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MVC-AACN Newsletter
FALL 2015
30th Anniversary
Celebration!
Our Chapter celebrated 30 years this year with a
party at Lenzi’s on September 17th. A good time
was had by all!
Our Chapter has grown over the past 30 years and
is still going strong today! Thank you for being
part of this influential group of critical care nurses
who make a difference in healthcare decisions and
patients’ lives!
(see story on page 14 and more photos on our
Chapter Face Book page)
INSIDE THIS ISSUE
1
30th Anniversary celebration
2
Holiday party invitation
2-13
NTI 2015: A Review
13
Future NTI and Horizons dates to remember
14
30th Anniversary event
15-16
Chapter information
17
2015 Scholarship winners
18-19
Endnotes
19-31
Spring 2015 Program Review
Our Distinguished group!
Front row seated (left to right) - Frances McDonald,
Ellen Stokinger, Kathleen Heery, Mary Lavieri
1st row- standing (left to right) - Laura Pruyn, Margaret
Chernaik, Christina Cebollero, Susan Sadowski, Sue
Ouellette
2nd row (left to right) - Diane Meagher, Michele
Woonton, Valerie Fernald, Lisa Bourgeois, Susan
Wheeler, Krista DePietro, Linda McGowan, Steve
Ouellette
Back row (left to right) - Lisa Govoni, Dianne Forsyth,
Maureen Ide
Not pictured - Doris Barreiro, Mary Nihan, Ellie
Dicenso, and Reva Belmore
Newsletter 1
It may only be October but
you should have already
received an invitation to the
Chapter Christmas Party on
NTI 2015: A Review
th.
December 13 We are
(Be sure to check out photos on our Chapter Face
planning to attend the Boston
book page!)
Pops at the Lowell Memorial
Auditorium with dinner
By Diane Meagher RN BSN CCRN
This year the AACN National Teaching
Institute (NTI) & Critical Care Exposition was
held May 17-21 in San Diego, California! My
husband and I flew out there a few days early
the week before to get in a little vacationing. It
was not as warm as I expected with
temperatures in the 60’s every day. Touring on
the hop-on hop-off trolley we learned that the
average temperature in San Diego is 70
degrees. They also say it “never” rains in San
following at 50 Warren St in
Lowell (U-Mass Lowell).
RSVP’s were due to Sue
Wheeler by Oct 20th.
Diego – (“♪it never rains in southern
Don’t forget to bring an
California♪”). They get ~10 inches of rain per
unwrapped toy for our annual
Toys for Tots donation too!
year, compared to over 40 inches per year in
Boston. However, it rained part of each day
that my husband was with me in San Diego –
but they are having a drought out there and we
did not let it interfere with our vacationing!
Newsletter 2
(Continued on page 3)
(Continued from page 2)
We went on a Seal Tour (like a Boston
Duck Tour), visited Balboa Park, had pizza in
Little Italy, ate (and drank) Mexican in Old
Town, had dinner in the Gaslamp Quarter, and
toured the USS Midway Aircraft Carrier
Museum . Michele and I went back to Balboa
Park on Sunday to attend an organ concert at
the Spreckels Organ Pavilion - one of the
world's largest outdoor pipe organs.
Merrimack Valley Chapter (MVC)
members Michele Woonton and Rachel
Sorrentino joined me in San Diego for NTI.
Other MVC members who attended include
Ellen Stokinger, Sue & Steve Ouellette, Sue
Wheeler, and Colleen Heafey, as well as recent
Lowell General Hospital retiree Frances
“Twilly” McDonald. Maureen McLaughlin
presented at NTI again this year! Natalie
Brunetto, who moved to California last year
also joined us – it was so great to see her there!
And Lowell General Hospital “alumnus” Kathy
Laferriere, who also moved out to California
this past year, met us for dinner one night
while we were there. There may have been
other MVC members there, but I did not see
them. It’s funny – you seem to run in to the
same people again and again, but then never
see others.
AACN President Teri Lynn Kiss’ theme
for this past year was, “Focus the Flame.” At the
Monday morning SuperSession she recounted
stories that AACN members had shared with
her over the past year about how they focused
the flame. At the end of the SuperSession
everyone received a notepad encouraging them
to find ways to refuel their flames every day.
The 2015 Visionary Leaders Awards
were presented at this SuperSession and one of
the three recipients, Dr. Paul Batalden said a
few funny and unexpected words, “surround
yourself with people you consider friends and
stay away from jerks!”
The keynote speaker on Monday was Dr.
Margaret Hefferman who spoke about “willful
blindness” “with anecdotal stories and a
startling statistic that 85 percent of employees
are afraid to speak up about problems they see
within their organization.” “However, we can
overcome willful blindness. ‘The health and the
survival and the success of our institutions
depend not just on the leaders at the top,’ she
said. She added that people are the eyes and
ears of an organization. ‘It is always the people
in an organization who really know what’s
going on. And when they dare to look, and they
dare to think for themselves, and they dare to
speak up, the seven-nation army could never
hold them back.’” This willful blindness falls
right in line with the “Silence Kills” study and
the AACN Healthy Work Environments (HWE)
initiative. (Please refer to the links in the
endnotes for more information.)
The first concurrent session I attended
was, “Using Your Bold Voice: The Good, the Bad
and the Ugly,” presented by Mary Bylone, RN,
MSM, CNML, Regional Vice President of Patient
Care Services at William W. Backus Hospital in
Norwich, CT. I knew Mary from the AACN
Region 1 Horizons committee, and she has also
been involved with AACN on a national level.
This presentation also fell in line with the HWE
initiative, specifically the skilled
communication standard.
She reviewed the elements of skilled
communication and described various ways to
effectively use the bold voice of nursing in all
conversations around patient care to influence
decision-making. She also cautioned about
communication in this age of advanced
technology and social media and the (cont. . . )
Newsletter 3
(NTI 2015 cont. . . )
potential risks of violating patient privacy and
jeopardizing continued employment despite
innocent intentions – I know I have heard of
nurses being fired for posting inappropriate
content on Facebook.
This was the first year I attended the
Distinguished Research Lecture session. The
AACN Distinguished Research Lectureship
recognizes significant contributions to acute
and critical care nursing research, and the
award is sponsored by Philips Healthcare. This
year’s recipient was Elizabeth J. Bridges, RN,
PhD, CCNS, FCCM, FAAN – she is one of my
favorite speakers at NTI. She presented,
“Research at the Bedside: It Makes a Difference,”
and shared some of her research around the
continuum of care of our wounded warriors on
their 8,000 mile journey home to the US – the
care environment is very different in the back
of a cargo aircraft!
The last session I attended on Monday
was one of my favorites, “Improving Practice
Through EBP: Moving Sacred Cows Out to
Pasture,” presented by Mary Beth Makic, RN,
CNS, PhD, CCRN, CCNS, FAAN, Research Nurse
Scientist at the University of Colorado Hospital.
Carol Rauen usually co-presents this session
but unfortunately was unable to be there due
to a family emergency. Mary Beth announced
that when they put out feelers for “Sacred Cow”
practice habits still in use but not supported by
research, they did not receive any new
suggestions. So this year she reviewed and
gave updates on “Sacred Cows” from the
previous seven years.
The first topic was Hospital Acquired
Conditions: Infection Prevention, CAUTI
(Catheter Associated Urinary Tract Infection)
and VTE (venous thromboembolism).
Principles of infection prevention
include isolation of patients, barrier
precautions, decontamination of the
environment, decontamination of items and
equipment, and antibiotic stewardship, but the
resounding theme is hand washing. She shared
a couple of quotes from Florence Nightingale,
“true nursing ignores infection except to
prevent it,” and “every nurse ought to be
careful to wash her hands frequently during
the day…”
CAUTI is among the most common HAIs
(Healthcare-Associated Infections), but there is
an additional risk of patient falls and increased
risk of morbidity in older patients. We should
all have CAUTI prevention initiatives at our
facilities to decrease unnecessary urinary
catheter insertions and to promote early
removal – nurse driven removal protocols, as
well as evidence-based routine care of patients
with urinary catheters. Mary Beth shared
multiple CAUTI evidence-based resources (see
links in endnotes).,,,,,,,
All patients should be assessed for risk
of VTE. PE (pulmonary embolism) is the most
preventable cause of death. Risk factors include
bedrest, post-op, immobility, cancer diagnosis,
pregnancy, hypercoagulable states, advanced
age, extended travel, obesity, and all ICU
patients. Prevention is both mechanical and
pharmacologic. Intermittent pneumatic
compression (IPC) therapy should be fitted
properly and in use at all times – remove
only to bathe, assess underlying skin, or
ambulate. On occasion when I walk into my
patient’s room in the morning I find that their
IPC has been off all night. Moderate-risk
patients should be treated with low dose UFH
(unfractionated heparin), LMWH (lowmolecular-weight heparin, e.g., enoxaparin or
Lovenox), or fondaparinux (Arixtra). High-risk
patients should be treated with LMWH, (cont.)
Newsletter 4
fondaparinux, or an oral vitamin K antagonist,
e.g., warfarin or Coumadin. Maximize mobility
whenever possible.i
This appropriately leads in to the next
topic – Progressive Mobility, Turning Q2.
Complications of immobility affect every body
system. Challenges to effective mobility and
turning effectiveness include severity of illness,
excessive moisture, sheer and friction forces,
tissue perfusion and patient weight. Strategies
that have been successful over the years
include: increased frequency of turning and offloading pressure areas; turn assist devices and
turn teams; bariatric beds/surfaces; mobility
assessment and progressive mobility
programs/standards. Patients should be moved
early and often – turning, passive ROM (range
of motion), active resistance PT (physical
therapy), sitting position, sitting on edge of
bed, transfer to chair, and ambulation
(marching in place, walking in halls).ii
The next topic was Gastric Tube
Management and Fecal Incontinence.
Verification of gastric tubes in adults is
recommended by radiograph. Carbon dioxide
readings, aspirate and pH testing may be used
to predict tube location during the insertion
procedure, but are not sufficient to confirm
placement.
Mark and document the tube’s exit site
from the nose or mouth after radiographic
confirmation to monitor for and detect tube
dislocation. Listening over the epigastrium
for air insufflated through the tube is not
reliable in distinguishing between
respiratory and gastric placement.iii There is
no significant relationship between gastric
residual volume (GRV) and aspiration. GRV of
250-500 ml are acceptable. An isolated
increased GRV should not lead to holding the
tube feeding, but gastric motility should be
reassessed for persistent increased GRV. She
suggested that avoiding checking GRVs
improves nutrition/caloric goals being met.
