Next Leanne spoke about the ABCDE Bundle,
which provides the first steps in creating a
framework or backdrop for implementation of
the PAD guidelines. The ABCDE protocol is
multiple components, interdependent, and
designed to improve collaboration among
clinical team members, standardize care
processes break the cycle of oversedation and
prolonged ventilation. The components of the
ABCDE Bundle are:
ABC – Awakening and Breathing
Coordination
D
– Delirium Identification and
Management
E
– Early Exercise and Mobility
Awakening and breathing coordination
provides for synergy of daily awakening and
spontaneous breathing trial, and an
opportunity for more effective independent
breathing. Awakening and breathing safety
screens should be performed prior to initiating
a Spontaneous Awakening Trial (SAT) and
Spontaneous Breathing Trial (SBT).
SAT safety screen includes no active seizures,
no active alcohol withdrawal, no active
agitation, no active paralytic use, no myocardial
ischemia (24h), and normal intracranial
pressure.
SBT safety screen includes no active agitation,
oxygen saturation ≥88%, FiO2 ≤50%, PEEP ≤8
cm H2O), no myocardial ischemia (24h), normal
intracranial pressure, and no significant
vasopressor or inotrope use.xxiv
MVC-AACN Newsletter 7
If the patient fails the SAT safety screen, try
again the next day; if the patient passes,
proceed with SAT - sedation cessation. Turn
off/hold all sedatives (off = zero). It is
appropriate to continue analgesic drips in postsurgical, trauma, or chronic pain patients.
Closely monitor and provide reassurance and
repeated explanation of the circumstances. If
the patient fails the SAT (anxiety, agitation,
pain, respiratory rate (RR)>35/min, SpO2
<88%, respiratory distress, acute cardiac
arrhythmia), restart sedation at 50% previous
dose, titrate to goal, and try again the next day.
If the patient passes SAT, proceed with SBT. If
the patient passes the SBT consider extubation;
if the patient fails (RR >35/min, RR <8/min,
SpO2 <88%, respiratory distress, mental status
change, acute cardiac arrhythmias), resume full
ventilatory support. “Wake up & Breathe”
resulted in less benzodiazepine use, faster
extubation, sooner ICU and hospital discharge,
and better survival at 1 year.xxv
Delirium identification and management begins
with identifying risk factors and etiology, and
nonpharmacologic prevention and
management. “Stop and THINK” - should any
medications be stopped or lowered, especially
sedatives; use the minimal amount of sedation
necessary – light sedation, daily sedation
cessation; assess for pain. Use the THINK
mnemonic to identify the etiology of delirium:
Toxic situations (CHF, shock, dehydration, HTN,
new organ failure (liver/kidney)); Hypoxemia,
Infection/sepsis (nosocomial); Immobilization;
Nonpharmacologic interventions (sleep
protocols, noise control, early mobility, hearing
aids, glasses reorientation, music); K+ or
electrolyte problems. xxvi
Assess for delirium with a validated scale,
identify and reverse/treat underlying causes of
delirium, and optimize non-pharmacologic
strategies. Non-pharmacologic interventions
include sleep preservation and enhancement,
environmental changes (e.g., noise reduction),
sensory aids (e.g., glasses), and reorientation
and cognitive stimulation. Early mobility is the
only non-pharmacologic intervention shown to
reduce ICU delirium.xxvii See the PAD guidelines
above for recommendations for pharmacologic
management of delirium.
The final component is Early Exercise and
Mobility. The benefits of exercise include
functional independence at discharge,
decreased duration of delirium, decreased time
on ventilator, decreased LOS, decreased costs
and improved neurocognitive outcomes.xxviii,xxix
,xxx ,xxxi The Early Exercise and Mobility Protocol
begins with passive range of motion (ROM) and
progresses to active ROM, sitting/dangling,
transferring to chair, marching and walking.
The benefits of the ABCDE Bundle include
liberation from the ventilator, earlier ICU and
hospital discharge, return to normal brain
function, independent functional status, and
increased survival.xxxii The ABCDE Bundle
requires the collaboration of the
interdisciplinary patient care team – nursing,
respiratory therapy, PT/OT, physicians and
pharmacists. For further information and
resources, see www.ICUdelirium.org and
www.aacn.org.
