Telemetry Floor Research Articles

Abstract 3101: Precision Medication Communication Through Teach-back Method Among Patients With Cardiovascular Disease Admitted To The Telemetry Unit

Background: Limited qualitative research has identified clinician skills and behaviors that enhance precision communication, a challenging task when patients exhibit limited health literacy(HL). The teach-back method, a technique aimed at confirming patients' comprehension of health information has been suggested as a valuable strategy to address HL. Our quality improvement study examined the patients’ understanding of newly prescribed cardiac medications during hospitalization. We aimed to pinpoint barriers in communication between healthcare providers and patients as well as use the teach-back method to improve literacy about newly prescribed medications before their discharge. Methods: 50 participants, including 28 males and 22 females with a mean age of 71.72, (SDN+/-2:11.59) admitted to the telemetry floor between 11/2023 and 01/2024. Yes/No questionnaire interview was conducted to gauge their understanding of the newly prescribed cardiac medication and its adverse effects. The interviewer encouraged participants to articulate their understanding in their own words. A follow-up telephone interview was conducted 2-4 weeks post-discharge to assess the retention of information regarding the newly initiated medication(s). Results: Among 50 patients, 54% demonstrated awareness of the reason behind the prescription of the medication, while only 26% knew about its serious adverse effects before employing the teach-back method. Following the application of the method during the interview, 92% exhibited an enhanced understanding of the information related to their medications. Follow-up telephone interviews conducted 2-3 weeks post-discharge, 74% retained information about the indication and adverse effects of the prescribed medications. Conclusion: Integration of the teach-back method during discharge planning is a highly effective strategy in improving patient education and communication for newly prescribed cardiac medications.

PULMONARY AND CORONARIES OF THE HEART SHOULD STAY APART: A CASE OF MULTIPLE CORONARY TO PULMONARY ARTERY FISTULAS

PULMONARY AND CORONARIES OF THE HEART SHOULD STAY APART: A CASE OF MULTIPLE CORONARY TO PULMONARY ARTERY FISTULAS

Cardiogenic Shock Following Successful CTO Revascularization

<h3>Introduction</h3> The role of urgent mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is not well studied. This case highlights myocardial recovery in a patient with ventricular fibrillation following a CTO PCI supported with MCS. <h3>Case Report</h3> A 45 year-old man with recent non-ST elevation myocardial infarction, found to have triple vessel coronary artery disease treated with drug-eluting stent to LAD and OM1, due to patient preference, presents for an elective revascularization of CTO of RCA. Left ventricular function at time of discharge from his prior hospitalization was preserved. Revascularization of CTO was accomplished with placement of Resolute Onyx 3.5x38 mm stent and Resolute Onyx 3.0x26 mm stent to the mid RCA and a Resolute Onyx 3.0x22 mm stent to the distal RCA. There were no complications, and the patient was transferred to a telemetry floor. Soon after transfer he suffered cardiac arrest with ventricular fibrillation. He was defibrillated with return of spontaneous circulation however remained hemodynamically tenuous. Bedside echocardiogram demonstrated severe biventricular dysfunction. Coronary angiography showed stable anatomy with patent stents. Given declining hemodynamic status an Impella CP was placed emergently via the left femoral artery. He was transferred to the cardiac critical care unit where he subsequently developed monomorphic ventricular tachycardia with further hemodynamic deterioration. He was cannulated for VA ECMO and hemodynamic stability was achieved. Due to ongoing hemolysis, Impella CP was exchanged for an axillary Impella 5.5. As results of medical management and aggressive supportive care, subsequent echocardiograms demonstrated recovery of left and right ventricular function. He was decannulated from VA ECMO and Impella 5.5 after four days. Outpatient transthoracic echocardiogram performed four weeks later demonstrate preserved biventricular function. LV ejection fraction was measured at 55% and global longitudinal strain -16.7%. RV longitudinal strain -21.4%. He is tolerating guideline-directed medical therapy for heart failure. <h3>Summary</h3> This case describes ventricular fibrillation following CTO revascularization and highlights the positive outcomes associated with early recognition of deteriorating cardiogenic shock and rapid escalation of mechanical circulatory support.