Measures to prevent aspiration include:
head of bed (HOB) 30-45 degree angle; use
sedation sparingly; frequent assessment
(~Q4H) of gastric tube placement; avoid
“bolus” tube feedings; monitor ET
(endotracheal tube) cuff pressures; oral care;
and swallowing evaluation after ET removediv
if intubated ≥3 days. Recommendations for
managing fecal incontinence include: anticipate
incontinence; toileting schedule; good skin
hygiene with pH balanced solution; avoid
excessive rubbing; apply skin barrier creams;
avoid diapers; fecal pouch; fecal containment
device – assess rectal tone prior to placement;
and pharmacy and dietary consults.
She briefly touched on multiple other
topics:
 Normal saline (NS) ET instillation
unfortunately continues at the bedside –
but is better. I personally find
respiratory therapists are more likely to
use NS ET instillation than nurses in my
practice.
 Arterial line and cuff blood pressure (BP)
measurements should not be compared,
but rather accurate measurements,
accurate technique, and appropriate
trending. BP cuff should be
appropriately sized and level with the
heart.v
 Arterial line pressure monitoring system
should be assessed for optimal dynamic
response (square wave test) and level.vi
 Fluid resuscitation should be goal
directed, albumin is back, synthetic
starch (hetastarch, Hespan) is out.
 Do not routinely strip or milk chest tubes
to maintain patency. (cont. . . .)
MVC-AACN Newsletter 5
 Trendelenberg position provides no
demonstrated cardiovascular benefit
but poses potential adverse effects, i.e.,
increased ICP (intracranial pressure),
impaired pulmonary gas exchange, and
potential for gastric aspiration. However
passive leg raising (PLR) at a 45-degree
angle with the HOB flat provides a viable
alternative.
 Not all temperature modes are created
equal – consider user and device
limitations. Here are some tips for using
temporal artery thermometers:
1. Place the probe on the center of the forehead,
depress the button and keep it depressed. Slide
the probe in a straight line across the forehead
to the hairline(if you curve down the side of the
face, you will miss the temporal artery).
2. Touch the soft depression behind the ear
(the "perfume spot").
3. Remove, read and record temperature.vii
 It is safe to transfuse blood products
through an intravenous (IV) catheter as
small as 25 gauge without hemolysis.
 ICU patients should be allowed blocks of
120 minutes of uninterrupted sleep.
 Visiting policies should be open,
unrestricted, and based on the patient’s
preference.viii, ix
 The patient’s self-report remains the gold
standard for pain assessment. Use a
validated behavioral pain scale
(Behavioral Pain Scale (BPS), Critical
Care Pain Observation Tool (CPOT)) for
pain assessment for critically ill adult
patients who are unable to self-report.
Also consider proxy reports of pain by
family members.x Please refer to the
AACN Practice Alerts cited in the
endnotes.
What practice “habit” will you change?
The keynote speaker at the Tuesday
morning SuperSession was Michael Bungay
Stanier, author of “Do More Great Work.” “Great
work is the work that makes a real difference,
has real impact and real meaning for you.”
Stanier then encouraged the audience to think
about how to remain in a place where great
work is possible without stepping foot into
what he called the ‘drama triangle.’” He
identified three roles in the drama triangle –
victim, persecutor and rescuer. He said nurses
are rescuers by default. But “rescuers create
victims, rescuers create persecutors.” He
demonstrated how one person can convert
between the 3 roles.
He offered some advice to avoid the
drama triangle: “First, physically disengage
from the situation by walking away and shifting
your body into a new position, no matter how
silly you feel. Second, ask how you can help, but
realize you’re not obligated to say yes to every
request. Finally, learn to say no — or at least
slow down your rush to say yes.” xi
Tuesday afternoon I attended my other
favorite session, “Critical Care Studies You
Should Know About,” presented by Elizabeth
Bridges, PhD, RN, CCNS, FCCM, FAAN, Associate
Professor at University of Washington School of
Nursing and Clinical Nurse Researcher at the
University of Washington Medical Center. Liz
shares the principles of research to encourage
us to evaluate research for ourselves. She
discussed the relative risk or risk ratio (RR) –
the risk of an event occurring in the
experimental group vs the control group. If the
RR is 1, both groups are equal; <1 means less
incidence of event in the experimental group;
>1 means less incidence of event in the control
group. RR is referred to with a 95% confidence
interval (CI) – if the 95% CI includes “1,” e.g.,
0.88-1.51, then there is no significant
MVC-AACN Newsletter 6
difference between the two groups.
Liz shared some studies about
chlorhexidine (CHG) bathing and HAIs. Overall
there is no difference, however, she shared
some caveats: the effectiveness may depend on
the baseline infection rate; decreases skin
colonization – is it a decrease in BSI
(bloodstream infection) or a decrease in false
positive blood cultures? Where does the CHG
reach? VRE carriage primarily perineal, MRSA
carriage primarily nares/respiratory;
demonstrated effect of CHG on CLABSI (central
line-associated BSI); effect of CHG bathing on
VAP, CAUTI, CDiff equivocal; CHG may be more
effective on gram negative bacteria; and
concern re decreased susceptibility to CHG.
The next topic was post-ICU posttraumatic stress (PTS). A person with posttraumatic stress disorder (PTSD) has been
exposed or a witness to a traumatic event and
responded with intense fear, helplessness or
horror (DSM IV-R1). Symptoms usually start
three months after the event and include reexperiencing phenomena such as intrusive
thoughts or recurrent dreams, nightmares,
memories; avoidance and numbing – avoiding
thoughts, places or situations that serve as
reminders of the traumatic event; and
increased arousal, e.g., irritability,
hypervigilance, easy startling. Symptoms can
be assessed using a questionnaire, Impact of
Event Scale – Revised (IES-R). Diagnosis
requires direct clinical assessment – clinician
administered PTSD scale. PTS has become all
too common in patients who have survived
critical illness – ~1 in 5 ICU patients.
Davydow described factors associated
with post intensive care PTS including acute
stress symptoms during hospitalization and
history of major depression and/or prior
trauma exposure; benzodiazepines were not an
independent risk factor.xii Liz suggested that
perhaps the patients who develop PTS are
already at risk due to previous
psychopathology and/or previous traumatic
experience. Parker found a significant
association for PTS symptoms with pre-ICU
psychopathology, benzodiazepines, and postICU factors, i.e., early post-ICU memories of
frightening ICU experiences and post-ICU
psychopathology; no association was found
with age, sex, corticosteroids, sedation strategy,
delirium, severity of illness, admission
diagnosis, or mechanical ventilation. ICU
diaries decreased PTS symptoms.xiii
Ringdal reported that all ICU trauma
patients had improved HRQOL (health-related
quality of life) at one and five years, but
patients with delusional memories had poorer
HRQOL.xiv Wade merged factual memories
(pain, bleeding, choking) with delusional
memories (persecution, religious cults,
zombies, aliens, trials and torture) – patients
were traumatized with the hallucinations
rather than the real events.xv Guttormson found
that patients who were minimally arousable
had more delusional memories of ICU. Neither
higher sedative exposure nor deeper sedation
decreased patients’ awareness or memories of
facts and frightening experiences.xvi Weinert
found more severe PTS symptoms associated
with recall of delirious memory during ICU
illness but not to factual recall.
PTS symptoms were lowest in patients
who were most awake or least awake.xvii Long
suggested the introduction of psychological
support in the ICU for high-risk patients, and
the introduction of coping and mindfulness
techniques after hospital discharge as PTS
prevention strategies, as well as diagnosis,
treatment, and psychological support for
patient with PTS.xviii Liz recommended an
MVC-AACN Newsletter 7
article by Loretta F. Rock about sedation and
PTS in Critical Care Nurse.xix The use of an ICU
diary has been the subject of some research but
there is insufficient evidence for a definitive
recommendation. Liz posed many questions:
How frequently should notes be completed?
Who should write notes (MD, RN, family,
others)? How much detail in notes? What to put
in – what to leave out? When to give to the
patient? How to give to the patient? Who
should have access to the diary? What to do
with the diary if the patient dies? HIPAA?
Next she shared a few studies about
sepsis and septic shock: ProCESS (Protocolized
Care for Early Septic Shock), ARISE
(Australasian Resuscitation in Sepsis
Evaluation), and ProMISe (Protocolised
Management of Sepsis). Each trial basically
challenged the findings of the Rivers Early
Goal-Directed Therapy (EGDT) trial back in
2001 that included CVP (central venous
pressure) and ScvO2 (central venous oxygen
saturation) monitoring, IV fluid resuscitation to
a goal CVP of 8 to 12, vasopressor
administration to a goal MAP (mean arterial
pressure) of ≥65, transfusion of red blood cells
to a goal hematocrit of ≥30%, and inotropic
agents to a goal ScvO2 ≥70%.
ProCESS sought to determine whether the
findings of EGDT “were generalizable and
whether all aspects of the protocol were
necessary.”xx EGDT was compared to a protocol
based standard therapy that did not require
placement of a central venous catheter,
administration of inotropes, or blood
transfusions, and a third group randomized to
usual care. They found “no significant
advantage, with respect to mortality or
morbidity, of protocol-based resuscitation over
bedside care that was provided according to
the treating physician's judgment.” They “also
found no significant benefit of the mandated
use of central venous catheterization and
central hemodynamic monitoring in all
patients.” Also of note, antibiotics were
administered early prior to enrollment.
The ProCESS trial used the Shock Index to
guide fluid administration in one of its
intervention groups. “The Shock Index has
been proposed as a reliable and easy to use tool
for the early identification of hypovolemic
shock, and the need for intervention, in a
number of settings,” although “there are
currently no well-designed, prospective studies
that validate the use of the Shock Index to
guide resuscitative interventions.”
The calculation for the shock index is
heart rate divided by systolic blood pressure
(SBP), and “0.5-0.7 is believed to be a normal
shock index. Higher numbers have been shown
to be more sensitive than vital signs alone in
diagnosing occult shock, need for transfusion
and/or operation.”xxi The general idea is that
the heart rate should not be higher than the
blood pressure.
The ARISE trial set out “to test the
hypothesis that EGDT, as compared with usual
care, would decrease 90-day all-cause
mortality among patients presenting to the
emergency department with early septic shock
in diverse health care settings.”xxii Again, there
was no significant difference in mortality
between the experimental and control groups.
Of note, patients were already volume
resuscitated and had been administered their
first antibiotic prior to enrollment. Finally, the
ProMISe trial also compared EGDT to standard
care and also found no significant difference in
mortality.xxiii
Another noteworthy point – the 60-day
mortality for the usual care group in the
ProCESS trial was 18.9%, compared to 44.4%
MVC-AACN Newsletter 8
in the control group in the Rivers trial. Clearly
“usual care” is not what it used to be. Key
points include: When patients receive first
antibiotics? How long for initial volume
resuscitation? Central line – for monitoring vs
vasoactive medication administration? When
were hemodynamic goals met?