--------------------------------------------------
http://www.survivingsepsis.org/Bundles/Pages/default
.aspx. Accessed 5/9/14.
http://www.survivingsepsis.org/Guidelines/Documents
/Hemodynamic%20Support%20Table.pdf. Accessed
5/9/14.
http://www.survivingsepsis.org/Guidelines/Documents
/Other%20supportive%20therapy.pdf. Accessed
5/9/14.
MVC-AACN Newsletter 8
Endnotes:
i
Barr J, et al. Crit Care Med. 2013;41:263-306.
Payen JF, et al. Crit Care Med. 2001;29(12):2258-2263.
iii
Gélinas C, et al. Am J Crit Care. 2006;15:420-427.
iv
Barr J, et al. CritCare Med. 2013;41:263-306.
v
Payen JF, et al. Anesthesiology. 2009;111:1308-1316.
vi
Barr J, et al. Crit Care Med. 2013;41:263-306.
vii
Barr J, et al. Crit Care Med. 2013;41:263-306.
viii
ShehabiY, et al. Am J Respir Crit Care Med. 2012;186(8):724-731.
ix
Treggiari MM, et al. Crit Care Med. 2009;37(9):2527-2534.
x
Kress JP, et al. N Engl J Med. 2000;342:1471-1477.
xi
Needham DM, et al. Crit Care Med. 2012;40(2):502-509.
xii
Barr J, et al. CritCare Med. 2013;41:263-306.
xiii
Vasilevskis EE, et al. Chest. 2010;138(5):1224-1233.
xiv
Bruno JJ, Warren ML. Crit Care Nurs Clin North Am. 2010;22(2):161-178.
xv
Shehabi Y, et al. Crit Care Med. 2010;38(12):2311-2318.
xvi
Rockwood K, et al. Age Ageing. 1999;28(6):551-556.
xvii
Jackson JC, et al. Neuropsychol Rev. 2004;14:87-98.
xviii
Nelson JE, et al. Arch Intern Med. 2006;166:1993-1999.
xix
Pisani MA. Am J Respir Crit Care Med. 2009;180:1092-1097.
xx
Girard TD, et al. Crit Care Med. 2010;38:1513-1520.
xxi
Misak CJ. Am J Respir Crit Care Med. 2004;170(4):357-359.
xxii
Barr J, et al. CritCare Med. 2013;41:263-306.
xxiii
Barr J, et al. Crit Care Med. 2013;41:263-306.
xxiv
Girard TD, et al. Lancet. 2008;371(9607):126-134.
xxv
Girard et al. Lancet 2008; 371:126-134.
xxvi
Jacobi J, et al. Crit Care Med 2002;30:119-141.
xxvii
Schweickert WD, et al. Lancet. 2009;373:1874-1882.
xxviii
Schweickert et al 2009; 373:1874-82.
xxix
Chiang et al 2006; 86:1271-81.
xxx
Needham et al 2010; 91:536-42.
xxxi
Morris et al CCM 2008; 36:2238-43.
xxxii
Morandi A et al. Curr Opin Crit Care,2011;17:43-9.
ii
A Review of Horizons by a New Critical Care RN!
Submitted by Krista DiPietro
Horizons 2014 was especially inspiring for me; it was my first as an RN. I have been a member of AACN since I was a
nursing student and attended Horizons twice while in nursing school. I currently work on an IMC unit and feel that I
was able to absorb a substantial amount of information from each and every session. From listening to AACN
president, Vicki Good, give the keynote address with her inspiring words, to belly laughing while attending a humor
session, there wasn’t a moment I didn’t like. There was a large variety of topics this year, ranging from sepsis to
heart failure updates to street drugs and many more. Most of the speakers were so engaging that the hour long
sessions felt like five minutes.
MVC-AACN Newsletter 9
Vicki Good opened the conference with a presentation focused on her motivating AACN theme, “Stepping Forward.”
She explained how the first step starts with a decisive moment that leads to transforming knowledge into positive
action. This action leaves a “wake” representing our character that changes and grows as we gain experience. The
wake we leave can be either choppy or smooth; it’s up to us to decide what kind of wake we will leave. Being new to
critical care, this really spoke to me as I begin to envision my new career path.
Kathleen Vollman will always represent what I aspire to be….a true mentor. She spoke on several topics including
mouth care and ventilator acquired pneumonia and the “power of one” that each of us are in this aspect of patient
care. This session really opened my eyes about how only a few minutes can prevent a patient from becoming even
sicker than when they were admitted. Kathleen has such a way of presenting the evidence to empower us to act on
behalf of the patients entrusted to us. I left Kathleen’s sessions feeling driven to advocate for what our patients
need and deserve.
