Critical Appraisal of a Research Study

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What are the key concepts of critical appraisal? This blogpost features a very good series of critical appraisal training videos published by Cochrane Mental Health on Youtube (full credits can be found at the bottom of this blogpost).

Hierarchy of Evidence

Retrieved from https://www.sketchbubble.com/en/presentation-hierarchy-of-evidence.html on 18th February 2023

Critical Appraisal Introduction

In this first video, the key concepts of critical appraisal are introduced, and the learning objectives for the series are clearly defined.

Systematic Reviews and Meta Analysis

In this second video, we are introduced to the fundamentals of systematic reviews and the ways in which we can apply the critical appraisal concepts of validity, trustworthiness of results, and value and relevance using the CASP checklist. The full text version of the study by Hay et al (2019) mentioned in this video can be found here.

Randomised Controlled Trials

In this third video, we are introduced to the fundamentals of randomised controlled trials and the ways in which we can apply the critical appraisal concepts of validity, trustworthiness of results, and value and relevance using the CASP checklist. The full text version of the study by Sugg et al (2018) mentioned in this video can be found here.

Cohort Studies Critical Appraisal

In this fourth video, we are introduced to the fundamentals of cohort studies and the ways in which we can apply the critical appraisal concepts of validity, trustworthiness of results, and value and relevance using the CASP checklist. The full text version of the study by Gerhard et al (2015) can be found here.

Case Control Studies

In this fifth video, we are introduced to the fundamentals of case control studies and the ways in which we can apply the critical appraisal concepts of validity, trustworthiness of results, and value and relevance using the CASP checklist. The full text version of the study by Drucker et al (2018) can be found here.

Cross Sectional Studies

In this sixth video, we are introduced to the fundamentals of cross-sectional control studies and the ways in which we can apply the critical appraisal concepts of validity, trustworthiness of results, and value and relevance. The full text version of the study by Boden et al (2010) can be found here.

Diagnostic Studies Critical Appraisal

In this seventh and last video, we are introduced to the fundamentals of diagnostic studies and the ways in which we can apply the critical appraisal concepts of validity, trustworthiness of results, and value and relevance using the CASP checklist. The full text version of the study by Hollis et al (2018) can be found here.

Reference

The above embedded videos are part of a project which was developed to enhance research use and development across two NHS Trusts.

The project founding partners were:

  • Cochrane Common Mental Disorders
  • Northumberland, Tyne and Wear NHS Foundation Trust (NTW), UK
  • Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), UK

Delivery of the project was supported by the Centre for Reviews and Dissemination at the University of York.

Funding Acknowledgement: The production of the critical appraisal modules was jointly funded by:

  • Economic and Social Research Council (ESRC), UK – as part of the University of York ESRC Impact Acceleration Account (ES/M500574/1)
  • Northumberland, Tyne and Wear NHS Foundation Trust (NTW), UK
  • Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), UK
  • University of York, UK

Cochrane Review Group Funding Acknowledgement: The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Common Mental Disorders Group.

Disclaimer: the views and opinions expressed herein are those of the module authors and do not necessarily reflect those of the ESRC, NIHR, the National Health Service (NHS), the Department of Health and Social Care or the University of York.


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Infection Prevention and Control in the Critical Care Setting

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Patients in the critical care setting are more susceptible to Health Care Associated Infections (HCAIs), making infection prevention and control even more crucial within this setting. Some of the most common infection manifestations in the critically ill patient include pneumonia following intubation, bloodstream infections following IV catheterisation, and UTIs following urinary catheterisation.

Susceptibility to HCAIs within the critically ill population can be due to:

  • altered immunity – due to steroid use, surgery, anaesthesia and age
  • invasive lines – provide direct entry of bacteria into the patient’s bloodstream
  • underlying illnesses or conditions
  • broad spectrum antibiotics
  • mechanical ventilation

These risks cause an increased morbidity and mortality rate, a longer hospitalisation stay, and subsequently, higher treatment costs.

Antibiotic Use

We are currently witnessing a dramatic increase in infections by multi-drug resistant pathogens, leading to difficult infection management due to the scarcity of available antibiotics. Even more so, within the critical care setting there is an increased risk of patient-to-patient transmission, increased antibiotic use, and critically sick patients.