Multisystem inflammatory syndrome in adults: a\xa0case report\xa0and review of the literature

BackgroundThe current coronavirus disease pandemic has brought recognition of multisystem inflammatory syndrome in adults as a de novo entity, temporally associated with severe acute respiratory syndrome coronavirus 2 viral infection in adults. Hypothesis about its true pathophysiology remains controversial.Case reportThe patient was a 22-year-old African American female presenting to the emergency department with fever, sore throat, and neck swelling for the past 3 days. During her initial emergency department visit, her blood pressure was stable at 110/57 mmHg, temperature of 39.4 °C, and heart rate of 150 beats per minute. While in the emergency department, she received broad-spectrum antibiotics (vancomycin and ceftriaxone) and 30 cc/kg bolus of normal saline. Originally, she was admitted to a telemetry floor. The following night, a rapid response code was called due to hypotension. At that time, her blood pressure was 80/57 mmHg. She appeared comfortable without signs of respiratory distress. She received intravenous fluids and vasopressors, and was transferred to the intensive care unit. The patient had reported a previous coronavirus disease infection a few weeks prior. She was diagnosed and treated for multisystem inflammatory syndrome in adults. Intravenous immunoglobulin infusion was initiated and completed on hospital day 5. She was weaned off vasopressors by day 6, and discharged home on day 11.ConclusionOur case report is an example of the presentation, diagnosis, and management of multisystem inflammatory syndrome. Our research into previous case reports illustrates the wide range of presentations, degree of end organ damage, and treatment modalities. This diagnosis needs to be considered in the presence of recent coronavirus disease infection with new-onset end organ failure, as prompt diagnosis and treatment is crucial for better outcomes.

Current Utilization Trends of SGLT-2 Inhibitors in Type 2 Diabetics With Heart Failure

Background: Sodium glucose cotransporter-2 inhibitors (SGLT2 inhibitors) are a recent addition to the armamentarium for treating type 2 diabetes. Over the last couple of years, these agents have been studied in patients with cardiovascular disease, particularly heart failure. Results of the EMPA-REG (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients), CANVAS (Canagliflozin Cardiovascular Assessment Study) and DECLARE-TIMI (Dapagliflozin Effect on Cardiovascular Events‐Thrombolysis in Myocardial Infarction) have clearly shown SGLT2 inhibitors to be beneficial for patients with heart failure. FDA has approved Canagliflozin and Dapagliflozin for reduction of risk of adverse cardiovascular events in patients with Type 2 Diabetes with established Cardiovascular disease. This study was conducted to determine the current utilization trends of SGLT2 inhibitors in Type 2 Diabetics admitted with congestive heart failure exacerbation at Abington Memorial Hospital. Methods: The study was an observational retrospective chart review of 287 patients who were admitted to the telemetry floor with an admitting diagnosis of Congestive Heart Failure with a concomitant diagnosis of Type 2 Diabetes from 06/01/2019 to 11/30/2019. 186 patients met the inclusion criteria. Results: Mean age of the patient population was 69 years. Mean ejection fraction was 39%. Mean A1C was 7.7. Out of 186 patients who met the inclusion criteria, 2 patients were on SGLT2 inhibitor on admission and were discharged on it. 1 patient was started on a SGLT2 inhibitor during hospitalization and was discharged on it. Out of our patient population, only 1.6% of the patients were discharged on SGLT2 inhibitor. Conclusion: Even after FDA approval of SGLT-2 inhibitors in reducing heart failure hospitalizations in patients with known history of Type 2 diabetes and heart failure, the utilization of these drugs is very minimal. No other drug has been proven to improve mortality in patients of heart failure with preserved ejection fraction. Based on the results of this study, we propose that initiation of SGLT2 inhibitor should be one of the core measures during discharge of Type 2 Diabetics after a hospitalization with Heart Failure.

Evaluation of Team-Based Learning to Increase Nurses' Knowledge of the Ventricular Assist Device.

