Cardiac index based on measurements obtained in a bedside chair and in bed.

BACKGROUND: Accurate measurements for determining cardiac index can be obtained while patients are supine in bed at various backrest elevations. It is not clear if these measurements are accurate when patients are in a bedside chair. OBJECTIVE: To determine if cardiac index based on measurements obtained with the patient in a chair is similar to cardiac index based on measurements obtained with the patient in bed. METHODS: A convenience sample of cardiac surgical patients and a method-comparison design were used to compare cardiac index values based on measurements obtained with patients in 2 different positions: in a chair and in the bed. A standard thermodilution technique was used to measure cardiac output. Measurement of cardiac output in the second position was obtained immediately after measurement in the first position. Positions were randomly assigned. Bias and precision were calculated and graphed with the Bland-Altman method. Differences in cardiac index of 0.50 or more were considered clinically significant. Analysis of variance was used to determine differences between cardiac index values for the 2 positions. RESULTS: A total of 27 postoperative cardiac surgical patients were studied. Cardiac index values based on measurements obtained with patients in the 2 different positions did not differ significantly (F(1,50) = 0.446; P = .51). The mean difference score (bias) between the 2 positions was -0.07 (precision, 0.30). CONCLUSIONS: The practice of putting cardiac surgical patients whose hemodynamic status is stable back to bed before obtaining measurements for calculation of cardiac index may not be required for accurate values.

Update on ventricular assist device technology.

Ventricular assist devices are an important component in the arsenal of therapies to support the failing heart. This article provides an update on the variety of pulsatile, centrifugal, and axial-flow devices available in the United States. Common indications such as Bridge to Recovery and Bridge to Transplant are explored, as are the emerging indications Destination Therapy, Bridge to Decision, and Bridge to Bridge. Ventricular assist devices as support during high-risk percutaneous coronary intervention and the devices that can be rapidly deployed for this support are included. Clinical aspects of patient care including common complications, psychosocial concerns, and ethical considerations are reviewed.

Outcomes in special populations undergoing cardiac surgery: octogenarians, women, and adults with congenital heart disease.

Understanding the needs of the very elderly, women, and adults who have contenital heart disease undergoing cardiac surgery can contribute to successful outcomes. The very elderly have higher mortality and morbidity and special recovery implications. Heart disease is the number one cause of death in women in the United States. Contributing to this problem are lack of awareness of risks, delays in diagnosis and treatment, and gender-specific issues of undergoing cardiac surgery. There are more adults than children living with congenital heart disease. Advances in the treatment of congenital heart disease present a growing population with unique needs and ongoing health care issues.

Ventricular assist devices in the adult.

Ventricular assist devices (VADs) play an increasingly important role in the care of cardiovascular patients. Developed initially for support of cardiothoracic surgery patients experiencing difficulty in weaning from cardiopulmonary bypass, these devices have been used extensively as a bridge to cardiac transplantation for patients who are failing on medical management. Research has demonstrated the effectiveness of a VAD as destination therapy, providing a permanent means of support for patients with advanced heart failure who are not eligible for heart transplantation. Applications for VADs are expanding and advances in technology occurring to support these new applications. This article provides an overview of current and emerging VADs and nursing management of the VAD patient.

A prospective comparison of 3 new-generation pulse oximetry devices during ambulation after open heart surgery.

OBJECTIVE: To assess the clinical performance of 3 new-generation pulse-oximetry signal-processing software systems (Philips FAST, Masimo SET, and Nellcor N-3000) during ambulation after open-heart surgery. DESIGN: Prospective, convenience sample. SETTING: Cardiac surgical progressive care unit in a 629-bed, not-for-profit, tertiary-care teaching hospital. PATIENTS: Status post-cardiac-surgery patients (n = 36) during their first postoperative ambulation. INTERVENTIONS: None. PROTOCOL: Randomization was used for digit and hand selection, and all 3 devices were used continuously during ambulation. Data on dropouts, false alarms, and correlation with heart rate were recorded. We continuously measured arterial oxygen saturation via pulse oximetry during ambulation with all 3 devices. RESULTS: Pairwise comparisons indicated significant differences among the 3 devices for data dropout and false alarm. In repeated-measures analysis, the Nellcor N-3000 had the greatest likelihood of data dropout (odds ratio of 31.9 to Masimo and 5.6 to Philips, at the 95% confidence interval). However, the converse was true for false alarms; the Masimo had the most false alarms, with an odds ratio of 17.9 to Nellcor and 2.3 to Philips, at the 95% confidence interval. There were also significantly more dropouts with all 3 devices when readings were taken on a hand on an arm from which a radial graft had been taken (p = 0.004). For heart-rate correlation, the mean absolute difference among the 3 devices was similar: Philips = 4.3 beats/min, Masimo = 5.1 beats/min, and Nellcor = 3.0 beats/min. CONCLUSIONS: There are significant differences among the 3 devices with regard to dropout and false alarms. High numbers of dropouts are problematic because no pulse-oximetry patient information is available during dropout. However, false alarms are even more problematic, because they desensitize clinicians to alarms and call into question the accuracy of displayed data. While our data highlight the statistical differences between the studied oximeters, the clinical implications of these differences warrant further study.

Breakthroughs beckon new approaches to existing procedures.

The latest technology supplements cardiac care, sedation monitoring, and infection control.

Match critical care situations with savvy devices. High-tech solutions give a new twist to familiar procedures.

Advances in cardiac resynchronization therapy, stents, robotics, and monitoring offer patients new treatment options.

Ventricular assist devices: developing and maintaining a training and competency program.

Ventricular assist devices (VADs) have made it possible for patients with end-stage heart failure to survive until a donor heart is available. In addition to serving as a bridge to transplantation, evolving indications for VADs include bridge to recovery and destination therapy. There are many VAD programs, but in the majority of programs only a small number of devices are implanted each year. Low volume poses a challenge in terms of provision of comprehensive education and training for nurses who will care for patients with VADs and in terms of maintaining competency to care for these patients. This article briefly addresses current VAD technology and VAD program development. The major focus is on the education and competency challenges and solutions the authors have experienced as infrequent users of VAD technology.