The Surviving Sepsis Campaign has just
revised their bundles:
TO BE COMPLETED WITHIN 3 HOURS:
1) Measure lactate level
2) Obtain blood cultures prior to
administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 ml/kg crystalloid for
hypotension or lactate ≥4mmol/L
“Time of presentation” is defined as the time of
triage in the emergency department or, if
presenting from another care venue, from the
earliest chart annotation consistent with all
elements of severe sepsis or septic shock
ascertained through chart review.
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 hypotension after
initial fluid administration (MAP < 65 mm Hg)
or if initial lactate was ≥4 mmol/L, re-assess
volume status and tissue perfusion and
document findings according to Table 1.
7) Re-measure lactate if initial lactate elevated.
TABLE 1
DOCUMENT REASSESSMENT OF VOLUME
STATUS AND TISSUE PERFUSION WITH:
EITHER:
• Repeat focused exam (after initial fluid
resuscitation) including vital signs,
cardiopulmonary, capillary refill, pulse, and
skin findings.
OR TWO OF THE FOLLOWING:
• Measure CVP
• Measure ScvO2
• Bedside cardiovascular ultrasound
• Dynamic assessment of fluid responsiveness
with passive leg raise or fluid challenge
Of note, the 6-hour bundle has been
updated; the 3-hour SSC bundle is not
affected.xxiv
The last topic Liz presented was Thirst in
ICU Patients. She shared multiple studies that
revealed a 70-90% incidence of thirst.xxv, xxvi,
xxvii Samuelson found in ventilated patients,
thirst is 1 of 3 most remembered ICU
experiences.xxviii Puntillo reported in patients at
risk of dying, among 10 symptoms, the patients
rate thirst as the most intense and the second
most prevalent symptom.xxix Stotts, et al.
identified predictors of the presence, intensity
and distress of thirst in ICU patients.
Thirst presence was predicted by high
opioid doses (≥ 50 mg), high furosemide doses
(>60 mg), selective serotonin reuptake
inhibitors, and low ionized calcium. Thirst
intensity was predicted by patients not
receiving oral fluid and having a
gastrointestinal (GI) diagnosis. Thirst distress
was predicted by mechanical ventilation,
negative fluid balance, antihypertensive
medications, and a GI or "other" diagnosis.xxx
Puntillo, et al. tested an oral care
intervention bundle for thirst intensity, thirst
distress and dry mouth. Inclusion criteria
included: oriented to name, ICU >24 hours,
RASS -1 to 1 (not sedated/agitated), thirst
intensity (TI) (0-10) ≥3, thirst distress (TD) (010) ≥3, and no open oral sores or
desquamation. The intervention bundle
consisted of oral swab wipes, sterile ice cold
water sprays, and a lip moisturizer. “The
average decreases in TI and TD scores from
MVC-AACN Newsletter 9
pre-procedure to post-procedure were
significantly greater in the intervention group
vs the usual care group. The usual care group
was 1.9 times more likely than the intervention
group to report dry mouth for each additional
session on Day 1.xxxi
Again, Liz posed some questions: Do I
need to repeat the intervention 3 times over 15
minutes? Can we give the resources to the
patient/family for prn use? How long does the
intervention last? Does it work in intubated
patients/patients with altered mucosa? How to
apply in more deeply sedated patients? How to
use in conjunction with oral care to prevent
VAE (Ventilator-Associated Events)? As always,
Liz creates a culture of inquiry. She ended this
topic by stating, “there is no evidence that ice
chips help thirst.”
Early Wednesday morning I attended a
session, “Patient Hand Hygiene: Overlooked
Factor in the Spread of Healthcare-Associated
Infections,” presented by Kelly Drumright, RN,
BSN, CCRN-CMC, CSC, and Jolanda Coffey, RN,
BSN, from the Veterans Affairs Tennessee
Valley Healthcare System in Nashville, TN.
Hand washing is key to preventing HAIs. So the
speakers posed the question, “what about the
patient’s hands and their hand hygiene? They
listed four significant ways patients can
transmit pathogens: through the transfer of
pathogens in the environment, by direct spread
of pathogens to other patients, by crosscontamination through direct contact with
HCWs (healthcare workers), and by increasing
their own risk of infection from an endogenous
source.
The CDC (Centers for Disease Control and
Prevention) recommends patient hand
hygiene: before preparing or eating food;
before touching eyes, nose, or mouth; before
and after changing wound dressings or
bandages; after touching hospital surfaces such
as bed rails, bedside tables, doorknobs, remote
controls, or the phone; after blowing your nose,
coughing, or sneezing; and after using the
restroom. Challenges with patient hand
hygiene include high acuity level, patient’s
physical ability, lack of patient/family
education, impeded movement, and perceived
importance.
They presented research data on hand
hygiene compliance among HCWs (doctors,
nurses, other staff) as well as patients and
visitors. Barker, et al. found that patient hand
washing significantly decreased while in the
hospital, especially after using the bathroom
and prior to eating. However, patients who had
better hand-washing practices at home and
placed a high value in hand hygiene, tended to
have good hand hygiene practices while in the
hospital.xxxii The presenters recommended an
article that provided a great review of
literature and evidence regarding the role of
patient hand hygiene in preventing infection,
and the authors provide recommendations on
developing a patient hand hygiene program.xxxiii
The presenters also referred to an article
“hot off the press” in the May issue of American
Journal of Critical Care.xxxiv Next they shared
their own trial at their facility. Finally they
shared many hand hygiene resources, including
The Joint Commission’s Speak up program,
“Five Things You Can Do to Prevent
Infections;”xxxv The World Health
Organization’s, “Save Lives: Clean Your
Hands,”xxxvi and “My 5 Moments for Hand
Hygiene for HCWs;”xxxvii and The CDC’s, “Clean
Hands Save Lives,”xxxviii as well as others. I
personally have considered patient hand
hygiene specifically after they clean themselves
when using the restroom – but I would most
often hand them a bath wipe if there were
MVC-AACN Newsletter 10
some leftover in the room. However, they are
not antibacterial, so now I have improved my
practice by ensuring the presence of a small
bottle of hand sanitizer gel that we have
available on our supply cart and encouraging
the patient to use it.
At the Wednesday morning
SuperSession AACN President-elect, Karen
McQuillan revealed her new theme,
“Courageous Care.” She encouraged members
to share their stories of Courageous Care with
her throughout this next year. The keynote
speaker was Allison Massari, a motivational
speaker who shared her story of surviving a
devastating car accident where she was
trapped and burned alive. “Despite being
devoured by that excruciating pain, I was
shocked to see that the anguish of my
loneliness was more potent than the physical
agony of burning.” “She went on to tell
attendees about Roger Pepper, the stranger
who pulled her out of the car and saved her life,
the firefighters who discreetly covered her up
after the fire stripped her of her clothes and the
nurses and medical staff who cared for her so
compassionately, and who, over the years, have
lifted her up to her calling of spreading love,
healing, strength and courage to everyone she
meets.” “Sometimes, all it takes is one person to
change a life. One moment. One look. You never
know the impact you can have on someone
else’s life.”xxxix
Late Wednesday afternoon a bunch of us
attended the session, “Focus the Flame on PAIN:
Providing Competent and Compassionate Care to
the Patient in Pain,” presented by Maureen
McLaughlin, MS, RN, CPAN, CAPA, Clinical
Nurse Specialist at Lahey Clinic Hospital and
MVC member! Maureen began her presentation
with this quote, “pain may be the warning
signal that saves the lives of some people but
destroys the lives of countless others.”xl She
shared some data about pain, prevalence, and
financial impact. “Most critically ill patients will
likely experience pain sometime during their
ICU stay.”xli
She shared definitions of pain – the one
that resonated with me was, “pain is whatever
the experiencing person says it is, existing
when he or she says it is.” She described types
of pain – nociceptive vs neuropathic; acute vs
chronic. She described the neurophysiology of
pain. She discussed challenges in the care of the
patient with chronic pain, as well as critically ill
patients with substance use disorder/longterm opioid use. These complex patients
require opiates to sustain their substance use
and prevent withdrawal, and they deserve the
right to analgesia during an acute illness. Acute
on chronic pain management may require a
30% to 100% dose increase to cover the acute
pain aspect.xlii
Other pain management strategies
include trying another opiate, around the
clock/continuous dosing, and multimodal. She
referred to the adage “prn” is “plan relapse
now.” Maureen stressed the importance of
accurate medication reconciliation. Although
self-report is the gold standard for pain
assessment, standardized pain assessment
tools (BPS, CPOT) are indicated for patients
who cannot self-report. Proxy report by
family/caregivers may also provide valuable
assessment data.
Maureen reviewed a multitude of pain
management options including mechanism of
action, side effects and special considerations:
opioids, neuroaxial or regional analgesics (e.g.,
epidural, peripheral nerve blocks), NSAIDS
(nonsteroidal anti-inflammatory drugs), local
anesthetics, NMDA (N-methyl-D-aspartate
MVC-AACN Newsletter 11
receptor) antagonists (e.g., ketamine), alphaadrenergic analgesics (e.g., dexmedetomidine),
antidepressants/anticonvulsants (e.g.,
gabapentin, Lyrica), muscle relaxants,
adjuvants, nonpharmacological interventions,
and multidisciplinary teams. Maureen ended
her presentation with this quote, “Pain [is] no
longer just a physiologic response awaiting a
pharmacologic treatment. Pain [has] become a
human response; pain [is] a suffering person in
need of both competent treatment and
compassionate attention.”xliii
Wednesday evening was “Nurses’ Night
Off” at the San Diego Zoo. We grabbed a bite to
eat before going to the zoo, so by the time we
got there it was already getting late and
starting to get dark, and the animals were
mostly sleeping and/or out of view. But we did
get to see the pandas (sleeping), koala beers, a
kangaroo, rhinoceros, giraffes, and zebra.
Thursday morning I attended a session,
“Case Studies in Critical Care as a Result of
Information from the Internet,” presented by
Ann Lystrup, RN, BSN, CEN, CFRN, CCRN,
Clinical Educator at Sutter Physician Services.
This was a fascinating session, but most of the
case studies were about various types of drug
overdoses. The speaker did not provide a
handout so I am limited by my memory, but I
will share the cases that stand out in my
memory – most of which I had never heard of
before.
First she spoke about vaping (inhaling)
alcohol – vaping skips the waiting period to feel
the “buzz” because it is absorbed directly into
the bloodstream, but the feeling is also shortlived. Evidently some web sites report that it
will not be detected on a breathalyzer test, but
that is not necessarily true. Another web site
points out that you don’t ingest calories, carbs
or fillers. There is a higher risk of overdose
than with drinking because you don’t know
how much alcohol you are ingesting, and
inhaled alcohol cannot be purged from the
body by vomiting, which is the body’s main
protection against alcohol poisoning.xliv Alcohol
soaked tampons are another alternative to
drinking alcohol. The speaker presented a case
study of a young woman who was found
unresponsive by her parents, and ultimately a
friend spoke up and admitted that the patient
had used an alcohol soaked tampon. Again,
absorption is direct and there is no way to
control the amount of alcohol ingested.
