Management In Acute Settings Research Articles

A-009 Analytical Characterization of a Novel NT-proBNP Assay on a Central Laboratory Platform

Abstract Background N-terminal pro-B-type Natriuretic Peptide (NT-proBNP) or B-type Natriuretic Peptide (BNP) assay(s) are widely measured with a Class 1, Level of Evidence A recommendation in professional heart failure (HF) guidelines for diagnosis and prognosis. We present the analytical characteristics of the first NT-proBNP assay on Beckman Coulter platforms. Methods Measurements were conducted with the Access NT-proBNP assay, a one-step sandwich immunoenzymatic assay using monoclonal capture and detection antibodies, on the DxI 9000 Immunoassay Analyzer with Lithium Heparin (LiHep) plasma samples. Performance was characterized according to CLSI guidelines for: Limit of Blank (LoB), Limit of Detection (LoD), Limit of Quantitation (LoQ), linearity, imprecision (repeatability, reproducibility) and matrix comparison with LiHep, EDTA and serum. Reference intervals (RI) were evaluated in a healthy, adult U.S. population comprised of 675 subjects with 54.6% females, 79.1% White and 15.1% Black individuals. Exclusion criteria included elevated cardiac troponin, abnormal eGFR and cardiac medications. The 97.5th percentile RI upper limit was defined for age-stratified ranges of <50, 50-75, and >75 years old. Results Performance was LoB=1.1ng/L; LoD=4.8ng/L; LoQ=4.8ng/L; linearity=35,000ng/L. Repeatability ranged from 1.5%-3.5% and reproducibility from 2.3%-7.9% in seven samples ranging from 38ng/L to 23,848ng/L. Matrix measurement regression (n=68) yielded slopes of 1.00, 1.01; intercepts -0.03 to -2.63; r=0.98. Table 1 shows that NT-proBNP values increase with age and women generally have higher values than men. Conclusions The LoB, LoD and LoQ demonstrate highly sensitive low-end characteristics. Repeatability and reproducibility show excellent performance across a wide measurement range. NT-proBNP values are known to be age dependent, and the age-stratified 97.5th percentile RI upper limits were 162 ng/L for <50 years, 311 ng/L for 50-70 years, and 457 ng/L for >75 years. This novel Access NT-proBNP assay offers robust analytical performance as an aid to clinical HF management in acute settings.

Management of hyperkalemia: Expert consensus from Kuwait - a Modified Delphi Approach.

Hyperkalemia is common in heart failure (HF) patients on renin angiotensin aldosterone inhibitors (RAASi), in chronic kidney disease (CKD), and in hemodialysis, and it negatively impacts their management. New potassium binders, such as sodium zirconium cyclosilicate (SZC), are effective in management of acute and chronic hyperkalemia. However, guidelines inconsistencies and lack of standardized treatment protocols are hindering proper and wider use of such agents. Therefore, an expert panel from Kuwait developed a consensus statement to address hyperkalemia management in acute settings, in HF, in CKD, and in hemodialysis. A three-step modified Delphi method was adopted to develop the present consensus, which consisted of two rounds of voting and in-between a virtual meeting. Twelve experts from Kuwait participated in this consensus. Statements were developed and shared with experts for voting. A meeting was held to discuss statements that did not reach consensus at the first round and then the remaining statements were shared for final voting. The consensus consists of 44 statements involving an introduction to and the management of hyperkalemia in acute settings, HF, CKD, and hemodialysis. Thirty-six statements approved unanimously in the first vote. In the second vote, four statements were removed and four were approved after editing. Hyperkalemia management lacks standardized definitions, treatment thresholds and consistent guidelines and laboratory practices. This consensus is in response to lack of standardized treatment in the Arabian Gulf, and it aims to establish guidance on hyperkalemia management for healthcare practitioners in Kuwait and highlight future needs.

