Short- and Long-Term Outcomes of Hematologic Malignancy Patients After Cardiopulmonary Resuscitation: Experience of a Large Oncology Center.

PURPOSE: The objective of this study is to describe characteristics and short- and long-term outcomes of patients with hematologic malignancies who received cardiopulmonary resuscitation (CPR). METHODS: A retrospective review was conducted of all Code Blues at a large comprehensive cancer center. Demographic, clinical, and outcome variables were analyzed for patients with a hematologic malignancy who underwent CPR. RESULTS: Of 258 patients, 60.1% had leukemia. Outcomes included return of spontaneous circulation (70.2%), hospital survival (12%), and 90-day, 6-month, and 1-year survival rates of 9.8%, 8.2%, and 5.9%, respectively. Factors associated with hospital mortality included establishing a do not resuscitate order after CPR (p < .0001), location of CPR (p = .0004), cause of arrest (p = .0019), requiring vasopressors (p = .0130), mechanical ventilation (p = .0423), and acute renal failure post CPR (p = .0006). Although no difference in hospital survival between leukemia and non-leukemia patients was found, more non-leukemia patients were alive at 90 days (p = .0099), 6 months (p = .0023), and 1 year (p = .0119). CONCLUSIONS: Factors including organ dysfunction, location of CPR, and cause of arrest are associated with hospital mortality post CPR. However, immediate survival post CPR does not seem to be affected by a diagnosis of leukemia. These data should assist health care providers with discussions regarding advance care planning and goals of care after cardiac arrest.

Survey of Nurses' Experiences Applying The Joint Commission's Medication Management Titration Standards.

BACKGROUND: Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses' autonomous decision-making. OBJECTIVES: To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions. METHODS: A survey of nurses' experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses. RESULTS: The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulting from pressure to comply with orders, 70% deviated from orders to meet patient needs, and 84% requested revised orders to ensure compliance. Suboptimal care and delays in care significantly and strongly (regression coefficients ≥0.69) predicted moral distress. CONCLUSIONS: Critical care nurses perceive TJC medication titration standards to adversely impact patient care and contribute to moral distress. The improved 2020 updates to the standards do not address delays and inability to comply with orders, leading to moral distress. Advocacy is indicated in order to mitigate unintended consequences of TJC medication management titration standards.

Management of a patient with severe sepsis.

Severe sepsis and septic shock affect more than 700,000 people annually and represent approximately $17 billion annually in health care costs. Mortality in patients with 3 or more failed organs is up to 70%. Early identification and prevention of severe sepsis and septic shock are key factors in impacting mortality rates. Health care providers must be knowledgeable in early identification and aggressive management. This case presentation outlines the components of care identified in the literature in the early and ongoing management of patients with severe sepsis and septic shock.

Ischemic middle cerebral artery stroke: a case study.

Stroke is the third leading cause of death, ranking lower only to cardiac disease and cancer. Patients with stroke involving large vessels, including the middle cerebral artery, account for almost half of all patients with ischemic strokes and have an increased risk for poor outcomes and mortality at 6 months. Despite the availability and use of published guidelines for the early management of ischemic stroke, evidence to support treatment modalities for cerebral edema is still lacking. This case presentation will include the pathophysiology of an ischemic stroke and outline the established management guidelines. Literature related to the management of cerebral edema will also be discussed.

Intensive care unit delirium.

Once considered a benign iatrogenic consequence of intensive care unit (ICU) admission, ICU delirium is now recognized as a prominent disorder that negatively affects patient morbidity and mortality. The primary goal in the detection and treatment of ICU delirium is to ensure the safety of the patient and caregiver(s). Most critically ill patients possess 1 or more risk factors for the development of delirium; therefore, interventions that target delirium assessment and prevention are essential. This article highlights some of the recent data that have emerged regarding ICU delirium, including its definition, incidence, risk factors, diagnostic tools, and treatment.

Bringing research to the bedside: the role of induced hypothermia in cardiac arrest.

Despite progress in resuscitative practices, there has been little improvement in mortality and neurologic morbidity outcomes after cardiac arrest. Updated resuscitative guidelines were published in 2005, and included changes in resuscitation measures and recommendations in postresuscitation interventions including induced hypothermia. Treatment with induced hypothermia after cardiac arrest for up to 24 hours has been shown to significantly improve the neurologic outcomes and mortality in patients with primary cardiac arrest who remain comatose after return of spontaneous circulation. St. Luke's Episcopal Hospital, a private, not-for-profit teaching hospital licensed for 949 beds located at the Texas Medical Center in Houston, Tex, has incorporated this research into practice. A multidisciplinary team led by a neurointensivist was formed to develop and implement a protocol to support induced hypothermia after cardiac arrest. Twenty-five patients have received induced hypothermia with a 74% survival rate. Of those who survived, 47% went home for a regular discharge, 29% transferred to acute rehabilitation, and 23% transferred to a long-term care facility.

An interdisciplinary approach to transitioning ventilator-dependent patients to home.

Home mechanical ventilation was once a remote idea and thought to be used only in extreme cases. However, patient preference as well as limited financial resources to care for these patients in a long-term setting is forcing acute care facilities and families to make the choice of home care. This article describes how an interdisciplinary team used a quality process to develop and implement tools to assist with discharge planning in this complex patient population.