She also talked about pruno or prison
wine, made from fruit and fermented in plastic
bags. She shared a case study of a prisoner who
used potatoes because he did not have any
fruit, and contracted botulism because of the
spores commonly found in soil. The physician
made the diagnosis based on symptoms,
specifically including drooping eyelids. The
final case study that I can remember was a man
who had taken some kind of energy
supplement, but had taken much more than the
recommended dose. He could not sit still and
was yelling in the emergency room, mostly
unintelligible, but intermittently could be heard
to say, “I can’t slow down.” He ultimately died
and the speaker said it was like he burned from
the inside due to the excessively stimulated
metabolism. Sorry about the lack of details with
these case studies but my memory is not what
it used to be!
After NTI was over early Thursday
afternoon, Rachel, Michele and I went shopping
for souvenirs in the Seaport Village, then went
for a late lunch at Seasons 52 where Rachel’s
daughter worked as a waitress. Later we took a
taxi to Mission Beach, dipped our feet in the
Pacific Ocean, and had drinks on a rooftop bar
while watching the sunset. We flew home on
MVC-AACN Newsletter 12
the red eye that night in time for the Memorial
Day holiday weekend because it was my
weekend and holiday to work.
Upcoming NTI events will be
Next year NTI is being held in New Orleans –
hope to see you there!
held in:
(See Endnotes on last page of newsletter)
NTI 2016 is in New
Orleans! Hope you can
make it!
2017 Houston, TX
2018 Boston !!! Our Chapter will be
ready to help out again!
Horizons 2016 in Warwick, RI
Save the dates April 5, 6 & 7, 2016!!
Go to www.horizons2016.org for more information!
MVC-AACN Newsletter 13
Merrimack Valley AACN Chapter Celebrates 30th Anniversary!
Merrimack Valley Chapter members celebrated our 30th anniversary at Lenzi’s on September
17, 2015 with a cocktail reception. Members had a chance to socialize with old and new friends and
check out our photo boards with priceless pictures of MVC members and gatherings throughout the
years Attendees also received a badge holder with the MVC AACN logo.
Linet Americas sponsored our gathering which provided a lovely waitress circulating with
delectable treats such as fresh melon and asparagus wrapped in prosciutto, mini rare steak
sandwiches with horseradish sauce, and grilled kielbasa with sweet and sour sauce, to name a few.
There was also an assorted cheese, cracker, & fruit display with artfully arranged crudités & herb
dips. Assorted fancy miniature desserts with coffee and tea (decaf available) were set out near the
end of our evening, and judging by the crowd around the table, a big hit!
After we all had a chance to socialize, Russell Perkins, the Massachusetts Account Manager
for Linet Americas, a hospital bed company, provided an in-service on their ICU bed, the Multicare.
Doris Barreiro, Nurse Manager MICU & RRT at Lahey has experience with the bed in her unit and
verbalized her satisfaction with helpful features offered on the bed.
Next, Sue Wheeler, MVC President for FY 2015 -2016 was pleased to introduce our first
MVC President and one of the founding members, Kathy Heery. Kathy worked in the ICU at LGH
at the time of MVC’s inception. She has had multiple clinical and management positions in both the
private and public sectors as well as leadership roles with national and international companies.
Kathy now runs a private practice as an RN Community Care Manager & Organizational consultant.
She has published many professional articles and authored 3 books with a fourth coming by the end
of his year. I am currently reading her third book, “Too High a Price to Pay: The Health Care
Reform Revolution”, and finding that her observations regarding the current health care system are
spot on.
Kathy reflected on the amazing success of our MVC – initially it was a struggle to recruit
enough nurses interested in becoming members for consideration to establish a chapter by AACN
National. Kathy related how the interest of critical care nurses in the area to join other chapters in
the Northeast in forming the Horizons committee was the driving force behind the formation of our
MVC. She closed with a raffle of her book to whomever could name the inaugural year of Horizons
(1986), Sue Wheeler was the winner!
The MVC BOD presented our Programs Chairperson, Diane Meagher with a framed
inspirational quote by Jean Piaget – “The principle goal of education is to create men and women
who are capable of doing new things, not simply repeating what other generations have done.”
Diane will be stepping down after our Spring 2016 program and we wanted to acknowledge the
wonderful job she has done with Programs over the past 15 years. Affordable, quality education and
networking opportunities continue to be our main focus as we strive to maintain the vision of
AACN – to create a healthcare system driven by the needs of patients and their families where acute
and critical care nurses make their optimal contributions.
MVC-AACN Newsletter 14
About Our Chapter – Merrimcak Valley AACN
In 1985 the Merrimack Valley Chapter started with 20 members. Now, 30 years later,
there are almost 90 members and we are growing each year. Please Step Forward with
Courageous Care and exercise your ability to show leadership traits. There are
opportunities in the chapter to join a committee, attend board meetings, and help set up
educational programs and events. Then once you are familiar with the board activities you
can, and should, run for an office. Many chapter officers have transitioned from staff to
management positions possibly because they have “dared to” “step forward” “with
confidence”.
P.S. membership dues age 55 years and up are reduced to $59/year; Also if you submit four
members for AACN renewal together you can save $10 off each - see forms on AACN
website. (www.aacn.org).
Also don’t forget to renew your annual Chapter membership (only $10!). Go to the
AACN.org website to obtain a MVC application.
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 15
Join Us for the next Chapter Education Class –
AACN Class on Critical Care Cornucopia
November 3, 3015
7:30am-4:00pm
Wyndham Boston in Andover, 123 Old River Rd, Andover, MA
See attachment to newsletter e-mail for more details or visit the
MVC Chapter page on the AACN.org website
2015-16 Chapter Board Members:
Sue Wheeler is the President as of July 2015
Michele Woonton is the Past-President from 2014
Chrissy Cebollero is the President Elect for 2016 and Webmaster
Linda McGowan and Doris Barreiro - Scholarship committee
Diane Meagher – Programs (until May 2016)
Ellen Stokinger – Membership
Sue Ouellette – secretary
Dianne Forsyth – treasurer
Valerie Fernald – publications
MVC-AACN Newsletter 16
MVC – AACN 2015 Scholarship Winners
Each year our Chapter presents (2) $500 scholarships to high school
graduates who are admitted to a nursing program. They submit scholarship
applications and the Scholarship committee reviews them and chooses 2 winners
each year. The winners for 2015 were Joel Emmott who will be attending the
University of Rhode Island and Alison Dunfee who will attend Palm Beach
Atlantic University. Joel and his mom were able to join us for dessert at our
Transitions dinner at Jules Restaurant in Methuen, but Alison was attending
orientation that day and could not attend.
Please check out our photos of this evening on our Facebook page!
The Scholarship Committee is sending out applications for 2016 scholarships to local high schools. If you
have any questions about this process please e-mail our Scholarship Committee (e-mail addresses are on the
AACN website on the Chapters page).
Be sure to join the Merrimack Valley Chapter AACN page on Face Book!
Stay Tuned to the Chapter website, Face Book page and your e-mail for photos
and updates from the Chapter on recent and upcoming events!
MVC-AACN Newsletter 17
Endnotes from NTI 2015 article
i
http://www.aacn.org/wd/practice/docs/practicealerts/vte-prevention-practice-alert.pdf?menu=aboutus
http://www.aacn.org/wd/practice/docs/tool%20kits/early-progressive-mobility-protocol.pdf
iii
http://www.aacn.org/wd/practice/docs/practicealerts/verification-feeding-tube-placement.pdf?menu=aboutus
iv
http://www.aacn.org/wd/practice/docs/practicealerts/prevention-aspiration-practice-alert.pdf?menu=aboutus
v
http://www.aacn.org/wd/practice/docs/practicealerts/non-invasive-bp-monitoring.pdf?menu=aboutus
vi
http://www.aacn.org/wd/practice/docs/practicealerts/pap-cvp-measurement.pdf.
vii
http://www.exergen.com/tathermometry/thermal-images.htm
viii
http://www.aacn.org/WD/practice/docs/practicealerts/family-visitation-adult-icu-practicealert.pdf
ix
http://www.aacn.org/wd/practice/docs/practicealerts/family-presence-during-resuscitation-invasive-procedures.pdf
x
http://www.aacn.org/wd/practice/docs/practicealerts/assessing-pain-critically-ill-adult.pdf
xi
http://www.ntivoices.com/tuesday-supersession-step-away-from-the-drama-triangle/
xii
Davydow DS, Zatzick D, Hough CL, Katon WJ. A longitudinal investigation of posttraumatic stress and depressive symptoms
over the course of the year following medical‐ surgical intensive care unit admission. Gen Hosp Psychiatry. 2013;35:226‐ 232
xiii
Parker AM, et al. Posttraumatic stress disorder in critical illness survivors: a meta‐ analysis. Crit Care Med.
2015;43(5):1121‐ 1129
xiv
Ringdal M et al. Memories and health‐ related quality of life after intensive care: A follow‐ up study. Crit Care Med.
2010;38:38‐ 44
xv
Wade DM et al. Intrusive memories of hallucinations and delusions in traumatized intensive care patients: an interview study.
Br J Health Psychol. 2014
xvi
Guttormson JL. “Releasing a lot of poisons from my mind:” Patient’s delusional memories of intensive care. Heart Lung.
2014;43(5):427‐ 431
xvii
Weinert CR, Sprenkle M. Post‐ ICU consequences of patient wakefulness and sedative exposure during mechanical
ventilation. Intens Care Med. 2008;34(1):82‐ 90
xviii
Long AC, et al. Posttraumatic stress disorder among survivors of critical illness: creation of a conceptual model addressing
identification, prevention and management. Intensive Care Med. 2014;40(6):820‐ 829
xix
Rock LF. Sedation and its association with posttraumatic stress disorder after intensive care. Crit Care Nurse.
2014;34(1):30‐ 37
xx
The ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370:16831693
xxi
http://www.mdcalc.com/shock-index/
xxii
The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic
shock. N Engl J Med. 2014;371:1496-1506
xxiii
Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med.
2015;372:1301-1311
xxiv
http://www.survivingsepsis.org/Bundles/Pages/default.aspx
xxv
Nelson JE, et al. The symptom burden of chronic critical illness. Crit Care Med. 2004;32(7)1527‐ 1534
xxvi
Nelson JE, et al. Self‐ reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med.
2001;29(2):277‐ 282
xxvii
Li DT, Puntillo K. A pilot study on coexisting symptoms in intensive care patients. Appl Nurs Res. 2006;19(4):216‐ 219
xxviii
Samuelson KA et al. Stressful experiences in relation to depth of sedation in mechanically ventilated patients. Nurs Crit Care.