Multi Drug Resistant organisms (MDRO)

GRAM POSITIVES

  • VRE – Vancomycin-resistant Enterococci
  • MRSA – Methicillin-resistant Staphylococcus aureus

GRAM NEGATIVES

  • CRE – Carbapenem-resistant Enterobacterales
  • Pseudomonas aeruginosa CRE
  • ESBL-positive bacteria

OTHERS

  • Clostridium difficile
  • Neisseria meningitidis
  • Mycobacteria tuberculosis
Retrieved from https://slideplayer.com/slide/13193459/ on 28th January 2023

Infection Prevention and Control in the ICU Setting

General Preventive Techniques

  • follow the 5 moments of hand hygiene
  • alcohol hand rub should be the first hand hygiene choice – unless hands are visibly soiled
  • nails should be kept well trimmed with no gels
  • reduce jewellery use to just one plain wedding band if necessary
  • keep patients with MDRO in isolation rooms if possible
  • allocate equipment to one patient without sharing
  • screen patients for MDRO, specifically for MRSA, CRE and VRE on admission and at least weekly thereon
  • promote awareness on ANTT (aseptic non-touch technique) amongst colleagues
  • ensure disinfection of shared equipment such as monitoring lines, saturation probes, ECG leads, and blood pressure cuffs
  • promote education on infection prevention and control for staff and cleaners
  • educate patients’ relatives on infection prevention and control measures
  • ensure appropriate antibiotic use
  • ensure terminal cleaning of bed area upon patient discharge
infection prevention and control
Retrieved from https://surewash.com/news/moments-hand-hygiene/ on 28th January 2023

Glove Use

  • change gloves between procedures on the same patient when performing dirty vs aseptic tasks
  • change gloves between patients
  • don gloves immediately before contact with patient body fluid, mucous membranes, or non-intact skin
  • remove and discard immediately after a procedure and perform hand hygiene so that contamination is not transferred to another patient

Rectal screening for CRE and VRE

  • insert a charcoal swab approximately 2cn inside the rectum and rotate gently
  • ensure swab is brown-stained with faeces to ensure a good sample has been taken, as inadequate samples are not processed by the lab

Bathing Patients in Critical Care Setting

  • as previously mentioned, there is a high prevalence of MDROs in the critical care setting
  • daily chlorhexidine bathing of patients in the critical care setting is encouraged since chlorhexidine helps reduce the risk of acquiring MDROs
  • washing the patient’s body with chlorhexidine has been showing effectiveness in the prevention of carriage and possibly bloodstream infections with Gram-positive MDROs (MRSA and VRE)
  • chlorhexidine washes have shown possible eradication of carriage and infection prevention of Gram-negative MDROs, however, more evidence is required in this regard

Disinfecting Isolation Rooms

  • isolation rooms should be disinfected on a daily basis
  • isolation rooms should be cleaned last using yellow cloths, disposable gloves, and chlorine-based disinfectant
  • terminal cleaning and disinfection of isolation rooms should be done following patient discharge; all surfaces need to be cleaned with detergent; mattresses and pillows should be cleaned with environmental disinfectant wipes; UV-C disinfection should be performed, by which more than 99.9% of C. difficile spores and MRSA are killed in minutes

ADVANTAGES OF USING CHLORINE-BASED DISINFECTANT:

  • inexpensive
  • low toxicity
  • rapid effect
  • broad spectrum disinfectant – bacteriocidal, tuberculocidal, fungicidal, virucidal

DISADVANTAGES OF USING CHLORINE-BASED DISINFECTANT:

  • corrosive
  • long contact time
  • employee complaints

The Nurse’s Role in Proper Antibiotic Management

  • knowledge on antibiotic resistance
  • knowledge on the most frequently used antibiotics within the critical care setting
  • knowledge on the disadvantages of using broad spectrum antibiotics – prolonged use increases risk of C. difficile
  • administer antibiotics at the recommended dosage intervals for optimal effectiveness
    • administer IV antibiotics safely and effectively, with diligence to dosage, dilution, timing and calculations
  • administer IV antibiotics to patients with sepsis within 1 hour following diagnosis to increase risk of survival
  • list reminders for antibiotic review eg. stop date, reason for prescription, change of route, etc
  • therapeutic monitoring of antibiotic levels eg. Gentamicin, Amikacin and Vancomycin require serum blood level checking for safe and effective treatment; ensure samples are taken at the appropriate time for best results
  • understand when to withold an antibiotic dose until results are available eg. in the case of Gentamicin
  • serum blood level samplings should be properly documented in both the patient’s notes and on the lab request form
  • proper handover on transfer from ICU to another ward

Ventilator Associated Pneumonia (VAP)

Pneumonia is an infection in the lung parenchyma, particularly in the bronchioles and alveoli, which is caused by pathogens such as bacteria, fungi and viruses.

Ventilated Associated Pneumonia (VAP) is pneumonia which develops 48 hours following intubation and initiation of mechanical ventilation. VAP is considered to be the 2nd most common HCAIs but the most serious one, with 25% of these patients with VAP ending up dead.

VAP happens because intubation bypasses all natural defense mechanisms within the tracheo-bronchial tree that protect the lower respiratory tract from infections.