Ventricular assist devices (VAD) are used to extend life expectancy for patients with advanced heart failure. Approximately 102 hospitals nationwide have a VAD program, but the majority implant only a small number of devices each year. This low-volume and high-acuity patient population can create concerns for maintaining nursing knowledge skill levels. Nursing staff from a step-down telemetry floor in a large urban hospital completed an Individual Readiness Assessment Test to assess their knowledge and accuracy in the care of mechanical circulatory support patients using the Immediate Feedback Assessment Technique. The nurses were then assigned to small groups and worked as a team to complete the same test known as the Group Readiness Assessment Test. Study results suggest that team-based learning was effective in increasing knowledge of mechanical circulatory support. [J Contin Educ Nurs. 2021;52(1):13-20.].

Abstract 14626: Propofol and Dexmedetomidine Related Transient High-grade Symptomatic Av Block

Introduction: Dexmedetomidine and propofol are both associated with risk of sinus bradycardia and hypotension. High grade AV block has rarely been reported with these medications. We present a case of high grade AV block (Mobitz II) in the setting of co administration of dexmedetomidine and propofol resulting in hypotension, that resolved with discontinuation of propofol. Case: 85 year old female with history significant for hypertension and CLL was admitted to the ICU with ARDS secondary to COVID-19 requiring mechanical ventilation. Along with management of ARDS, dexmedetomidine and propofol were administered for adequate sedation while trying to limit high dose of propofol. On day one of administration of the combination (16 mcg/kg/min propofol and 0.6 mcg/kg/hr dexmedetomidine), patient developed Mobitz II AV block associated with hypotension with systolic pressure in 60s. Propofol was discontinued and AV block and hypotension resolved. Patient continued to improve and was eventually extubated and transferred to the telemetry floor. Her telemetry during hospital course did not reveal any further high grade AV block and thus patient did not require placement of a pacemaker. Discussion: Optimizing sedation in intubated patients and knowledge of associated adverse effects is warranted to minimize mechanical ventilation time and prevent life threatening complications. Dexmedetomidine has been associated with a reduction in mechanical ventilation duration but an increased risk of bradycardia and hypotension as compared to midazolam and propofol. (1) Hypotension is common with propofol but sinus bradycardia and arrythmias have also been reported. (2) Rarely propofol can precipitate high grade AV block that can be life threatening if not promptly addressed. (3) Co administration of dexmedetomidine and propofol can be associated with exaggeration of individual side effects. Mindfulness of such adverse effects can not only help prevent life threatening complications but also decrease chances of unnecessary pacemaker placements. Conclusion: Propofol though associated with sinus bradycardia, may result in high grade AV block when co-administered with dexmedetomidine that is usually reversible with discontinuation of the offending drug.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Monitoring the Use of Telemonitor: A Resident-run Quality Improvement Initiative Decreases Inappropriate Use of Telemonitor in a Community Hospital.

BackgroundCardiac telemetry is an important tool to detect life-threatening conditions in hospitalized patients but is used widely and inappropriately. We sought to assess current usage and improve the appropriate use of telemetry in a community hospital.MethodsWe conducted a quality improvement project on patients who were admitted on telemetry floors between January and March 2017 (pre-intervention). The indication(s) and duration of telemonitor use, event(s) recorded on telemonitor and outcome of the event(s) were documented. A six-month educational intervention was undertaken and the effect of intervention was assessed among patients admitted between December 2017 and February 2018 (post-intervention).ResultsIn the pre-intervention group, 329 patients qualified for the study, with a median age of 78 years. The post-intervention group had 383 qualified patients with a median age of 77 years. Mean duration of telemonitor use was four days in both groups. In the pre-intervention group, 54% had class I, 32% had class II, and 14% had class III indications. In post-intervention group, 46% had class I, 42% had class II, and 12% had class III indications. The educational intervention resulted in a trend towards less inappropriate use of telemetry, particularly in teaching service. Telemonitor events were recorded in 22 (7%) of the pre-intervention patients and 13 (4%) of the post-intervention group. Two patients died in the pre-intervention group and one in the post-intervention group from non-cardiac causes.ConclusionOur results highlight that change in practice requires sustained education interventions.