Unusual Intracerebral Hemorrhage Secondary to Delayed Posttraumatic Middle Meningeal Artery Pseudoaneurysm, Successfully Treated by Endovascular N-Butyl Cyanoacrylate Embolization

AbstractPseudoaneurysm of the middle meningeal artery, presenting as a delayed sequela of trauma, being a rare entity, may sometimes present as an acute intraparenchymal hemorrhage, with a risk of rerupture and mortality. The optimal management in acute settings remains undetermined. We, hereby, report a case of elderly gentleman with a history of a road traffic accident. Noncontrast computed tomography (NCCT) brain was reported to have left parietal hemorrhagic contusion without any mass effect. The patient was managed conservatively without any major neurological deficits. After 7 months, the patient presented with severe headache, altered sensorium, and right hemiparesis. NCCT brain showed acute left thalamocapsular hemorrhage with minimal subarachnoid hemorrhage with associated mass effect and impending herniation. Considering the fall in patient's baseline Glasgow comma scale response, pupillary asymmetry, and CT findings, immediate decompression and hematoma evacuation were advised. In view of atypical morphology, the patient was planned for urgent digital subtraction angiography prior to the surgery to rule out the ruptured aneurysm or pial arterio-venous fistula. Selective angiography of the left external carotid artery demonstrated a dissecting pseudoaneurysm feeding from the middle meningeal artery (MMA), which was embolized using n-butyl cyanoacrylate (NBCA). Postprocedure DynaCT revealed the left temporal bone fracture, indicating this pseudoaneurysm to be most likely posttraumatic delayed sequelae. Postembolization, the patient underwent surgical decompression and excision of hematoma. Patient's neurological status gradually improved and was discharged with the minimal deficit. Our case highlights the importance of awareness of the posttraumatic MMA pseudoaneurysm as an uncommon but treatable entity, which can be easily diagnosed using cerebral angiography and amenable to safe and effective endovascular embolization using NBCA.

Design and Implementation of Airway Response Teams to Improve the Practice of Emergency Airway Management.

Emergency airway management (EAM) is a commonly performed procedure in the critical care setting. Despite clinical advances that help practitioners identify patients at risk for having a difficult airway, improved airway management tools, and algorithms that guide clinical decision-making, the practice of EAM is associated with significant morbidity and mortality. Evidence suggests that a dedicated airway response team (ART) can help mitigate the risks associated with EAM and provide a framework for airway management in acute settings. We review the risks and challenges related to EAM and describe strategies to improve patient care and outcomes via implementation of an ART.

Patient-level and organizational-level factors influencing in-hospital falls.

In-hospital fall is one key safety issue in a healthcare setting. Although healthcare providers apply several strategies for preventing falls, falls still occur in hospitals. The aim of this study was to investigate patient-level and organizational-level factors influencing in-hospital falls. A multicentre retrospective observational study. This study used the national healthcare database and supplemented with organizational data obtained through a survey. Data extraction and survey were conducted between July and August 2020. A mixed-effect logistic regression model was used to analyse factors influencing in in-hospital falls. A total of 43,286 patients admitted in 86 hospitals were included in this study. Fall rate was 0.85 per 1000 days. Length of stay was significantly longer for fall patients than for no-fall patients. Patient-level factors (including age, mobility impairment and surgery) and organizational-level factors (including nurse staffing and proportion of new nurses) were significant factors influencing in-hospital falls. Since in-hospital falls increase economic burden to patients, we should consider various fall prevention strategies to reduce falls. For a strategy to be applied stably to patients, organizational factors must be supported. Proactive fall management in acute settings is essential to ensure patient safety. Considering that the number of patients with fall risk is increasing due to ageing, organizational factors should be supported to provide quality nursing care for fall risk patients. Therefore, nurse leaders should primarily ensure an appropriate level of nurse staffing. They also need to make efforts to strengthen clinical competency of nurses.

Delirium – are we doing enough prevention and basic management in acute settings?