Causative organisms, some of which are often present in the oropharyngeal cavity and the gastrointestinal system, are:

  • Gram-negative aerobes – Pseudonomas aeruginosa, Klebsiella pneumonia, Acinetobacter, Enterobacter
  • Gram-positive aerobes – Staphylococcus aureus/MRSA

There are 5 defense mechanisms which are bypassed during ventilation:

  • The Larynx and the Glottis – prevent aspiration of oral content
  • The Coughing Reflex – helps in the expelling of secretions and aspirated matter from the larger airways
  • Mucous – helps trap small particles
  • Cilia – hair-like structures which help move mucous up from the lower respiratory tract towards the larynx to be expelled
  • Phagocytic Cells – engulf bacteria if or when they manage to reach the alveoli

Aspiration of contaminated fluids and secretions into the lungs can happen in various ways:

  • colonisation of pathogenic bacteria within the oropharynx or tracheo-bronchial tree
  • the stomach, through enteral feeding, certain drugs (eg. stress ulcer prophylaxis), and supine patient positioning, may act as a source of pathogens for VAP
  • inhalation of aerosols through contaminated intubation or nebulisation equipment

Pathological development of pneumonia

  1. aspiration of contaminated fluids or secretions into the lungs
  2. initiation of the inflammatory response
  3. swelling of the mucous membranes of the alveoli and bronchi
  4. pus collects within the alveoli
  5. interference of pus with the gas exchange process
  6. development of pneumonia
infection prevention and control
Retrieved from https://www.uptodate.com/contents/pneumonia-in-adults-beyond-the-basics/print on 28th January 2023

Signs & Symptoms of VAP Pneumonia

  • temperature of >38°C
  • tachypnoea and/or dyspnoea
  • purulent sputum (off-white, yellow or green, and opaque)
  • worsening ABGs – poor SaO2 and increased ventilatory demands
  • positive sputum and/or blood cultures
  • leukocytosis >12,000 WBC/mm2
  • chest x-ray or CT scan with evidence of pneumonia

NOTE: Diagnosing VAP can be difficult!

infection prevention and control
Chest X-rays and CT-scan of a 65-year-old man who developed ventilator-associated pneumonia. Chest X-ray performed the day VAP was suspected seems normal (a), whereas the CT-scan performed the same day showed consolidation of the left inferior lobe (b, d). Bronchoalveolar lavage yielded 105Enterobacter aerogenes. The next day, chest X-ray showed progression of pulmonary infiltrates (c). VAP diagnosis based on chest X-ray would have been delayed – Retrieved from https://link.springer.com/article/10.1007/s00134-020-05980-0 on 28th January 2023

VAP Risk Factors

  • length of time in which the patient is exposed to the healthcare environment
  • predisposing host-related factors such as age, malnutrition etc
  • treatment factors eg. endotracheal intubation, prolonged exposure to antibiotics

VAP Consequences

  • increased mortality
  • prolonged mechanical ventilation
  • increased antibiotic use
  • prolonged stay at the ITU and hospital
  • increased medical cost

VAP Infection Prevention and Control

  • do not intubate patient unless necessary
  • choose non-invasive ventilation over invasive ventilation where possible
  • elevate head of bed 30-45° especially for patients receiving enteral feeding
  • minimise aspiration of contaminated oropharyngeal and tracheal secretions
  • suction subglottic secretions
  • avoid gastric over distention
  • avoid unplanned extubation
  • maintain correct ETT cuff pressure (20cm H2O)
  • provide frequent oral hygiene – suctioning, toothbrushing, and using chlorhexidine mouthwashes
  • use HME filters rather than heated humidifiers
  • remove condensate from ventilatory circuits periodically
  • extubate as soon as possible

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Neonatal & Paediatric Intensive Care Nursing

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One of the most common measures required in neonatal and paediatric intensive care nursing is respiratory support. Such assistance for the neonate or paediatric patient may include the use of nasal prongs, high flow nasal cannulae, non-invasive ventilation, or invasive ventilation. Invasive ventilation should be left as a last resort in babies.

Respiratory Support Devices

BAG & MASK VENTILATION

neonatal and paediatric intensive care nursing
Retrieved from https://litfl.com/bag-valve-mask-bvm-ventilation/ on 27th January 2023

NEOPUFF

neonatal and paediatric intensive care nursing
Retrieved from https://litfl.com/bag-valve-mask-bvm-ventilation/ on 27th January 2023

NASAL PRONGS

neonatal and paediatric intensive care nursing
Retrieved from https://vapotherm.com/blog/when-hfnc-is-not-enough-for-your-babies-and-why-hvni-could-help/ on 27th January 2023

OPTIFLOW

neonatal and paediatric intensive care nursing
Retrieved from https://www.mcri.edu.au/news-stories/new-%E2%80%98high-flow%E2%80%99-oxygen-therapy-will-improve-treatment-infants-bronchiolitis on 27th January 2023

Non-Invasive Ventilation

Non-invasive ventilation (NIV) is a well recognised and increasingly prevalent intervention in the paediatric critical care setting. In the acute setting NIV is used to provide respiratory support in a flexible manner that avoids a requirement for endotracheal intubation or tracheostomy, with the aim of avoiding the complications of invasive ventilation.

Morley, 2016.

