Consensus must be found on intravenous fluid therapy management in trauma patients

Introduction: Trauma is an important cause of death among young people and 30-40% of this mortality rate is due to hypovolemic shock, intensified by trauma's lethal triad: Hypothermia, Acidosis, and Coagulopathy. Nurses are responsible for managing fluid therapy administration in trauma victims. The purpose of this study is to analyse the reasons why intravenous fluid therapy is recommended for trauma patients' hemodynamic stabilization. Methods: This narrative literature review included published and unpublished studies in English, Spanish or Portuguese between 1994 and January 2019. The search results were analyzed by two independent reviewers. Inclusion criteria encompasses quantitative studies involving trauma victims aged over 18 who underwent fluid therapy in a prehospital assessment context. Results and Discussion: 11 quantitative studies were included. 9 involved the use of fluid therapy for hypotension treatment and 2 of the studies analyzed involved the use of warmed fluid therapy for hypothermia treatment. The analysis performed reveals that the administration of aggressive fluid therapy seems to be responsible for the worsening of the lethal triad. In the presence of traumatic brain injury, permissive hypotension is not allowed due to the negative impact on cerebral perfusion pressure. Used as warming measure, warmed fluid therapy does not seem to have a significant impact on body temperature. Conclusions: There is no consensus regarding the administration of fluid therapy to trauma patients. This conclusion clearly supports the need to develop more randomized controlled trials in order to understand the effectiveness of such measure when it comes to control hypovolemia and hypothermia

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Cuidados al paciente con estado hiperosmolar hiperglucémico en una Unidad de Medicina Intensiva / Care for patients in hyperosmolar hyperglycaemic state at the Intensive Care Unit

La diabetes mellitus constituye un problema importante de salud, ya que en los últimos 20 años se ha triplicado el número de personas que viven con esta enfermedad en todo el mundo. Una de las principales complicaciones agudas de la diabetes es el estado hiperosmolar hiperglucémico (EHH), causado por la deficiencia de insulina, acompañado de disminución de la volemia con o sin anormalidad del equilibrio ácido-base, y caracterizado por hiperosmolaridad plasmática consecuencia de la deshidratación grave. En esta ocasión se presenta un caso clínico de un paciente con diagnóstico de EHH, atendido en una Unidad de Medicina Intensiva, utilizando la metodología del proceso de Enfermería con la taxonomía NANDA-NIC-NOC, según el modelo conceptual de Virginia Henderson. Las intervenciones de Enfermería, junto a las actuaciones del equipo multidisciplinar, permitieron la remisión del diagnóstico a los siete días del ingreso, obteniendo como resultado un menor compromiso del estado de salud del paciente (AU)

Diabetes Mellitus represents a major health problem, because during the last 20 years the number of persons who live with this disease has tripled around the world. One of the main acute complications of diabetes is the Hyperosmolar Hyperglycaemic State (HHS), caused by insulin deficiency, accompanied by a reduction in blood volume with or without an abnormal acid-base balance, and characterized by plasma hyperosmolarity caused by severe dehydration. We present here the clinical case of a patient diagnosed with HHS, managed at an Intensive Care Unit, using the methodology of the nursing procedure with the NANDA-NIC-NOC taxonomy, according to Virginia Henderson's Conceptual Model. Nursing interventions, together with the actions by the multidisciplinary team, allowed the remission of diagnosis at seven days of admission, obtaining as a result a lower involvement in the patient's health condition (AU)

Can all neonatal resuscitation be managed by nurse practitioners?

AIM: To assess the ability of nurse practitioners to manage the care of all babies requiring resuscitation at birth in a unit without on site medical assistance. METHOD: A prospective review, and selective external audit, of the case records of all 14 572 babies born in a maternity unit in the north of England during the first eight years after nurse practitioners replaced resident paediatric staff in 1996. RESULTS: Every non-malformed baby with an audible heart beat at the start of delivery was successfully resuscitated. Twenty term babies and 41 preterm babies were intubated at birth. Eight term babies only responded after acidosis or hypovolaemia was corrected following umbilical vein catheterisation; in each case the catheter was in place within six minutes of birth. Early grade 2-3 neonatal encephalopathy occurred with much the same frequency (0.12%) as in other recent studies. Independent external cross validated review found no case of substandard care during the first hour of life. CONCLUSION: The practitioners successfully managed all the problems coming their way from the time of appointment. There was no evidence that their skill decreased over time even though, on average, they only found themselves undertaking laryngeal intubation once a year. It remains to be shown that this level of competence can be replicated in other settings.

Nursing considerations for fluid management in hypovolaemia.

Nurses need to be aware of the physiological aspects of fluid homeostasis and the nursing care and management required to manage patients with fluid balance problems effectively. This paper examines fluid management for patients with hypovolaemia, and provides reflective study points to encourage nurses to investigate the issues further.

Third-space fluid shift in elderly patients undergoing gastrointestinal surgery: Part II: nursing assessment.

Third-space fluid shift is the mobilisation of body fluid to a non-contributory space rendering it unavailable to the circulatory system. It is a recurrent clinical phenomenon requiring swift identification to minimise deleterious effects. Nurses experience difficulties however in its early identification, diagnosis and subsequent treatment because of the lack of consensual and consistent information regarding third-spacing. This article, part II, building on the previous article, explores the clinical validly and reliability of signs and symptoms of both phases of third-space fluid shift. In addition it reinforces the use multiple patient assessment cues if nurses are to differentiate between, and accurately respond to, the various causes of both hypovolaemia and hypervolaemia. It assists nurses to increase their knowledge and uderstanding of third-space fluid shift in patients undergoing gastrointestinal surgery.

Clinical decision making by nurses when faced with third-space fluid shift. How well do they fare?

Nurses' use of knowledge, the connection of this knowledge to treatment decisions and information actually used to reach such decisions, delineates nurses' level of expertise. Previous research has shown that nurses in their clinical decision-making use the hypothetico-deductive method and intuitive judgment or pattern recognition. This interpretive study explored experienced critical care nurses' (n = 5) and gastrointestinal surgical nurses' (n = 5) clinical decision-making processes through ascertaining their knowledge and understanding of third-space fluid shift in elderly patients undergoing major gastrointestinal surgery. Both groups of nurses, because of their experience with elderly patients undergoing gastrointestinal surgery, were assumed to be experts. Data collection techniques included semi-structured interviews and the use of think aloud protocol for clinical scenario analysis. The findings demonstrated that the gastrointestinal surgical nurses used the hypothetico-deductive method to recognize critical cues and the existence of a problem but could not name the problem. The critical care nurses, on the other hand, used a combination of the hypothetico-deductive method and pattern recognition as a basis for identification of critical cues. The critical care nurses also possessed in depth knowledge of third-space fluid shift and were able to use pivotal cues to identify the actual phenomenon. Ultimately, it would appear that the structure of critical care nurses' work, their increased educational qualifications and the culture of the critical care unit promote a more proactive approach to reasoning in the physiological domain. The findings have implications for the development of practice guidelines and curriculum development in both tertiary and continuing nurse education.