2007;12(2):93‐ 104
xxix
Puntillo KA, et al. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med. 2010;38(11):
2155‐ 2160
xxx
Stotts NA, Arai SR, Cooper BA, et al. Predictors of thirst in intensive care unit patients. J Pain Symptom Manage.
2015;49(3):530-538
xxxi
Puntillo K, et al. A randomized clinical trial of an intervention to relieve thirst and dry mouth in intensive care unit patients.
Intensive Care Med. 2014;40(9):1295‐
1302
xxxii
Barker A, Sethi A, Shulkin E, et al. Patient hand hygiene at home predicts their hand hygiene practices in the hospital . Infect
Control Hosp Epidemiol. 2014;35(5):585-588
xxxiii
Landers T, Abusalem S, Coty M-B, & Bingham J. Patient-centered hand hygiene: the next step in infection prevention. Am J
Infect Control. 2012;40:S11-S17
xxxiv
Fox C, Wavra T, Drake DA, et al. Use of a patient hand hygiene protocol to reduce hospital-acquired infections and improve
nurses’ hand washing. Am J Crit Care. 2015;24(3):216-224
xxxv
http://www.jointcommission.org/assets/1/18/Infection_Control_Brochure.pdf
ii
MVC-AACN Newsletter 18
xxxvi
http://www.who.int/gpsc/5may/en/
http://www.who.int/gpsc/5may/Hand_Hygiene_When_and_How_Leaflet.pdf?ua=1
xxxviii
http://www.cdc.gov/handwashing/
xxxix
http://www.ntivoices.com/the-essence-of-courageous-care
xl
As cited in Church, E.J. What imaging teaches us. Radiologic Technology. 2013;84(4):349-372
xli
Barr, J. et al. Clinical practice guidelines for management of pain, agitation, and delirium in adult patients in ICU. CCM.
2013;41(1):263-306
xlii
Drew D. & St. Marie B. (2011). AACN Adv Crit Care. 2011;22(3):238-254
xliii
Pasero C & McCaffery M. Pain Assessment and Pharmacological Management. 2011. St. Louis, MO: Mosby; page vii
xliv
http://en.wikipedia.org/wiki/Alcohol_inhalation
xxxvii
Also for your reading enjoyment and education please read this program review.
2015 Spring Program Review – “Getting to the Heart of the Matter”
By Diane Meagher RN, BSN, CCRN
On April 14, 2015 we held our spring program, “Getting to the ‘Heart’ of the Matter,” which
included a variety of cardiac topics. Over 100 participants attended so we were “bursting from the seams” of
the Concord Amphitheater!
The first speaker was Kathleen Schultz, RN, BSN, BC, a Staff Nurse and ECMO Educator in the
Cardiac Surgical ICU at Massachusetts General Hospital. Kathleen began the day with, “Back to the Basics:
A Review of the Cardiac System.” She started with a review of basic cardiac anatomy, including valvular
structures, coronary arteries, muscle and electrical conduction.
Kathleen introduced a mnemonic to describe the determinants of cardiac output:
Contractility – amount of ‘stretch,’ or force of the cardiac muscle
Rate – frequency of blood ejected from the heart
Afterload – pressure the left ventricle generates to contract
Preload – volume of blood in left ventricle prior to contraction
Cardiac output (CO) = HR (heart rate) x SV (stroke volume). Decreased CO translates to decreased
perfusion to all organs: lungs – congestion leads to pulmonary edema, decreased oxygenation, shortness of
breath; liver – congestion leads to peripheral edema; kidneys – decreased excretion of water. Ejection
fraction (EF) is the percentage of blood ejected from the left ventricle during systole. Normal is 55-70%, 4050% is mildly reduced, 30-40% is moderately reduced, 20-30% is moderately severe reduction, and <20% is
severely reduced.
MVC-AACN Newsletter 19
Next she described the pathophysiology of heart failure. Systolic dysfunction is associated with loss
of contractility – ineffective squeezing of the ventricles can be due to impaired contractility, e.g., myocardial
infarction (MI); increased afterload, e.g., hypertension (HTN); cardiomyopathy and valvular disease.
Diastolic dysfunction is associated with impaired ventricular filling and decreased stroke volume, and may
be due to left ventricular hypertrophy, hypertrophic cardiomyopathy, aortic stenosis, and chronic HTN.
She further described the pathophysiology of cardiomyopathy.

Dilated cardiomyopathy is associated with an enlarged left ventricle and systolic dysfunction
with diminished contractility resulting in decreased EF, increased end-diastolic volume,
decreased ventricular SV, and biventricular failure, and may be due to ischemia, mechanical
(valve disease, HTN), viral (coxsackie, CMV, HIV, etc.), peripartum, and toxic (alcohol).

Hypertrophic cardiomyopathy is usually a genetic disorder associated with a thickened left
ventricle, impaired diastolic function and decreased ventricular compliance – thickening of
the septal wall causes obstruction to the left ventricular outflow tract.

In restrictive cardiomyopathy, the walls of the ventricles become stiff, but not necessarily
thickened – the myocardium becomes rigid and noncompliant, ventricular filling is impeded,
and filling pressures are increased during diastole, resulting in right heart failure, systemic
venous congestion, cardiomegaly and dysrhythmias. Causes of restrictive cardiomyopathy
include scleroderma, lymphoma, and amyloidosis.

Signs and symptoms of right-sided heart failure include fatigue, distended jugular veins,
ascites, enlarged liver and spleen, anorexia and complaints of gastrointestinal distress, weight
gain and dependent edema.

Signs and symptoms of left-sided heart failure include pulmonary congestion (cough,
crackles, wheezes, blood-tinged sputum, tachypnea), restlessness, confusion, orthopnea,
exertional dyspnea, paroxysmal nocturnal dyspnea, tachycardia, fatigue and cyanosis.
Cardiogenic shock is systemic hypoperfusion (oliguria, cold extremities, confusion) in the setting of
severely depressed cardiac output (cardiac index <1.8 x m2/min) and sustained systolic arterial hypotension
(systolic arterial pressure <80 mmHg) with elevated filling pressures (pulmonary capillary wedge pressure
>18 mmHg). Cardiogenic shock is predominantly due to left ventricular (LV) failure, but can be due to right
ventricular (RV) shock, ventricular septal rupture, and tamponade; MI with LV failure is the most common
cause.
She reviewed the New York Heart Association (NYHA) Functional Classification for heart failure:
I
no symptoms
II
symptoms with moderate-marked activity
III
symptoms with mild activity
IV
symptoms at rest
She described the stages in the development of heart failure. Patients with stage A heart failure are at
high risk for heart failure but do not have structural heart disease or symptoms of heart failure – this includes
MVC-AACN Newsletter 20
patients with HTN, diabetes, coronary artery disease, previous exposure to cardiotoxic drugs, or a family
history of cardiomyopathy. Patients with stage B heart failure have structural heart disease but have no
symptoms of heart failure – this includes patients with left ventricular hypertrophy, previous MI, LV systolic
dysfunction, or valvular heart disease, all of whom would be considered to have NYHA class I symptoms.
Patients with stage C heart failure have known structural heart disease and current or previous symptoms of
heart failure. Their symptoms may be classified as NYHA class I, II, III, or IV. Patients with stage D heart
failure have refractory symptoms of heart failure at rest despite maximal medical therapy, are hospitalized,
and require specialized interventions or hospice care. All such patients would be considered to have NYHA
class IV symptoms. Then she presented recommended therapy by stage.
Primary interventions for the treatment of heart failure begin with lifestyle changes: diet – low salt,
alcohol free; weight loss; physical activity; and smoking cessation. Oral medications include: ACE
(angiotensin-converting-enzyme) inhibitors – lower BP, block neurohormones, inhibit remodeling; beta
blockers – slow HR, lower BP, decrease stress hormones; digoxin – slows HR, improves EF; ARBs
(angiotensin II receptor blockers) – lower BP; diuretics – remove excess fluid; nitrates – vasodilators, reduce
preload.
Critical care interventions include IV therapy: diuretics; inotropes – milrinone, dobutamine,
dopamine; vasodilators – nitroglycerin, nitroprusside, and nesiritide. Other critical care interventions
include: Swan-Ganz catheter – measures filling pressures; intra-aortic balloon pump (IABP) – unloads LV;
Ventricular Assist Device (VAD) – provides resting of ventricles; Extracorporeal Membrane Oxygenation
(ECMO) – provides resting of ventricles and/or lungs; transplant/artificial heart; palliative care.
Invasive interventions include: electrophysiology lab – biventricular pacing, ICD (implantable
cardioverter defibrillator); catheterization lab – angioplasty, stents, TAVR (transcatheter aortic valve
replacement), MitraClip; cardiac surgery – CABG (coronary artery bypass graft), valve replacement, septal
myomectomy.
Copyright © American Heart Association, Inc. All rights reserved.
MVC-AACN Newsletter 21
Kathleen’s next presentation was, “ECLS Explained: Adult ExtraCorporeal Life Support for Bedside
Nurses.” She began with a little history – the first successful use of adult ECMO was in 1972. ECMO is a
heart and/or lung support – similar to bypass used during cardiac surgery. Candidates for ECMO are patients
with severe respiratory and/or cardiac failure who are thought to benefit from support, and when all other
options have been exhausted. Inclusion criteria for VV (venovenous) ECMO include: acute hypoxic or
hypercarbic respiratory failure – sat 88% on FiO2 100%, respiratory acidosis with pH <7.20; normal
RV/LV function; minimal vasopressor/inotrope support. Inclusion criteria for VA (venoarterial) ECMO
include: cardiogenic shock with end-organ hypoperfusion – CI <2.2 or SvO2 <60% on two inotropes, high
biventricular pressures with PCW >20, CVP >15, worsening metabolic acidosis, hypotension with
significant vasopressor requirement; unstable arrhythmias. Absolute contraindications to ECMO include:
unrecoverable cardiac or respiratory function and not a candidate for transplant or VAD, neurologic
catastrophe, mechanical ventilation >7 days, CPR >60 minutes in-house (otherwise CPR >30 minutes),
severe aortic insufficiency, acute aortic dissection, end-stage liver disease, BMI >40, contraindication to
anticoagulation or refusal to receive blood products. Relative contraindications to ECMO include: age >70,
active cancer, suicide attempt, chronic kidney disease, multi-organ system failure 3 organs, significant
PVD.