EasyFlow nCPAP Non-Invasive Ventilation

CPAP non-invasive ventilation leaves extra air in the lungs to keep the lungs slightly inflated; this minimises the effort required for the progressive breath.

neonatal and paediatric intensive care nursing
Retrieved from https://www.stephan-gmbh.com/en/products/easyflow-ncpap/ on 27th January 2023

Complications of Non-invasive Ventilation

  • Nasal Septum Injury –
  • Nasal Bridge Injury –
  • Eye Puffiness & Hyperemia –
  • Abdominal Distention –
  • Pneumothorax –

Nasal Septum – retrieved from https://www.drugs.com/health-guide/deviated-septum.html; Nasal Bridge – retrieved from https://www.mountsinai.org/health-library/symptoms/low-nasal-bridge; Abdominal Distention – retrieved from https://adc.bmj.com/content/97/Suppl_2/A160.4.short on 27th January 2023

Ventilation

Ventilation is used as a last resort on babies.

neonatal and paediatric intensive care nursing
Retrieved from https://www.cureus.com/articles/65216-endotracheal-tube-fastening-device-related-facial-pressure-ulcers#!/ on 27th January 2023

CHILD VS ADULT AIRWAY

Unlike the adult’s airway, a baby’s airway is funnel-like, and the cricoid sits lower than in adults.

neonatal and paediatric intensive care nursing
Child VS Adult Airway – retrieved from https://www.jems.com/patient-care/airway-respiratory/an-overview-of-ems-pediatric-airway-management/ on 27th January 2023

PAEDIATRIC LARYNGOSCOPY

The type of laryngoscope commonly used in case of ventilation of paediatric patients is the Miller Blade Laryngoscope with Fibre Optic.

neonatal and paediatric intensive care nursing
Paediatric Laryngoscopy – retrieved from https://emdaily.cooperhealth.org/content/back-basics-pediatric-etts-blades on 27th January 2023

CUFFED VS UNCUFFED ETT

  • we are moving towards commonly using the inflated microcuff ETT for paediatric patients, since it helps minimise the risk of aspiration
  • an inflated microcuff seals the trachea so as to prevent positive pressure from escaping the lower airway
  • an inflated microcuff also seals the upper airway so that material above the glottis cannot enter the trachea
Cuffed vs Uncuffed ETT – retrieved from https://www.semanticscholar.org/paper/An-emerging-clinical-paradigm%3A-the-cuffed-pediatric-Aker/9119cb9f395b3111cecdc1baeff984db4907b876 on 27th January 2023

Intubation Drugs

Babies that are intubated right after birth are NOT administered any intubation drugs during the procedure. Otherwise, babies being intubated later on are administered drugs from the following intubation drugs list:

RAPID SEQUENCE INTUBATION DRUGS (RSI)

  • Fentanyl – analgesic opioid
  • Atropine – treats symptomatic bradycardia
  • Suxamethonium – muscle relaxant

MAINTENANCE DRUGS

  • Morphine – analgesic opioid
  • Midazolam – benzodiazepine
  • Atracurium – muscle relaxant

DOSAGE CALCULATION

Rapid Sequence Intubation Drugs and Maintenance Drugs dosages are administered based on the baby’s weight according to protocol.

For antibiotic and other pharmacological drug use:

mg of drug required X volume of fluid drug is in

____________________________

mg of drug in the volume you have

NOTE: many drugs need to be administered slowly by IV infusion over half an hour.

Neonatal and Paediatric Intensive Care Nursing

WetFlag Acronym Table

neonatal and paediatric intensive care nursing
Retrieved from https://www.embeds.co.uk/2019/09/07/0-12yrs-wetflag/ on 27th January 2023

Procedural Pain Relief

Measures related to the baby’s surrounding environment, preparation, and use of non-pharmacological pain relief methods can be taken for support:

  • warmed area
  • calm surrounding
  • parental presence
  • reduction of light, noise, and handling
  • available staff to reduce interruptions and prepare requirements beforehand
  • available staff to assume a parental role if parents are unavailable
  • promote swaddling, nesting, tucking, holding, cuddling, skin-to-skin care, breast feeding, non-nutritive sucking, clean nappy, and distraction techniques.

24% sucrose solution ampoules (Babycalmine S) can be administered as a mild analgesic for short term pain and distress in neonates and infants up to 4 months of age during minor procedures, such as bloodletting and cannulation, invasive procedures including urinary catheterisation and lumbar puncture, as well as during IM or SC immunisation and other procedures which may require pain relief.

neonatal and paediatric intensive care nursing
Retrieved from https://deltamedint.com/products/sucrose-glucose-solution/#dosage on 27th January 2023
Retrieved from https://deltamedint.com/sucrose-solution-reduces-pain-and-cost/ on 27th January 2023

comprehensive assessment

Comprehensive assessment in neonatal and paediatric intensive care nursing needs to be based on observing and reading clinical signs, as well as interpreting different parameters:

  • heart rate
  • blood pressure
  • signs of distress
  • abdominal distention
  • pressure exerted by lines
  • cannula observation
  • signs of sepsis
  • functioning equipment observation

NOTE: a low temperature in a baby may be a sign of sepsis; capillary refill on a newborn is checked on the sternum.