AimsTo identify the prevalence of delirium and/or dementia on complex medicine wards.To assess the use non-pharmacological prevention and management options in these patients.BackgroundDelirium, a common hospital syndrome, is often multi-factorial. So, the management needs not only treating a reversible cause but also minimising the factors that could increase the risk of developing delirium, or worsen its course.The Scottish-Intercollegiate-Guidelines-Network (SIGN) and National-Institute-for-Health-and-Care-Excellence (NICE) guidelines outline non-pharmacological factors to reduce the risk of developing delirium, and for its management once established.These factors include orientation, ensuring patients have their glasses and hearing aids, promoting sleep hygiene, maintaining optimal hydration and nutrition, early mobilisation, appropriate lighting and providing cognitively stimulating activities.MethodSIGN, NICE and local guidelines were used to develop a checklist of core non-pharmacological factors that minimise the risk of developing delirium and help in its management. Adherence to recommendations from these guidelines was thus evaluated in 4 Complex Medical Units of The John-Radcliffe Hospital (Oxford University Hospitals NHS Foundation Trust), cross sectionally. The data were collected by interviewing nursing staff on the wards, assessing the ward environment, reviewing nursing charts and electronic patient records.ResultThere were 57 patients aged >65 years across all four wards, with average percentages of delirium and dementia patients being 46% and 34%, respectively. Nurses were unsure about their patients having hearing or visual aids in 41% and 29%, respectively. On all four wards there was no clear signage, no digital clock, no calendar, and earplugs were not offered. Overall, the use of non-pharmacological recommendations was sub-optimal across a number of items. After a month, when the notes were reviewed, it was found that 18 out of those 57 patients had passed away (32%) and the average length of stay for delirium/dementia patients was way more than the other patients during that admission.ConclusionWe found high rates of delirium and dementia and a lack of consistent use of recommended non-pharmacological strategies for their management. Better adherence to these could help shorten length of stay and improve patient outcomes.Recommendations for patients with/at risk of delirium: –Bedside board for each patient with the name of the ward/hospital, picture of the named nurse.–Ensuring visible clock/calendar.–Non-pharmacological delirium management checklist to be added to the daily nursing notes.Emphasis on visual/hearing aids and daily reorientation. –Appropriate lighting in the bays.–Offer earplugs if not sleeping at night.

Chapter 65 - Indications for the performance of neuroimaging in children

Pediatric neurology relies on ultrasound, computed tomography (CT), and magnetic resonance (MR) imaging. CT prevails in acute neurologic presentations, including traumatic brain injury (TBI), nontraumatic coma, stroke, and status epilepticus, because of easy availability, with images of diagnostic quality, e.g., to exclude hemorrhage, usually completed quickly enough to avoid sedation. Concerns over the risks of ionizing radiation mean re-imaging and higher-dose procedures, e.g., arteriography and venography, require justification. T1/T2-weighted imaging (T1/T2-WI) MR with additional sequences (arteriography, venography, T2*, spectroscopy, diffusion tensor, perfusion, diffusion- (DWI) and susceptibility-weighted imaging (SWI)) often clarifies the diagnosis, which may alter management in acute settings, as well as chronic conditions, e.g., epilepsy. Clinical acumen remains essential to avoid imaging, e.g., in genetic epilepsies or migrainous headaches responding to treatment, or to target sequences to specific diagnosis, e.g., T1/T2-WI for shunt dysfunction (with SWI for TBI); DWI, arteriography including neck vessels, and venography for acute hemiplegia or coma; coronal temporal cuts for partial epilepsy; or muscle imaging for motor delay. The risk of general anesthesia is low; "head-only" scanners may allow rapid MRI without sedation. Timely and accurate reporting, with discrepancy discussion between expert neuroradiologists, is important for management of the child and the family's expectations.

A nurse manager’s guide to support patients with dementia

Nurses may not have received training to care for patients with dementia. This article explores how nurse managers in acute settings can prepare nurses to manage patients with dementia. It includes advice on identifying patients' diagnosis on admission, working with carers and encouraging exercise, and emphasises the importance of establishing a rapport with patients.

How acute care managers can support patients with dementia

Not all hospital staff have had training in dementia care. This article describes how nurse managers in acute settings can prepare them to manage patients with dementia. It includes advice on identifying patients' diagnosis on admission, working with carers and encouraging activity, and emphasises the importance of establishing a rapport with patients.