RIGHT LUNG HERNIATION TO LEFT CHEST AFTER HEART-LUNG TRANSPLANT

SESSION TITLE: Complications You Don't Want to Miss SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/10/2018 10:45 AM - 11:45 AM INTRODUCTION: Lung herniation to contralateral pleural space is a rare complication after heart-lung transplant (HLT). CASE PRESENTATION: A 51-year-old Hispanic female with a history of congestive heart failure, pulmonary hypertension, Sjogren’s syndrome, and pulmonary fibrosis underwent HLT. Post-operative course was initially uneventful and she was extubated on post-operative day (POD) 3. Bilateral chest tubes were removed POD 5. Patient was transferred to the telemetry floor on low dose dobutamine on POD 6. Chest radiography showed right greater than left pleural effusion which progressed over the next few days. On POD 8 she underwent ultrasound-guided right thoracentesis with removal of 800 mL of fluid serosanguinous fluid and bronchoscopy revealed features concerning for right middle lobe torsion and right lower lobe (RLL) atelectasis. This prompted a computed tomography (CT) scan of the chest on POD 9 that showed herniation of the RLL into the left pleural space behind the heart with complete atelectasis of the RLL. On POD 10 she was taken to the operating room for mediastinal exploration and reduction of RLL herniation. RLL appeared viable. The airway and vessels appeared patent. Pneumopexy of right upper, middle, and lower lobes was completed. RLL was also pexied to the chest wall and diaphragm to prevent recurrence. Patient did well. She was extubated, and eventually discharged home without negative sequela related to herniation. DISCUSSION: This patient was doing well clinically despite lung herniation. Chest X ray findings suggestive of lung herniation were obscured by bilateral pleural effusions in our case. Lung herniation behind the heart into the contralateral thoracic cavity can increase infection risk, cause vascular compromise, or infarction. CONCLUSIONS: Lung herniation after HLT is a rare complication. CT scan is the diagnostic imaging of choice. Early diagnosis and surgical correction can prevent lung compromise. If diagnosis is delayed, irreversible damage may occur that may potentially require resection of the nonviable lung lobe. Reference #1: Yonan NA, Egan J, Deiraniya AK, et al. Right Lower Lobe Herniation After Domino Heart-Lung Transplantation. Ann Thoracic Surg 1995; 59:1223-1226. DISCLOSURES: No relevant relationships by Mudassar Ahmad, source=Web Response No relevant relationships by Thomas Kaleekal, source=Web Response

Sound and Light Levels Are Similarly Disruptive in ICU and non-ICU Wards.

To compare ambient sound and light levels, including SLCs, in ICU and non-ICU environments. Observational study. Tertiary-care hospital. Sound measurements of 0.5 Hz were analyzed to provide average hourly sound levels, sound peaks, and SLCs =17.5 decibels (dB). For light data, measurements taken at 2-minute intervals provided average and maximum light levels. The ICU rooms were louder than non-ICU wards; hourly averages ranged from 56.1 ± 1.3 dB to 60.3 ± 1.7 dB in the ICU, 47.3 ± 3.7 dB to 55.1 ± 3.7 dB on the telemetry floor, and 44.6 ± 2.1 dB to 53.7 ± 3.6 dB on the general ward. However, SLCs = 17.5 dB were not statistically different (ICU, 203.9 ± 28.8 times; non-ICU, 270.9 ± 39.5; P = 0.11). In both ICU and non-ICU wards, average daytime light levels were <250 lux, and peak light levels occurred in the afternoon and early evening. Quieter, non-ICU wards have as many SLCs as ICUs do, which has implications for quality improvement measurements. Efforts to further reduce average noise levels might be counterproductive. Light levels in the hospital (ICU and non-ICU) may not be optimal for maintenance of a normal circadian rhythm for most people.