The Nurse’s Role

INFANTS:

  • prompt treatment may be required by premature babies suffering from respiratory difficulties
  • nutritional needs of premature babies and sick neonates are calculated on the baby’s weight in kg
  • encourage parents to stay with their infant
  • provide the baby with opportunities for sucking
  • provide toys to provide comfort and stimulate interest
  • provide pharmacological and non-pharmacological pain control

TODDLERS:

  • encourage independent behaviours eg. self-feeding, hygiene, dressing
  • encourage continuation of toilet-training regime, accepting regression during hospitalisation
  • provide vigilance and safety within the toddler’s environment
  • provide short and simple explanations
  • reward appropriate behaviour

PARENTS:

  • support the parents, considering their possible anxiety and stress
  • encourage an active role in the care of their own child
  • teach parents to administer medications safely, to use any necessary equipment, to insert and/or use a feeding tube if needed
  • discuss with parents subjects related to home routine, safety, and how to coax a reluctant baby to feed
  • teach parents Basic Life Support
  • provide reassurance during discharge planning, since this transition may be quite difficult and scary for the parents

The Parents’ Role

Parents of young patients staying at NPICU are usually allowed to enter, excluding time in which ward rounds, handover, emergencies and admissions are being performed. The NPICU promotes:

  • family centered care
  • parents’ empowerment to prevent loss of parental role
  • interventions such as skin-to-skin contact and positive touch

Reference

Morley S. L. (2016). Non-invasive ventilation in paediatric critical care. Paediatric respiratory reviews, 20, 24–31. https://doi.org/10.1016/j.prrv.2016.03.001


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NPICU – Neonate and Paediatric Monitoring & Central Lines

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The first 28 days of life are the most crucial for survival. While on a global scale neonatal mortality is declining, 54% of the total deaths amongst Europe’s children under 5 occur in neonates. This sheds a light on the importance of adequate monitoring and care at the NPICU neonatal and paediatric intensive care unit.

Local causes of mortality in children under 5 years of age include:

  • prematurity
  • congenital anomalies
  • non-communicable diseases (eg. heart disease, cancer, chronic respiratory disease, and diabetes)
  • birth asphyxia (failure to establish breathing at birth) and trauma
  • acute lower respiratory infections
  • sepsis
  • meningitis

The NPICU – Neonatal & Paediatric Intensive Care Unit

Malta’s only NPICU caters for limitless admissions of neonates and children up to 3 years of age, with the majority of these young patients being premature babies (babies born before the 37th week of gestation) and neonates (from birth to 28 days of age).

Classification of care in the NPICU is as follows:

  1. Intensive Care – 1 or 2:1 care ratio
  2. High Dependency Care – 1:1 care ratio
  3. Special Care – 1:2 care ratio
  4. Nursery – 1:4 care ratio

Apart from being allocated according to experience and training needs, NPICU nurses may need to act as transport team members, Basic Life Support educators, and link nurses.

Why Do Neonates Require Intensive Care?

Maternal Factors

  • premature membranes rupture
  • multiple pregnancy
  • hypertension
  • diabetes
  • drug or alcohol exposure
  • sepsis
  • bleeding
  • too much or too little amniotic fluid

Delivery Factors

  • foetal distress
  • birth asphyxia
  • breech delivery
  • meconium
  • nuchal cord (umbilical cord wrapped around baby’s neck)
  • ventouse (vacuum cup) / KIWI (most common type of ventouse that does not use a suction machine)
  • cesarean

Baby factors

CHANGES AT BIRTH:

  • independent breathing
  • foetal to neonatal circulation
  • metabolic adaptation to thermoregulation, glucose homeostasis, and fluid balance

POST-NATAL CHANGES:

  • baby’s lungs become the primary respiratory organs
  • lungs’ blood vessels respond to oxygen increase from vasodilation, promoting blood flow to the lungs
  • increase in oxygen causes heart ducts to close, leading to neonatal circulation to establish itself

NORMAL CHANGES:

  • during the baby’s first breaths, air replaces the fluid within the lung

THERMOREGULATORY CHANGES:

  • at birth, intrauterine heat reservoir and heat exchange through the placenta is lost
  • following birth, thermal stability is normally achieved independently, as they adapt to the new environment by the non-shivering thermogenesis process
  • the newborn baby should be kept warm and dry straight from delivery, since becoming cold causes the brown fat stores to become depleted, leading to neonatal hypoxia and hypoglycaemia

GLUCOSE HOMEOSTASIS CHANGES:

  • at birth, the baby stops obtaining glucose from the mother through the placenta, and starts to produce glucose independently, which, following birth, may cause a decrease in the baby’s blood glucose levels
  • normally, if kept warm and is fed appropriately within the first few hours after birth, a full term baby is able to control his/her own blood glucose levels within normal limits

FLUID BALANCE CHANGES:

  • at birth, fluid balance undergoes significant adaptive changes, including extra-cellular fluid contraction following delivery, where neonates may lose up to 10% of their total birth weight

Premature vs Full Term Babies

Premature babies commonly experience respiratory issues, including:

  • respiratory distress syndrome (due to surfactant deficiency)
  • chronic lung disease of prematurity (caused by oxygen dependency and persistent inflammatory changes of the lungs past 28 days following birth)
  • apnoea of prematurity (due to immature brain stem)
NPICU
Retrieved from https://itcaonline.com/prematurity-and-sids-awareness/ on 26th January 2023

NPICU Admission Guidelines

  • 23 weeks-35 weeks or more than 42 weeks gestation
  • birth weight of 450g – 2kgs, SGA (small for gestational age) and LGA (large for gestational age)
  • respiratory issues – apnoea, cyanotic episodes, need for positive pressure ventilation, concerning respiratory distress, tachypnoea for over 1hr, perinatal asphyxia, and meconium aspiration
  • gastrointestinal issues – feeding problems, bile-stained vomiting, signs of obstruction
  • infection – sepsis suspicion, herpes, chlamydia, group B streptococcus
  • malformations
  • congenital heart defects
  • infants of mothers with diabetes
  • hypoglycaemia
  • seizures
  • surgical complications
  • neonatal abstinence syndrome – conditions caused when a baby withdraws from certain drugs he’s been exposed to in the womb prior to birth
  • hyperbilirubinaemia – higher-than-normal amount of bilirubin in the blood, causing jaundice
  • monitoring

Monitoring

CONTINUOUS MONITORING of:

  • heart rate
  • respiratory rate
  • arterial blood pressure
  • pulse oximetry
  • capnography
  • cerebral function monitoring

INTERMITTENT MONITORING of:

Central Lines

CVCs (central venous cannulas) can be used for longer than PVCs (peripheral venous cannulas). IV treatments as well as higher concentration IV fluids and TPN can be administered via a CVC with less irritation and damage to the veins.

UMBILICAL CATHETERS

A umbilical cord typically has 2 arteries and 1 vein. Catheters are placed into the blood vessel using sterile technique, followed by a confirmation x-ray to determine position.

An umbilical arterial catheter is used for:

  • blood sampling
  • ABGs
  • invasive blood pressure monitoring
  • DO NOT ADMINISTER IV FLUIDS IN AN ARTERIAL CATHETER!

An umbilical venous catheter is used for:

  • IV fluid administration
  • IV treatment
  • exchange transfusion
  • emergency access during resuscitation
Retrieved from https://clipart.me/free-vector/umbilical-cord on 26th January 2023

PICC LINE

A PICC line – Peripherally Inserted Central Catheter – is a thread-like tube which is inserted in a small vein and threaded into a larger vein leading to the Superior Vena Cava.

  • when handling the baby, the nurse should be extra careful as to not pull the catheter
  • infusion lines should be carefully changed on alternate days using a sterile technique

NOTE: Neonatal PICC lines SHOULD NOT be used for blood sampling!

NPICU
Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMvcm1101914 on 26th January 2023

TUNNELED LINES

  • a tunneled catheter is a catheter inserted under the skin, exiting on the chest a.k.a. Hickman
  • the line is anchored in place by the Dacron cuff, helping to prevent infection
NPICU
Retrieved from https://www.nationwidechildrens.org/family-resources-education/health-wellness-and-safety-resources/helping-hands/iv-tunneled-central-venous-catheter-care-at-home on 26th January 2023

NON-TUNNELED LINES

  • femoral line
  • jugular
  • subclavian
  • brachiocephalic
NPICU
Retrieved from file:///C:/Users/User/Downloads/Vascular%20Access.pdf on 26th January 2023

INTRA-OSSEOUS LINES

NPICU
Retrieved from https://www.neoresus.org.au/learning-resources/key-concepts/advanced-interventions/learning-resources-key-concepts-advanced-interventions-intraosseous-needle-insertion-io/ on 26th January 2023

TIVAD – TOTALLY IMPLANTED VENOUS ACCESS DEVICE

  • Totally Implanted Venous Access Devices are only used in older children
  • accessed and de-assessed by a certified nurse with a special needle – once needle is in place, it can be used like any other central line
NPICU
Retrieved from https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=aci2527 on 26th January

PERIPHERAL ARTERIAL LINES

  • used for frequent blood sampling
  • provide accurate invasive blood pressure monitoring
  • high risk
Retrieved from https://emedicine.medscape.com/article/1999586-technique on 26th January 2023

CENTRAL LINE MONITORING

Central line monitoring is very important since signs and symptoms may be indicating line blockages, vein irritation, thrombus, migration, and CLABSI (central line-associated bloodstream infection). Signs and symptoms that the nurse should watch out for include:

  • extremity discolouration
  • bleeding
  • swelling
  • extravasation
  • dislodgement
  • signs of sepsis
Infiltration – Retrieved from https://europepmc.org/article/pmc/6082416#free-full-text on 26th January 2023
Extravasation – Retrieved from http://www.worldwidewounds.com/1997/october/Neonates/NeonatePaper.html on 26th January 2023
Ischaemia & Necrosis following Peripheral Arterial Cannulation – Retrieved from https://www.semanticscholar.org/paper/Analysis-of-characteristics-of-peripheral-arterial-Kim-Lee/973dec4ffd825f9c336134d16004935b15a83921 on 26th January 2023

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Burn Patient Rehabilitation

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Burn patient rehabilitation is both a philosophy and an attitude which needs to start from the day in which the burn injury was inflicted.

Adequate nutrition is one of the most important aspects required for burn patient rehabilitation. Burn patients have increased caloric intake requirements. Lack of caloric intake leads the patient’s body to start metabolising protein, subsequently causing muscle wasting.

Retrieved from https://www.khanacademy.org/science/biology/macromolecules/proteins-and-amino-acids/a/orders-of-protein-structure on 24th January 2023

The Role of Nutrition in Burn Patient Rehabilitation

In patients with a burn injury, feeding should be established as early as possible, and ideally should be administered enterally. The patient’s weight should be monitored, especially since a 10% or more decrease in weight is considered to be a failure. However, it is important to note that while the catabolic state of large burn injuries result in a rapidly falling albumin level causing a decrease in dry weight, this decrease is masked due to the large fluid resuscitation volume administered in the first few days following the injury.

NOTE: patients requiring starvation for anaesthesia should be kept starved for the least time possible, starting from 6hrs pre-anaesthesia administration.

Basal Metabolic Rate – BMR

The Basal Metabolic Rate is the body’s resting rate of energy expenditure. The BMR doubles in cases where the patient has experienced more than 50% TBSA (Total Body Surface Area) burn. The larger the TBSA burned, the higher the hypercatabolism degree (excessive metabolic breakdown of complex substances including protein, within the body). The patient typically also experiences hyperglycaemia resulting as another endocrine response.

Typically, the patient’s BMR continues to increase and the core temperature resets to 1-2°C higher than normal, until the burn wound heals. During this healing process, the ambient temperature should be kept around 26-30°C to reduce the body’s energy demands.

NOTE: TBSA does not take into consideration superficial burns where only the epidermis is involved.

Nutritional Intake During Admission Stage

  1. the patient is weighed so that dry weight measurement is established and recorded
  2. a nasogastric tube is inserted, and feeding is started at low volume
  3. feed volume is gradually increased if the nurse determines that the feed is actually being absorbed

Caloric requirements are calculated by a dietician based on the TBSA burned. In burn patients the Curreri formula is used to determine nutritional intake requirement:

The Curreri Formula

(25 x weight in kg) + (40 x TBSA percentage)

Enteral Feeding

  • studies show that patients receiving enteral feeding have a decreased mortality and morbidity rate
  • enteral feeding is relatively easy to establish early on, and this helps decrease caloric deficit
  • in patients with extensive burns obviously requiring a longer hospital stay, a PEG or nasojejunal tube is recommended, since this helps avoid repeated periods of starvation, and can also be passed at the bedside; since by using this way of feeding, nutritional intake bypasses the stomach and goes directly into the intestines, the patient would not require starvation pre-anaesthesia
  • PEG feeding is used less in burn patients, especially if the abdomen has suffered from a burn injury, or if the abdominal skin may be required as donor skin
  • Total Parenteral Nutrition TPN is only indicated if enteral feeding cannot be established, since studies have shown an increase in burn mortality with IV supplemental feeding in severely burned patients; additionally, due to an increase in burn patients’ core temperature, phlebo-fix used to hold in place a central line tends to keep coming off, thus, a central line is ideally avoided
Retrieved from https://healthcarenutrition.org/methods-of-nutrition/ on 24th January 2023
Retrieved from https://www.myupchar.com/en/surgery/percutaneous-endoscopic-gastrostomy-peg on 25th January 2023

Burn Patient Co-morbidities

A burn patient may have other primary diseases such as diabetes, high cholesterol, and obesity. Such diseases are referred to as co-morbidities. For this reason, every burn patient needs to be managed in a holistic way, where all pre-existing medical conditions, any related social circumstances, and obviously the patient’s age, are taken into consideration when drawing a burn patient rehabilitation plan.