The other speaker who left an indelible mark on me was Mary Bylone. Mary spoke about how to use our “bold
voice.” Her presentation, Using Your Bold Voice: The Good, The Bad and The Ugly, concentrated on the healthy
work environment and how patient outcomes are influenced by it. But, she also spent some time talking about how
we have to become aware of our own values, strengths and weaknesses because that’s what the core for our bold
voice becomes, and that what I feel is important in my organization. It is from this foundation that we can spread
the message that patient safety is our goal as critical care nurses. She really broke down how to prioritize and
approach various situations; particularly with skilled communication as the means to hold ourselves and others
accountable. For my bold voice to be heard I have to develop strong communication skills to get the message of
patient safety out there.
Finally, Sue Goran had me in tears with her session on humor, titled “Humor: Not Just a Laughing Matter!” I was
laughing uncontrollably. She explained the difference between wit…the thought-oriented experience of humor,
mirth…the emotional response (joy), and laughter…the physiological response. She went on, in her own unique
comedic style, to point out all of the therapeutic physical and social effects of humor, as well as the benefits to the
workplace. Sue ended her session by having the audience members sing the following to the tune of “Row, Row,
Row Your Boat:” “Laugh…laugh…laugh out loud, Each and every day; Chuckling…chuckling…chuckling…chuckling,
Health is on the way!
The Horizons conference is a breath of fresh air, with hundreds of nurses gathering together for a few days of
learning, networking and fun. I am already looking forward to Horizons 2016 in Rhode Island. If you have never
attended a Horizons conference, whether you are a nursing student or a veteran nurse, you are missing out on
something special. Hope to see you in 2016!
MVC-AACN Newsletter 10
Don’t forget to mark your calendar for the upcoming MVCAACN program on June 10th being held at the Radisson Hotel
& Suites in Chelmsford from 7:30am – 4:30pm!
Deborah Tuggle MN, APRN, CCNS, FCCM will present
“Critical Care Concepts”
PROGRAM DESCRIPTION:
This program is designed to provide participants with a comprehensive review of a variety of critical
care topics, debunk a multitude of myths, and provide an update on the latest trends in evidencebased practice and critical care guidelines. Attending dynamic nursing conferences can be inspiring
and uplifting to professional morale, but the exciting information and new ideas may never make it
back to the bedside where it can benefit patients and staff. The final session will discuss methods
for keeping up momentum and motivating others towards change. This program is intended for nurses
at all levels and in every acute setting.
LEARNING OBJECTIVES:
At the completion of this seminar the learner will be able to:
Discuss the 4 steps of oxygenation.
For each step, describe clinical measures, barriers to achieving and therapeutic interventions.
Review the fluid compartments and fluid dynamics of the body.
Discuss past and current methods for assessing preload and fluid responsiveness.
Describe the effects of hypo, iso, and hypertonic fluids on the 3 fluid compartments.
Review current recommendations for fluid maintenance and fluid resuscitation.
Discuss the risk factors and clinical findings of DVT and PE including as seen in the ventilated patient.
Review the pros and cons of various diagnostic tests used in diagnosing DVT & PE.
Describe preventives therapy and management of DVT & PE in the critical care setting.
Describe common misconceptions about the meaning of arterial blood pressure readings.
Discuss how the blood pressure formula can be used to troubleshoot causes of hypotension.
Review better measures and better support strategies for perfusion than those conventionally
employed.
Describe three techniques for turning other nurses on to the information you have obtained.
Review 5 ways to raise the bar and cultivate a culture of evidence-based practice in your unit.
SCHEDULE:
7:30 – Registration/Continental Breakfast
8:00 – Oxygenation: Debunking Myths & Safeguarding Tissues
9:30 - BREAK
10:00 - The Sea Within: Fluid Replacement Therapy
11:15 – LUNCH (buffet lunch included)
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12:15 - Pulmonary Emboli: The Silent Killer
1:30 - BREAK
1:45 - Hypotension & Shock: The Truth About Blood Pressure
2:45 - BREAK
3:00 - Take Your Knowledge And Run
4:15 – Evaluation
CONTACT HOURS:
The American Association of Critical-Care Nurses is approved by the California Board of Registered
Nursing, Provider Number 01036. This program has been approved for 7.50 Contact Hours, Synergy
CERP Category A, File Number 00018749.