VV ECMO is respiratory support. Blood is drained from the venous system, oxygenated and
ventilated, then returned to the central venous circulation – removes CO2 and provides fully saturated blood
to the return vessel. VV ECMO provides no direct hemodynamic support, but increased oxygen delivery to
the coronary and pulmonary circulation can improve cardiac output. VV ECMO cannulation is typically
peripheral (right femoral vein and left femoral vein). Blood flows back into the patient at the level of the
right side of the heart, then through the patient’s native lungs. RA-PA central cannulation is used in the
setting of oxygenation requirement and RV failure, e.g., severe pulmonary HTN.
VV ECMO flow is low (2-4 L/min) so expect a lower SaO2 with VV ECMO due to ECMO blood
mixing with native blood – 85% is okay. The goal is oxygen delivery, so monitor hemoglobin levels closely
and maintain hematocrit >30. Hemodynamic stability should be maintained by volume, but also inotropes,
vasopressors and vasodilators as needed. If IABP is required, may change to VA ECMO. Intubation or
tracheostomy is only necessary for secretion control. Apnea is okay on VV support as ventilation and
respiration come from the ECMO circuit. Anxiolytics may be better for controlling tachypnea on an awake
patient. Mobility, i.e., ambulation, is important to prevent deconditioning and improve activity tolerance, as
well as decrease complications of mechanical ventilation.
VA ECMO provides cardiac and respiratory support – provides hemodynamic support and O2/CO2
exchange. Blood is pulled from the venous system and returned to the arterial system. VA ECMO is
indicated for: post-bypass (cardiotomy) support – failure to wean from bypass after surgery; post cardiac
transplant – usually due to primary graft failure; and other condition that lead to severe cardiac failure –
cardiomyopathy, cardiogenic shock s/p MI, pulmonary embolism, sepsis, overdose, and profound
hypothermia. Typical cannulation sites for VA ECMO are either peripheral – right femoral vein and left
femoral artery, or central – RA and aorta. VA ECMO provides full cardiac support (usually ~80%). Blood
flow is 4-6 L/min – adequate MAP 50-70 mmHg, adequate SvO2 >70%, and SpO2 >95% if obtainable. VA
ECMO is preload and afterload sensitive – provide hemodynamic support with volume, vasopressors,
vasodilators and inotropes as needed.
VA ECMO is partial bypass – some ‘native’ blood still goes through the native lungs, then to the
native LV, and then native blood is ejected from the LV into the aorta. The aorta feeds the innominate artery,
which feeds the head, neck and right arm – cerebral hypoxia is the perfusion of the ‘native ‘blood into the
MVC-AACN Newsletter 22
body. Cerebral hypoxia occurs only when the femoral artery is cannulated on VA ECMO when pulsatility is
present. The right radial artery reflects the upper part of the body, which is perfused by blood that goes
through the native lung and comes out of the LV. The left radial artery reflects the lower part of the body,
which is perfused by blood that comes out of the femoral artery cannula. Thus, arterial blood gases are
checked from both sites.
Non-pulsatile flow occurs on full support – no flow through the pulmonary circulation or the left side
of the heart – increases the risks of left heart distension, pulmonary or left heart thrombosis and coronary
ischemia. SpO2 may not be obtained on non-pulsatile flow. Pulsatile flow occurs on partial support – some
pulmonary flow is maintained – reduces the risks of left heart distension and thrombosis.
Kathleen summarized some key points:
 Preload is indirectly proportional to ECMO flow – as flow increases, preload decreases.
 Afterload is directly proportional to ECMO flow – as flow increases, afterload increases.
 Cerebral hypoxia is not present in VV ECMO.
 CO from a Swan-Ganz catheter is not accurate on VA ECMO since the majority of the circulating blood
volume is bypassing the pulmonary circulation.
 ECMO does not fix the problem, it just support patients to give them time to recover.
Next she reviewed the management of the patient on ECMO. Patient management goals include:
optimize blood pressure, perfusion and acid-base balance – hct, vasopressors, volume (fluids, plts, FFP,
blood if indicated), bicarbonate/sweep flow; evaluate and correct any electrolyte abnormalities; evaluate and
correct any coagulopathy – check CBC, plts, PT, PTT, fibrinogen. The ventilator is usually managed at low
settings to allow the lungs to rest – low rate (8-10/min), long inspiratory time, low PIP (20-25 cmH2O), low
FiO2 (<30%), low PEEP (~10 cmH2O). Endotracheal tube (ETT) suctioning should be gentle and slow, just
the length of the ETT to avoid bleeding. Bronchoscopes are performed as needed. Patients should be turned
every two hours or via bed rotation therapy – open chest precautions with RA-PA cannulation.
ECMO patients may need a lot of sedation during the first 12-24 hours. Propofol and fentanyl are first
choice medications. The goal of sedation and pain management is to avoid spontaneous breathing, minimize
the metabolic rate and patient movement, and maximize patient comfort. Patients should have daily sedation
holidays to allow for neurological examination, then resume sedation and narcotics – optimize, don’t
maximize. These patients are at high risk for skin breakdown, so diligent skin care is indicated – turn at least
every 2 hours, dry linens, barrier protection ointment as needed, fecal containment bags if indicated. ECMO
patients are at high risk for infection and require sterile cannula dressing changes daily and as needed, and
diligent line care (IV, central lines, chest tubes).
Prophylaxis antibiotics are indicated for open chest cannulation and peripheral cannulation, and patients
should be pan-cultured for fevers 38C. Renal compromise is another management issue – urine output will
initially be low or none. As renal blood flow increases, urine output will increase. Edema should be
controlled with diuretics and hemofiltration – early CVVH (Continuous Veno-Venous Hemofiltration) if
indicated – can be run through the ECMO circuit. The goal is the patient’s “dry” weight. Finally, nutrition
should be initiated within 24 hours of implant – consult re tube feeds or TPN. ECMO patients require full
caloric and protein support. Blood glucose should be monitored and continuous insulin infusion if indicated
– lowers the risk of infection. A bowel regimen should also be employed.
MVC-AACN Newsletter 23
Next she discussed ECMO weaning and decannulation. She listed indications of readiness to wean.
With VA ECMO – BP increases, pulsatility returns or improves on arterial line tracing, right radial arterial
line pO2 decreases (more blood is going through the native heart, this blood is typically less oxygenated),
and CVP and PA pressures increase. ECMO support is typically turned down to assess native function. With
VV ECMO – gas exchange can usually be maintained on low FiO2, native lungs are able to maintain
ventilation when the sweep rate is minimal (<2 lpm). ECMO support does not need to be changed to assess
native function.
The team evaluates if the patient can adequately support him/herself – adequate ACT/PTT,
initiation/increase of cardiac infusions, increase ventilator settings; recovery of function (heart and/or lungs):
VA – BP, echocardiogram, ABG; VV – ABG. VA percutaneously inserted cannulas are removed, and direct
pressure should be maintained for a minimum of 30 minutes. If bleeding continues after decannulation,
direct pressure must be maintained for another 20 minutes. Direct cut down access should be removed in the
OR due to the need to repair the femoral artery. The patient should remain flat for six hours after
decannulation.
Central cannulation is removed in the OR. VV percutaneously inserted cannulas are simply pulled,
and then a purse string suture is placed at the skin. Direct cut down access must be explored, and a purse
string suture can be placed on the femoral vein. Venous pressure will not create a hematoma. Observe the
site for bleeding, especially if the patient is coughing or straining. RA-PA is decannulated in the OR. Be
prepared for complications during decannulation – 2 nurses, blood cooler in room with 4 units each PRBC
and FFP, protamine, FiO2 at 100%, normal saline for volume, and open chest tray accessible. Postdecannulation therapy is optimized and weaned as indicated – inotropes, vasopressors, vasodilators, IABP,
mechanical ventilation.
Potential emergencies include bleeding, anticoagulation, hemodynamics, air in the circuit, accidental
decannulation, and lethal arrhythmias/CPR. Anticoagulation is generally required with ECMO – it is
necessary to balance the risk of clotting with the risk of bleeding. It is okay to hold anticoagulation if the
patient is bleeding. Bleeding complications occur in approximately 50% of patients. Transfusion thresholds:
Hgb >8.5 – >10 if SvO2 is low; Plts >20,000 - >80,000 if bleeding; INR <2.5 - <1.6 if bleeding; fibrinogen
>150.
Finally, she reviewed troubleshooting with ECMO – generally gradual declines are a patient related
issue, sudden declines are a circuit related issue. For example, a sudden drop in SaO2 in VA ECMO is
always a mechanical issue, i.e., empty oxygen tanks, oxygenator function. Sudden/accidental decannulation
is extremely dangerous – the patient who is on complete ECMO support will become unstable very quickly
and is at extremely high risk for cardiac arrest. Immediate interventions include holding pressure on the
decannulated site, clamping the other cannula, and maximizing IV pressors. Lethal arrhythmias are treated
per ACLS protocol with VV ECMO – chest compressions are typically indicated except with central
cannulation. Lethal arrhythmias are less concerning with VA ECMO – attempt chemical code first – chest
compressions are not indicated.
After the morning break, Marcia Bixby RN, MS, CS, CCRN presented, “Cardiac Cath Lab
Procedures.” Marcia is a Critical Care Clinical Nurse Specialist who has extensive critical care experience
including consulting for education programs, and she presented on Intra-abdominal hypertension at our GI
program 5 years ago. Marcia identified patients who are appropriate for cath lab procedures: patients whose
symptoms/disease are not readily identified by non-invasive methods; patients with chest pain/STEMI (ST
segment elevation MI) who need immediate diagnosis and treatment; patients who have progression of a
MVC-AACN Newsletter 24
new or known disease that need accurate information to manage medical therapies; patients who do not
respond as expected to medical management for hypertension, angina, unstable angina; patients with
pulmonary disorders, e.g., pulmonary hypertension; PFO (patent foramen ovale), ASD (atrial septal defect),
VSD (ventricular septal defect); valve disease – aortic and mitral; and cardiomyopathy – LVH (left
ventricular hypertrophy).
Next Marcia discussed non-invasive cardiac diagnostic procedures. EKG (electrocardiogram) is used
to identify old or new ischemic changes, old/missed MI, and irregular rhythms. 2-dimensional
echocardiogram (TTE – transthoracic echocardiogram) identifies heart structures, estimates pressures and
ejection fraction, identifies abnormal wall motion, clot or abscess formation, valve disease – aortic, mitral,
pulmonic. 3-dimensional echocardiogram (TEE – transesophageal echocardiogram) requires
sedation/analgesia and provides pressures, ejection fraction, valvular function and wall motion. Cardiac CT
(computed tomography) can be used to identify plaque, calcium, aneurysm, and pulmonary embolus (PE).
Cardiac MRI (magnetic resonance imaging) provides still or moving images of cardiac function, valve
movement with systole/diastole, wall motion, and ejection fraction.