Frequency of medical emergency team activation prior to pediatric cardiopulmonary resuscitation

BackgroundMedical Emergency Teams (METs) are designed to respond to signs of clinical decline in order to prevent cardiopulmonary arrest and reduce mortality. The frequency of MET activation prior to pediatric cardiopulmonary resuscitation (CPR) is unknown. MethodsWithin the Get With The Guidelines-Resuscitation Registry (GWTG-R), we identified children with bradycardia or cardiac arrest requiring CPR on the general inpatient or telemetry floors from 2007 to 2013. We examined the frequency with which CPR outside the ICU was preceded by a MET evaluation. In cases where MET evaluation did not occur, we examined the frequency of severely abnormal vital signs at least 1hour prior to CPR that could have prompted a MET evaluation but did not. ResultsOf 215 children from 23 hospitals requiring CPR, 48 (22.3%) had a preceding MET evaluation. Children with MET evaluation prior to CPR were older (6.8±6.5 vs. 3.1±4.7 years of age, p<0.001) and were more likely to have metabolic/electrolyte abnormalities (18.8% vs. 5.4%, p=0.006), sepsis (16.7% vs. 4.8%, p=0.01), or malignancy (22.9% vs. 5.4%, p<0.001). Among patients who did not have a MET called and with information on vital signs, 55/141 (39.0%) had at least one abnormal vital sign that could have triggered a MET. ConclusionThe majority of pediatric patients requiring CPR for bradycardia or cardiac arrest do not have a preceding MET evaluation despite a significant number meeting criteria that could have triggered the MET. This suggests opportunities to more efficiently use MET teams in routine care.

Amyloid Cardiomyopathy: All that sparkles is Amyloid

A 73 year old female with no past medical history presented to our emergency department (ED) with gradually worsening shortness of breath for a few weeks. She denied any associated complaints of chest pain, palpitations or dizziness. On physical exam, the patient had bilateral rales at the lung bases. The electrocardiogram showed low voltage complexes with right bundle branch block and left anterior fascicular block (Figure 1). The laboratory work came back significant for an elevated BNP (1452 pg/ml) with a normal complete blood count, serum chemistry and negative cardiac biomarkers. The patient was treated with intravenous diuretics in the ED and admitted to a telemetry floor.

Missed opportunities in use of medical emergency teams prior to in-hospital cardiac arrest

Hospitals often employ Medical Emergency Teams (METs) to respond to patients with acute physiological decline so as to prevent deaths from in-hospital cardiac arrest (IHCA). We determined the frequency of missed opportunities for MET evaluation, defined as no MET evaluation prior to IHCA despite evidence of severe vital sign abnormalities ≥1 hour preceding cardiac arrest. Within Get With The Guidelines-Resuscitation, we identified 21,913 patients from 274 hospitals with IHCA on general inpatient or telemetry floors who would be eligible for a MET evaluation prior to IHCA. We determined the proportion of patients with missed opportunities for MET evaluation, defined as no MET evaluation before IHCA despite at least 1 severe vital sign abnormality (pulse >150 or <30, respiratory rate >35 or <8, systolic blood pressure <80, and oxygen saturation <80%) 1, 2, and 4 hours before IHCA. The relationship between a hospital's proportion of missed opportunities for MET evaluation and its risk-standardized rate of survival to discharge for IHCA (derived using hierarchical linear regression models) was then evaluated. Overall, few (3,814 [17.4%]) patients with IHCA had a preceding MET evaluation, and the odds of a MET evaluation varied by >80% across hospitals (median, 14.6% [interquartile range, 9.1%-22.2%]; median odds ratio, 1.82). Vital sign data were available for 13,115 (72.5%) of the 18,099 patients without MET evaluation. Of these patients, 5,243 (40.0%), 4,078 (31.1%), and 1,767 (13.4%) had at least 1 severe vital sign abnormality ≥1, 2, and 4 hours before IHCA, respectively. Hospitals with the highest proportion of unevaluated patients despite severe vital sign abnormalities 2 and 4 hours preceding cardiac arrest had the lowest IHCA survival rate (correlation of -0.14 [P = .04] and -0.16 [P = .01], respectively). Although METs are designed to prevent IHCA, many patients with severe vital sign abnormalities prior to IHCA did not have a MET evaluation, and hospitals with higher rates of unevaluated patients had lower IHCA survival. These findings suggest missed opportunities to efficiently use METs in current practice.