ABOUT THE SPEAKER:
Deborah Tuggle, MN, APRN, CCNS, FCCM
is a Clinical Nurse Specialist with over 35 years of experience in critical care. She is a published
author, national speaker and chapter leader in the American Association of Critical Care Nurses
(AACN) and an active committee member of the National Association of Clinical Nurse Specialists
(NACNS). She is also a committee leader, Paragon Coach, and two-time Presidential Citation winner
for the Society of Critical Care Medicine (SCCM). As founder of the continuing education and
consultation company, Critical Care Curriculum, Deb has been instrumental in enriching patient care at
hospitals around the country. She has a passionate commitment to life-long learning and a reputation
for developing quality courses that are both evidence-based and patient-oriented. In addition, to
cutting-edge and pragmatic content, her dynamic style and sense of humor keeps audiences engaged,
entertained and motivated to improve their care. Deb's courses promote many best practice
initiatives including AACN Practice Alerts, Surviving Sepsis Campaign interventions, ihi infection
prevention bundles, Joint Commission's National Patient Safety Goals, and many more. She has
developed learning opportunities for nurses, physicians, respiratory therapist, and other ancillary
staff including ECG and hemodynamic monitoring accuracy, successful rescue responses, optimal
ventilator management, collaborative communication skills, and healthy work environments. Her
consultation with hospitals on critical care competency has brought them in alignment with AACN
expectations and promoted greater confidence and attainment of CCRN and PCCN credentials. Deb is
a graduate of the University of Kentucky and the University of Washington Schools of Nursing and
employed as a Critical Care CNS at Norton Women's Hospital in Louisville, KY.
FOR MORE INFORMATION:
Diane Meagher 978-455-4167 or
Email: [email protected]
MVC-AACN Newsletter 12
Thank you to all who participated in the Chapter Tastefully
Simple Fundraiser in support of “Cardiac Quest” - (three 7th
grade girls raising money to place AEDs on local playing fields and parks). The
girls have placed 3 AEDs in the past year and have plans for 2 more with help
from our Chapter! $120 was raised for this worthwhile cause! Thank you!
2014 Chapter Board Members:
Chrissy Cebollero will be finishing up her year as President as of June 30, 2014.
Michele Woonton will become the new Chapter President as of July 1, 2014.
Sue Wheeler is the President-Elect and she will be taking over in July 2015!
Sue Sadowski – Scholarship chairperson
Linda McGowan and Doris Barreiro - newly appointed to Scholarship committee
Diane Meagher – Programs
Ellen Stokinger – Membership
Chrissy Cebollero – Webmaster
Eileen Scondras – past President
Sue Ouellette – secretary
Dianne Forsyth – treasurer
Valerie Fernald - publications
If you would like to find out about how to become more involved in the Chapter
please reach out to any board member.
Go to the www.AACN.org website and at the bottom of the page click on
“Chapters”.
Next click on Massachusetts, Merrimack Valley, and e-mail a chapter officer”, or
simply click here:
http://www.aacn.org/dm/Chapters/EmailOfficers.aspx?mid=2874
MVC-AACN Newsletter 13
Photo Gallery
Chapter Christmas Dinner at Cobblestones – Dec 2013
One of the 2013 Chapter Scholarship winners, Rebecca Order, with Sue
Sadowski RN at the Transitions dinner in June 2013
2014 Scholarship winners are Thomas Coye from Georgetown, going to Salem
State College and Devinne Healy from Dracut High, going to Rivier College.
MVC-AACN Newsletter 14
Chapter member Maureen McLaughlin presenting at NTI 2014
Horizons 2014 Portland, ME – out on the town
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Horizons attendees enjoying the city of Portland after classes
HORIZONS 2014 in Portland, ME was a fun, well-attended learning event for critical
care RN’s from New England and beyond. The Horizons planning committee works on
this bi-annual event to make sure it is a worthwhile and fun time for all who attend.
Merrimack Valley Chapter member Laura Pruyn won the Nancy Houle Continuing
Education Scholarship - a full three-day paid scholarship to attend this Horizons –
Congratulations Laura!
The next Horizons is in 2016 and will be held in Providence, Rhode Island. Plan ahead
to attend in April 2016!
If you would like to apply for the Nancy Houle scholarship for Horizons 2016 go to the
website: www.Horizons2014.org.
MVC-AACN Newsletter 16