Stress testing monitors the patient while exercising – heart rate, blood pressure, EKG ST
depressions/elevations, chest pain or shortness of breath. Bruce protocol is a standardized method of
treadmill exercise testing with stages of incline in 3 minutes increments. Modified Bruce protocol uses
slower/lower incline. Medications may be used for stress testing in patients unable to exercise on the
treadmill. Nuclear imaging utilizes radioactive dye to reveal myocardial muscle perfusion – resting and
stressed images. When non-invasive testing is not helpful with the diagnosis, or when findings are not
consistent with the patient’s complaints/symptoms, cardiac catheterization is indicated.
Marcia started the “when to go to cath lab” portion of her presentation with, “why not go to cath
lab?” and listed potential risks and complications: venous or arterial access – vessel rupture or dissection,
compromise distal perfusion, arrhythmias or hemodynamic upset, contrast, anticoagulation, moderate
sedation, stroke, MI or death, radiation exposure/burn. Then she went on to discuss various cath lab
procedures.
RHC (right heart catheterization) requires venous access, evaluates hemodynamics, forward
flow, pulmonary HTN, pulmonary artery occlusive pressure, right or left heart failure, measures
oxygen saturations, and can be done with exercise-stress test.
LHC (left heart catheterization) requires arterial access and injects contrast to coronary
vessels to identify lesions/obstructions – RCA (right coronary artery) is associated with inferior EKG
lead changes; LCA (left coronary artery) – left main coronary artery spits to LAD (left anterior
descending – associated with anterior EKG lead changes) and circumflex – associated with posterior
EKG lead changes. A pressure wire can evaluate obstruction to flow.
LHC procedures include thrombectomy, angioplasty, stents, rotoblator – calcium lesions,
valve/vessel gradients. Defects, i.e., PFO, ASD, and VSD can be closed in the cath lab. Mechanical
support, e.g., IABP, LVAD (left ventricular assist device), RVAD (right ventricular assist device),
and ECMO can be placed in the cath lab. Finally, valve repair – balloon valvuloplasty, TAVR, Mitral
Clip can be performed in the cath lab.
In summary, cath lab procedures can identify vascular and structural abnormalities that are not
clearly identified by non-invasive workup, accurately measure blood flow to arteries, accurately measure
pressures, and diagnose structural anomalies, as well as perform minimally invasive procedures without
surgical intervention for patients who are/may not be surgical candidates. Marcia ended this session with a
reminder of the risks and potential complications: venous or arterial access – vessel rupture or dissection –
MVC-AACN Newsletter 25
EMERGENT; compromise distal perfusion – LOSS OF LIMB; arrhythmias/hemodynamic upset –
PRESSORS; contrast – CIN (contrast induced nephropathy); anticoagulation – BLEEDING,
RETROPERITONEAL BLEED; moderate sedation – RESPIRATORY/HEMODYNAMIC; MI or death –
“nothing is without risk!!!!!!!”
After lunch David Abate, the Northeast Region Senior Clinical Consultant for Thoratec Corporation
presented, “VADs – Ventricular Assist Devices.” David began with some statistics about the prevalence of
heart failure, advanced heart failure, and mortality. He compared the number of heart donations each year,
approximately 2200, vs 300,000 Class IV heart failure patients – although not everyone who is in Class IV
heart failure is a candidate for transplant.
A VAD is a mechanical device that circulates blood throughout the body when the heart is too weak
to pump blood on its own. He went on to discuss the history and progression of VADs. In 1982 Thoratec
manufactured the first implanted Paracorporeal Ventricular Assist Device (PVAD), and the first successful
bridge-to-transplant was in 1984. Thoratec’s next generation VAD is the HeartMate IIÒ Left Ventricular
Assist System (LVAS). The HeartMate II is indicated for inpatient and outpatient use in bridge-totransplantation and destination therapy. For patients waiting for a heart transplant, a VAD may help them
survive until a donor heart is available.
Bridge-to-transplant (BTT) criteria include non-reversible left heart failure, imminent risk of death,
and candidate for cardiac transplantation. Some advanced heart failure patients may not be candidates for a
transplant because of other comorbidities or age – these patients may benefit from long-term VAD support,
called Destination Therapy. Destination Therapy (DT) criteria include NYHA Class IIIB or IV heart failure,
optimal medical therapy 45 of last 60 days, and not a candidate for cardiac transplantation.
David described the components and function of the device but that is beyond the scope of this
article. He did have some samples of each device to pass around the room and there was quite a difference in
the size and weight between the first and second generation. Patient selection considerations include: no trial
data on BSA <1.3 m2, limited data on pediatric patients (age <18 years), ability to tolerate/allergy toward
anticoagulation, social support, acceptance of blood products, pregnancy, and nonreversible end organ
failure. Device troubleshooting is also beyond the scope of this article, but he did share some real life
operator errors – forgetting to have extra power with them at all times, showering without the shower kit,
and trauma to the percutaneous lead, e.g., hit with a hammer, slammed in car door, and caught on a shopping
cart.
Next he discussed Thoratec’s CentriMag Extracorporeal Blood Pump. CentriMag is indicated to
pump blood through the extracorporeal bypass circuit for extracorporeal circulatory support for periods
appropriate to cardiopulmonary bypass (up to 6 hours). It is also approved as a RVAD to provide temporary
circulatory support for up to 30 days for patients in cardiogenic shock due to acute RV failure – intended for
use in an ECMO circuit to provide cardiopulmonary support for up to 30 days when used with other
commercially available components approved for this application. Early recognition and early intervention
are key in patient selection for this device. CentriMag will not reverse late stage damage to organs caused by
periods of hypotension/hypoperfusion secondary to cardiac failure.
David ended his presentation with a hint about HeartMate III LVAS, which is currently in clinical trials.
After the afternoon break the next presentation was, ‘Transcatheter Valve Therapies,” by Kimberly
Guibone ACNP, Structural Heart Coordinator at Beth Israel Deaconess Medical Center in Boston, MA.
Aortic stenosis (AS) is the most prevalent native valve disease. Causes of AS include rheumatic valve
disease, bicuspid aortic valve (the aortic valve is normally tricuspid), and calcific/degenerative aortic valve
disease. Kim shared a mnemonic to describe the symptoms of AS:
MVC-AACN Newsletter 26
Syncope, dizziness
Exertional angina
Exertional dyspnea, shortness of breath, decreased exercise tolerance.
Medical therapy is to treat symptoms and manage CHF (congestive heart failure) – beta-blockers,
diuretics, and ACE inhibitors. Surgical aortic valve replacement (AVR) involves median sternotomy, open
pericardium, cardiopulmonary bypass machine, diseased valve cut out, replacement valve sewn in, and
carries a mortality risk of 1-3%.
Balloon aortic valvuloplasty improves the stenotic valve by placing a balloon catheter inside the
valve and inflating the balloon – this is a temporizing, palliative measure. TAVR (transcatheter aortic valve
replacement) is a minimally invasive approach to implanting an artificial heart valve inside a stenotic aortic
valve via catheter for those patients at high or extreme risk for surgical aortic valve replacement. Patient
selection criteria include: severe AS – AVA (aortic valve area) <0.8-1.0, mean gradient >40mmHg, peak
velocity >4.0, symptoms of NYHC II or greater, and determined to be of high or extreme risk for surgical
AVR by 2 cardiac surgeons.
Echocardiogram regularly establishes the diagnosis – left ventricular function, extent of hypertrophy,
amount of valve calcification, transvalvular pressure gradient, and aortic valve area. STS (Society of
Thoracic Surgeons) Risk Calculator is used to determine risk – a predicted mortality risk based on 30 clerical
and demographic inputs. STS risk score of >10% is considered high risk whereas STS risk score of >15% is
considered extreme risk. Some limitations include bleeding disorders, hostile chest (“any of the following or
other reasons that make redo operation through sternotomy or right anterior thoracotomy prohibitively
hazardous: abnormal chest wall anatomy due to severe kyphoscoliosis or other skeletal abnormalities
(including thoracoplasty, Potts' disease), complications from prior surgery, evidence of severe radiation
damage (e.g. skin burns, bone destruction, muscle loss, lung fibrosis, or esophageal stricture), history of
multiple recurrent pleural effusions causing internal adhesions)[i] and calcified aorta. Another consideration
is frailty – a multisystem dysregulation leading to decreased physiologic reserve and increased vulnerability
to stressors.
The Cardiovascular Health Study (CHS) index definition is when 3 or more of the following five criteria are
met:
1. Weight loss (>5% in the last year)
2. Exhaustion
3. Weakness (decreased grip strength)
4. Slow walking (>6-7 seconds for 15 feet)
5. Decreased physical activity (males <383 kcals, females <270 kcals)
Kim introduced two devices: Sapien XT Transcatheter Valve and CoreValve. Access routes include
transfemoral, subclavian, direct aortic and transapical. The procedure involves the structural heart team:
interventional cardiologist, cardiac surgeon, anesthesiologist (general anesthesia), perfusionist, OR team, and
cath lab team; hybrid operating room, and procedure time of 2 to 4 hours. Post-operative transfemoral cases
go to the CCU, direct aortic/transapical/thoracotomy cases go to CVICU. Patients are placed on dual
MVC-AACN Newsletter 27
antiplatelet therapy with aspirin and clopidogrel for > 3 months. Early extubation and mobilization are key.
Sapien recipients advance to the floor on POD#1, CoreValve recipients advance to the floor on POD#2.
Hospital length of stay is 4-7 days. Potential complications include neurological event/CVA,
arrhythmias/AV block, vascular access complications and CHF.
Mitral regurgitation (MR) is the most common type of heart valve insufficiency. Types of mitral
regurgitation include degenerative MR caused by mitral valve prolapse or by flail leaflet, and functional MR.
Symptoms include dyspnea, lethargy, fluid retention and arrhythmias/atrial fibrillation. Echocardiogram can
demonstrate the degree of MR: mild <20%, moderate 20-40%, moderate to severe 40-60%, and severe >60%
with >0.4 cm2 regurgitant orifice area. Treatment options include medical therapy, surgery and percutaneous
repair. Medical therapy includes afterload reducing agents, diuretics, calcium channel blockers, betablockers, rate controlling agents, and anticoagulation (for atrial fibrillation). Surgical options include repair
and annuloplasty, and mitral valve replacement. Transcatheter mitral valve repair (TMVR) is a percutaneous
option – percutaneous leaflet plication (edge-to-edge leaflet repair) for patients at high or extreme risk for
surgery. Kim introduced the MitraClip device for this procedure.
Kim went on to describe Heart Valve Centers of Excellence according to the AHA/ACC Guidelines.
She was very pleased and proud to announce that Beth Israel Deaconess Medical Center implanted the first
commercial CoreValve in the United States in January 2014! She also shared several current ongoing trials
of transcatheter valves: CoreValve Surtavi Intermediate Risk Trial, Lotus Valve – REPRISE I Trial, and
CoreValve Evolut Trial.