Abstract 220: Missed Opportunity for Medical Emergency Team Activation in Pediatric In-Hospital Cardiac Arrest

Background: Prior studies of Medical Emergency Teams (METs) in pediatric hospitals have shown inconsistent results in terms of their ability to improve outcomes. Whether the variable success is due to differential utilization of METs among hospitals is unknown. Methods: Within the Get With The Guidelines-Resuscitation Registry (GWTG-R), we identified children (age &lt;18 years) with an in-hospital cardiac arrest (IHCA) on the general inpatient or telemetry floors from 2007 to 2014. In cases of IHCA where MET evaluation did not occur, we examined the frequency of “missed” opportunities for activation of the MET based upon the presence of one or more abnormal vital signs. We also examined the variability in utilization of the MET among those hospitals with at least ten cases of IHCA. Results: Of 215 children from 23 hospitals sustaining an IHCA, 48 (22.3%) had a preceding MET evaluation. Children with MET evaluation prior to IHCA were older (6.8 ± 6.5 vs. 3.1 ± 4.7, p &lt; 0.001) and were more likely to have metabolic/electrolyte abnormalities (9/48 [18.8%] vs. 9/167 [5.4%], p=0.006), sepsis (8/48 [16.7%] vs. 8/167 [4.8%], p=0.01), or malignancy (11/48 [22.9%] vs. 9/167 [5.4%], p&lt;0.001) at the time of their IHCA. Hospital utilization of the MET varied substantially (median 20%; inter-quartile range [IQR]: 3.4%-29.8%; range: 0%-36.4%). Among patients who did not have a MET called prior to their IHCA, 78/141 (55.3%) had at least one abnormal vital sign that should have triggered a MET. Conclusion: In a large, national registry, we found that the majority of pediatric IHCA cases are not preceded by a MET evaluation despite meeting criteria that should have triggered a MET. Improved utilization of the MET by all hospitals could lead to fewer pediatric IHCA and improved outcomes following pediatric IHCA.

Abstract 11510: Missed Opportunities in Use of Medical Emergency Teams Prior to In-Hospital Cardiac Arrest

Background: Hospitals often employ Medical Emergency Teams (MET) to respond to patients with acute physiological decline to prevent in-hospital cardiac arrest (IHCA). However, it is unknown how often patients fail to have a MET evaluation preceding IHCA, and whether these patients have severe vital sign abnormalities suggesting missed opportunities for MET activation. Methods: Within Get With The Guidelines-Resuscitation, we identified 29,956 patients with IHCA on general inpatient or telemetry floors from 240 hospitals that submitted data on both IHCA and MET evaluations. We determined the proportion without MET evaluation before IHCA. Among those without MET evaluation, we examined the frequency of vital sign abnormalities 1, 2, and 4 hours before IHCA. We used stringent definitions for the following six vital sign abnormalities: heart rate &gt;150 or &lt;30 beats per minute, respiratory rate &gt;35 or &lt;8 breaths per minute, systolic blood pressure &lt;80 mm Hg, and oxygen saturation level of &lt;80%. Results: Overall, the vast majority (24,733 [82.6%]) of patients with IHCA did not have a preceding MET evaluation. Vital sign data were available for 18,064 patients without MET evaluation. Of these patients, 7109 (39.4%), 5536 (30.6%), and 2368 (13.1%) had at least one severe vital sign abnormality ≥ 1, 2, and 4 hours before IHCA, respectively (TABLE). Furthermore, 13.7% had a Modified Early Warning Score (MEWS) ≥ 4 at least 1 hour before IHCA. Conclusion: Although MET teams are designed to prevent IHCA, many patients with severe vital sign abnormalities prior to IHCA did not have a MET evaluation. These findings suggest missed opportunities to use MET teams efficiently in hospitals.

Dexmedetomidine Infusion for Analgesia Up to 48 Hours After Lung Surgery Performed by Lateral Thoracotomy

Patients undergoing a lateral thoracotomy for pulmonary resection have moderate to severe pain postoperatively that is often treated with opioids. Opioid side effects such as respiratory depression can be devastating in patients with already compromised respiratory function. This prospective double-blinded clinical trial examined the analgesic effects and safety of a dexmedetomidine infusion for postthoracotomy patients when administered on a telemetry nursing floor, 24 to 48 hours after surgery, to determine if the drug's known early opioid-sparing properties were maintained. Thirty-eight thoracotomy patients were administered dexmedetomidine intraoperatively and overnight postoperatively and then randomized to receive placebo or dexmedetomidine titrated from 0.1 to 0.5 μg·kg·h−1 the day following surgery for up to 24 hours on a telemetry floor. Opioids via a patient-controlled analgesia pump were available for both groups, and vital signs including transcutaneous carbon dioxide, pulse oximetry, respiratory rate, and pain and sedation scores were monitored. The dexmedetomidine group used 41% less opioids but achieved pain scores equal to those of the placebo group. The mean heart rate and systolic blood pressure were lower in the dexmedetomidine group but sedation scores were better. The mean respiratory rate and oxygen saturation were similar in the two groups. Mild hypercarbia occurred in both groups, but periods of significant respiratory depression were noted only in the placebo group. Significant hypotension was noted in one patient in the dexmedetomidine group in conjunction with concomitant administration of a beta-blocker agent. The placebo group reported a higher number of opioid-related adverse events. In conclusion, the known opioid-sparing properties of dexmedetomidine in the immediate postoperative period are maintained over 48 hours.

Alarms Pose Challenges to Healthcare Facilities

Medical device alarms provide essential warnings to alert caregivers of changes in a patient's condition. When alarms work well, the environment of care is enhanced. When alarms don't work well, they pull caregivers away from other duties and other patients—or worse, train caregivers to ignore the alarm sounds altogether. Alarms that are ignored can and have resulted in patient deaths.Today, by and large, medical device alarms don't work well. Too many devices sound too many alarms and are wrong too often. Why is that, and what can be done about it?As the number of devices in patient care areas have multiplied, so have the noises they make. Experts say that most alarms generated by medical devices don't require any action at the bedside—from 85% up to 99%. These “nonactionable” alarms add to the noise, confusion, and stress in an already-stressful environment.High false alarm rates intertwine with other alarm problems including:Some facilities have had astounding success at improving alarm performance. Dartmouth Hitchcock Medical Center in Lebanon, NH, undertook an alarms improvement initiative on a post-surgical orthopedic floor. It succeeded in reducing the average number of alarms per patient per day to only four. William Beaumont Hospital in Detroit, MI, reduced its mean alarm response time on a telemetry floor from 9.5 minutes to 39 seconds by implementing a new communication system. Johns Hopkins Hospital in Baltimore, MD, revamped alarm procedures in a medical step-down unit and achieved a 43% decrease in critical alarms.Experts agree that resolving problems with medical device alarms requires interdisciplinary effort and buy-in from a wide array of players at the highest levels. They also say that technology—the very devices that sound these alarms—can be used to alleviate the problems they have created.What can be done? Suggestions include:These topics and more will be considered at the fall Medical Device Alarms Summit, set for October 4–5, 2011 in Herndon, VA. Visit www.aami.org/alarms for details.