The final presentation of the day was, “Cardiac Transplantation,” by John Whitlock RN, MS,
Clinical Nurse Specialist for Cardiothoracic Surgery and Invasive Cardiology at Beth Israel Deaconess
Medical Center in Boston, MA. John began by describing the evaluation process for transplant. Patients
must meet certain criteria regarding heart failure: a history of repeated hospitalizations for heart failure; need
for VAD or artificial heart to support circulation; increasing types, dosages, and complexity of medications;
and a reproducible VO2 (oxygen consumption) <14 ml/kg/minute. Patients may be evaluated early and
placed at the bottom of the list – this avoids last minute decision-making, testing, etc. Patients must also
meet certain general criteria: age up to 70; BMI >21 kg/m2 and <40 kg/m2; and social – aptitude, supports,
financial needs. Patients may be taken off the list and placed back on – this can happen multiple times for
some patients.
Transplant evaluation includes patient interviews with a cardiologist, cardiac surgeon, transplant
coordinator, social worker, psychiatrist and dietician. Testing includes pulmonary function tests – strength,
capacity, oxygenation; myocardial VO2 – exercise tolerance; RHC – pulmonary blood flow/pressures, O2
samples; and echocardiogram – structural anomalies (tumor, aneurysm, etc.). Other testing includes EKG;
CXR (tumors, etc.); blood work – basics: CBC, PLT, coagulation studies; organ specific; infectious disease
(HIV, hepatitis, etc.) – antirejection drugs lower immunity thresholds; oncological – r/o subclinical process.
The Transplant Selection Committee includes the disciplines mentioned previously as well as bedside
nursing, financial coordinator, and consult services (ID, renal, etc.).
Nursing interventions for transplant evaluation include teaching, accurate information, and emotional
support – this is a big decision! What are the family dynamics? What is the patient’s coping history? How
can you help the patient be successful? If a patient is determined to be an appropriate candidate, the
following information is also entered into the United Network of Organ Sharing (UNOS): blood type, body
size (small body = small heart), severity of illness (list placement), and location – distance can play a vital
role – heart ex-situ 4 to 6 hours.
MVC-AACN Newsletter 28
·
·
·
·
·
·
·
·
John went on to describe the transplant list status:
 Status 1A:
Candidate admitted to transplant center and has at least one of the following devices or therapies in place:
Mechanical circulatory support
LVAD, RVAD, BiVAD – may be listed for 30 days once stable, drops to 1B after 30 days
Artificial heart
IABP
ECMO
Mechanical circulatory support with objective evidence of device-related complication
Continuous mechanical ventilation
Continuous infusion of single high-dose or multiple inotropes with continuous hemodynamic monitoring of
LV filling pressures
 Status 1B:
Candidate must have one of the following devices or therapies in place:
LVAD or RVAD
Continuous infusion of inotrope(s)
Status 2:
Candidates that do not meet the criteria for 1A or 1B are considered Status 2
Status 7:
Candidates that are temporarily unsuitable are placed on the Status 7 list
Treatable disease
Social situation
When a patient matches blood type, they are then matched using the following criteria:
age, body size (generally within 20% of donor), time on the wait list, severity of illness, and geographic
distance between the donor hospital and the transplant center (measured in increasing 500 mile distances
from the donor hospital). This system is regularly reviewed and revised with input from a wide variety of
interested parties including transplant professionals, recipients, and donor families.
Transplant coordinators/surgeons are called every time a potential match becomes available for their
patient. When a patient is matched, they are called into the hospital – a backup candidate is also called.
Donor organ evaluation continues as the procurement team is sent to harvest the organ – organ visualized
prior to removal and some are denied at the last minute. The donor heart is resected with the right atrium
intact. It is preserved in a cardioplegic solution designed to optimize myocardial metabolism or prevent cell
damage (KCl) and packed in ice. The donor heart must be transplanted within 4 to 6 hours.
The prognosis for heart transplant patients has increased over the past 20 years, and as of 2012
survival rates are 86.2% (females) to 88% (males) at 1 year, 77.2% (females) to 79.3% (males) at 3 years,
and 69% (females) to 73.2% (males) at 5 years.[ii]
The denervated heart has a loss of parasympathetic control – no mechanism to slow conduction rate
or velocity (HR almost always 90-110); no quick mechanism to respond to changes in filling pressures
(hypotension will lead to catecholamine release and eventual increase in HR); exercise – long, slow warmups recommended (10-15 minutes); transplant patient do not have chest pain. Postoperative complications
include bleeding, RV failure, hypovolemia, acute rejection, drug reactions/side effects, and infection. The
healthy heart is not used to working against high pulmonary artery pressures and starts to fail, usually
between days 2 to 4, characterized by elevated CVP. Isoproterenol increases HR to unload RV, inhaled nitric
oxide decreases pulmonary artery pressures – occasionally need to implant RVAD and slowly wean.
MVC-AACN Newsletter 29
There are several types of organ rejection. Hyperacute rejection occurs a few minutes after the
transplant when the antigens are completely unmatched – wrong cross-match. Acute rejection may occur any
time from the first week after the transplant to 3 months afterward. All recipients have some amount of acute
rejection. Chronic rejection can take place over many years. The body’s constant immune response against
the new organ slowly damages the transplanted tissues or organ. Signs and symptoms include: the organ’s
function may start to decrease; general discomfort, uneasiness, or ill feeling; pain or swelling in the area of
the organ (rare); fever (rare); flu-like symptoms including chills, body aches, nausea, cough, and shortness of
breath; general malaise – first clue to change in cardiac function! R
Rejection is graded: 0 (none); 1 (mild) – interstitial and/or perivascular infiltrate with up to one focus
of myocyte damage; 2 (moderate) – two or more foci of infiltrate with associated myocyte damage; 3
(severe) – diffuse infiltrate with multifocal myocyte damage with +/- edema or +/- hemorrhage or +/vasculitis.[iii] The strategy for treating rejection is based on the severity of rejection and the patient’s ability
to tolerate the treatment – renal function can be a limiting factor. Most often, it involves increased dosing of
immunosuppressive drugs or addition of a temporary agent. Patients may or may not be hospitalized based
on the scenario.
Postoperative nursing interventions include monitoring for bleeding and RV failure; support –
minimize blood products if possible, respond to changes in RV function (pulmonary dilators, inotropes,
mechanical support); and strict adherence to immunosuppressive therapy – blood levels same time every
day.
There are four categories of immunosuppression drugs.
Category I: Steroids – nonspecifically inhibit inflammatory response
Category II: Antiproliferatives – inhibit expansion of cell lines that modulate rejection, work primarily on T
and B cells
Category III: Other categories – work by blocking humoral response such as cytokine production
Category IV: Antibodies – monoclonal, polyclonal.
Consistency in timing of drugs is very important. The patient’s home schedule should be followed as
closely as possible. Steroids include methylprednisolone – used initially and pulse dosed with rejection
episodes, high dose weaned over time; and prednisone. Side effects include round face, hyperglycemia, bone
weakening, obesity, increased cholesterol, muscle weakness, cataracts, mood swings, and infection.
Antiproliferatives include: Azathioprine (Imuran) – T cells and B cells, dosage titrated to WBC of 5000/cc,
with side effects of low WBC, bone marrow suppression, liver abnormalities, and nausea; Mycophenolate
mofetil (Cell Cept) – T cells and B cells with BID dosing and side effects of nausea, diarrhea, and low WBC.
Other categories include: Cyclosporine (Neoral or Sandimmune or CsA) – humoral response
inhibitor, BID dosing titrated to trough blood levels, side effects of renal impairment, headache, tremors,
high potassium, photosensitivity, thickening of the gums, and increased hair growth; Tacrolimus (Prograf or
FK506) – inhibits cytokine production, BID dosing titrated to trough blood levels, side effects of renal
impairment, high potassium, seizures, headache, tremor, and hypertension. Monoclonal antibodies are
directed at specific antigens, so they are less toxic than polyclonal antibodies. OKT3 is the most common –
may be used for short periods if renal function is questioned (decrease dose of antiproliferatives), used to
treat rejection. Polyclonal antibodies – animal antithymocyte antigen (ATG) (rabbit or horse) – very potent
antibodies that attack all lymphocytes, reserved for steroid-resistant rejection, and always given in ICU due
to high risk of reaction. Supportive drugs include diuretics, antibiotics (Bactrim DS – careful with renal
impairment!), aspirin, calcium (prevent drug-induced osteoporosis), and GI prophylaxis (secondary to
steroids).
MVC-AACN Newsletter 30
Transplant precautions should include use of a positive pressure room – air is filtered and blows out
to the hallway. Otherwise use standard precautions with a few considerations – anyone with a fever or upper
respiratory infection may not enter the room (if it is essential for staff to enter the room to provide care for
these patients, the staff member should wear a surgical mask); anyone entering the room must disinfect their
hands with an alcohol-based waterless agent or antimicrobial soap; use only the stethoscope in the patient’s
room; communal patient care equipment is disinfected prior to bringing it into the patient’s room; patients
are assigned to a single room; keep the number of visitors to a minimum; and flowers are not allowed in the
room.
Long term complications include cardiac allograft vasculopathy – can be a slow, chronic process;
coronary arteries become thickened and hard; impairs coronary perfusion of donor heart; and eventually
leads to heart failure – treatment is transplant. Most long-term complications are related to drugs – infection
from immunosuppression, renal impairment, hypertension, diabetes, high cholesterol, cancer, osteoporosis,
and cataracts.
Eleven exhibitors supported the conference: Abbott Nutrition, AccuVein, Bard Medical, ConvaTec, Dale
Medical Products, Eloquest Healthcare, Mallinckrodt Pharmaceuticals, New England Organ Bank, Nihon
Kohden, NxStage Medical Inc., and the United States Army Nurse Corps Recruiting Company.
The following raffle prizes were awarded:
Membership (one year national AACN and Merrimack Valley Chapter) – Gail Landers
CCRN/PCCN certification/recertification – Kristen Richards
NTI 2015 (one-day complimentary registration) – Wendy Pelletier
Fall program – Jane Parris
Exhibitor form (fall program) – Mary Ann McNamara
Extra fall program raffle for participants in overflow seating – Gretchen Lord
Stay tuned for our fall 2015 program!
[i] Kappetein AP, Head SJ, Genereux P, et al. Updated Standardized Endpoint Definitions for Transcatheter
Aortic Valve Implantation. J Am Coll Cardiol. 2012;60(15):1438-1454.
[ii] Heart Disease and Stroke Statistics--2012 Update The American Heart Association. Retrieved 18 August
2014.
[iii] The International Society for Heart and Lung Transplantation (ISHLT) System for Grading Rejection:
Revised Grading:(2004).
MVC-AACN Newsletter 31