Aripiprazole‐induced orthostatic hypotension and cardiac arrhythmia

PSYCHOTROPIC MEDICATIONS SUCH as tricyclic antidepressants and antipsychotics have been known to cause cardiac conduction disturbances such as sinus nodal abnormalities and bundle branch block. Not much is known about the cardiovascular effects of newer atypical antipsychotics such as aripiprazole (Abilify, Bristol-Myers Squibb, Otsuka Pharmaceuticals, New York, USA). A 46-year-old HIV-positive woman with undetectable viral load and CD4 count >600 per cubic millimeter, presented to her physician with complaints of generalized weakness, fatigue, weight loss and anorexia. In the office she was found to have a heart rate of 170/min and was sent to the emergency room (ER) for further evaluation. In the ER she gave a history of 10–15 episodes of ‘syncope’ per month for the previous 6 months. The episodes were non-exertional, lasting for a few seconds and at times accompanied by palpitations. She had been diagnosed with neurocardiogenic syncope on the basis of a positive tilt-table test. In the ER she complained of palpitations, electrocardiogram showed intermittent supraventricular tachycardia with heart rate in the 150s that responded to vagal maneuvers and diltiazem (Cardizem, Biovail Pharmaceuticals Inc, Bridgewater, NJ, USA) drip. The patient was admitted to the telemetry floor for further evaluation. Echocardiogram did not indicate any significant abnormalities and electrophysiology indicated atrial tachycardia with variable conduction. No ablation was indicated and the patient was continued on diltiazem. The patient had a history of bipolar I disorder and schizophrenia and reported being on aripiprazole 15 mg/day, 8 months prior to the current hospitalization. The patient continued to have acute manic and mixed episodes associated with bipolar I disorder, and aripiprazole was titrated up to 30 mg/day. At the time of hospitalization the patient was not taking any antiretrovirals or other CYP 450 (CYP3A4) enzyme inducers or inhibitors. Medication side-effect was thought to be the most likely cause of the current presentation. Aripiprazole was discontinued and the patient was discharged on oral diltiazem. When last seen at follow up there had been no further episodes of syncope or palpitations. Aripiprazole, a new antipsychotic drug, functions as a partial agonist at the dopamine D2 and the serotonin 5-HT1A receptors and as an antagonist at serotonin 5-HT2A receptor. Although its mechanism of action is still to be fully elucidated its proposed efficacy is thought to be mediated through a combination of the aforementioned effects. Although overall it has a good side-effect profile, it may cause orthostatic hypotension due to its α-1 adrenergic receptor antagonism. In placebo-controlled trials on adult patients, orthostatic hypotension, postural dizziness and syncope were all reported. Fatigue and anorexia have also been reported. Aripiprazole has not generally been associated with cardiovascular effects that characterize other conventional antipsychotics and it has a low incidence of QTc prolongation. Egger et al. reported a case of dose-dependent incomplete right bundle-branch block after aripiprazole therapy. When the dose was increased from 15 mg to 30 mg an incomplete right bundle-branch block developed that disappeared on aripiprazole discontinuation.1 Hence caution should be exercised when initiating aripiprazole therapy in patients with known cardiovascular diseases and in patients with conditions that predispose them to hypotension (dehydration, hypovolemia and treatment with antihypertensive medications).

Portrayal of telemetry nurses

I am writing in response to the article “Rapid Response Team: Challenges, Solutions, Benefits” (February 2007:20–28). The article was well done but I found the case study a bit offensive, implying telemetry nurses could not handle rapid atrial fibrillation on their own.First, the bedside nurse is identified as a medical-surgical nurse, but the patient reportedly stayed in the telemetry unit. I think telemetry nurses at my hospital would be offended that the case study is about “education of the nurse about atrial fibrillation, the signs and symptoms associated with this condition, and the treatment of the rhythm,” if this is indeed a telemetry nurse. If this example was supposed to be using a medical-surgical nurse then perhaps that is understandable. Telemetry nurses are distinct from medical-surgical nurses. Neither one is more important than the other; they are just 2 different specialties.I understand the intent of the case study is to show how an RRT can help your patient and that is more important than anything, but please don’t talk about telemetry nurses as if they need education on rapid atrial fibrillation and how that could compromise a patient. Again the article overall was great; I was just a little insulted for telemetry nurses to be identified as needing education on atrial fibrillation.Please accept our apologies; it was never our intent to insult anyone. The patient in the case study was being cared for by a medical-surgical nurse on a telemetry floor. This model is done at our hospital by having a float pool nurse assigned to the telemetry charge nurse as a resource. The telemetry charge nurse was overseeing her strips and her care; however, because of the nature of the sudden increase in heart rate and change in rhythm, both nurses at the bedside found it appropriate to call the RRT. The RRT is encouraged to support the staff in any way that is needed. They are encouraged to allow staff to call the physicians and assist in problem solving and, if needed, mentor and educate staff.In this particular case, the nurse did not have a vast knowledge of atrial fibrillation; therefore, education by the RRT nurse was appropriate. The purpose at our organization of RRTs is to prevent “failure to rescue” cases, improve patient outcomes, and mentor and educate staff as needed. This case could have been presented more clearly, and will so be done in future cases, as not to offend any of our readers. Thank you for your input!