Diabetes

  • diabetes affects the healing process of the burn injury due to poor circulation leading to less oxygen perfusion
  • burn wounds, like any other wound, is likely to become infected in a patient with diabetes, thus, patients with diabetes are frequently checked for microbe presence by wound swabbing
  • careful monitoring and control of blood glucose levels in patients with diabetes promote better clinical outcomes, therefore this should be monitored right from admission stage
  • antibiotic administration is likely to help improve graft take as well as healing period in patients with diabetes
  • upon admission of a diabetic patient with a burn injury, the diabetic liaison nurse should be informed

Obesity

  • obesity limits burn injury outcome in various ways
  • typically, the force of abdominal viscera on the diaphragm limits lung tidal volumes

Age

  • young burn injury patients are quite resilient especially since their skin is relatively thin but the ratio of their skin surface area to blood volume is relatively high
  • elderly patients have very thin skin, and so, burn injuries endured by patients over 65 years of age are typically classified as full thickness burns; superficial burns in the elderly tend to progress to full thickness burns due to lack of nutrition, lack of self care, and sluggish circulation

Burn Reconstructive Procedures

Reconstructive procedures are performed following burns as well as cancer tumour removal. Plastic surgery uses the Aucher classification to classify burn reconstructive procedures according to their urgency. Burn reconstruction involves scar release or excision. Closure is done either by using a normal flap or by recruiting local skin.

  • Primary Intention Burn Injury Healing – done through surgery; surgery however doesn’t restore sensory functioning
  • Secondary Intention Burn Injury Healing – done through normal wound healing, with dressing changes as required and antibiotics to avoid infection; normal wound care without plastic surgery tends to lead to contractures that limit the patient’s functionality

An injury in which part of the body is lost eg. dog bites, human bites, woodwork injuries, butchers etc, is ideally subjected to secondary intention healing, since unintentionally closing the wound with microbes inside may lead to infection and subsequent surgical reconstruction or possibly amputation.

burn patient rehabilitation
Skin Contractures – Retrieved from https://link.springer.com/chapter/10.1007/978-3-030-44766-3_13 on 25th January 2023

Skin Grafts

A skin graft is a surgical intervention in which tissue is moved from one area (donor site) to another (recipient area). The donor area can be either from the same body or from another.

burn patient rehabilitation
Retrieved from https://michaelkimmd.com/procedures/skin-grafts on 25th January 2023

FULL THICKNESS SKIN GRAFTS

  • include the epidermis and dermis
  • full thickness grafts can be harvested from only a few body sites
  • may be used to cover bone exposure
  • donor sites require direct closure or split thickness graft closure
  • uptake rate is higher than that by split thickness grafts since the dermal layer is involved
  • antibiotics are administered as prophylaxis to avoid infection of skin grafts
burn patient rehabilitation
Full Thickness Skin Graft – Retrieved from https://stevevumd.com/galleries/skin-graft/ on 25th January 2023

SPLIT THICKNESS GRAFTS

  • include the epidermis and less than the whole thickness of the dermis
  • is commonly done for acute burn wound closure
  • healing is done through secondary intention
  • uptake rate is less than full thickness skin grafts since only the epidermis is involved, and this is mashed, causing fenestrations in the graft area, and is also quite stretched
burn patient rehabilitation
(left) Right leg contact burn in a 42-year-old man. No hematoma was seen 5 days after split-thickness skin grafting using fibrin glue. (right) No skin loss orsuture mark scar was observed 1.5 months postoperatively – Retrieved from https://springerplus.springeropen.com/articles/10.1186/s40064-016-3599-x on 25th January 2023

Care of Grafts

  • foam is usually sutured or stapled over the graft to increase pressure
  • foam is removed after 5 days so that the graft is reviewed
  • graft is covered with antibacterial dressings
  • alternate removal of staples from graft is carried out after 2 days

Care of Donor Site

  • following harvesting of the skin, the donor site is covered with an alginate dressing (kaltostat) to control bleeding and protect the wound from becoming infected through contamination
  • donor site is exposed after 15 days so as to minimise bleeding; DO NOT REMOVE, even if bleeding is noted – remove ONLY if the wound becomes very smelly, signalling infection
burn patient rehabilitation
Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0305417916304351 on 25th January 2023

Flaps – Local and Distant

  • flaps refer to the transferring of tissue that contains its own blood supply since vascularity is moved along with the flap during surgery
  • local flaps have some continuity with the defect they cover
  • distant flaps are separated by distance through the use of micro-surgery
  • flaps need to be kept warm at all times

The difference between grafts and skin flaps is in the fact that grafts do not bring their own blood supply, however, skin flaps carry their own blood supply to the recipient area.

burn patient rehabilitation
Retrieved from https://www.researchgate.net/publication/335695228_The_Reappraisal_of_the_Slide-Swing_Skin_Flap_A_Versatile_Technique_for_Surgical_Defects/figures?lo=1 on 25th January 2023

Care of Flaps

  • flaps are held in place by staples or sutures
  • removal of staples or sutures is done based on the surgeon’s advice

NOTE: NEVER apply pressure over the flap since this impedes circulation to the area, causing flap necrosis.

Burn Patient Rehabilitation Into Society

Burn injuries have comprehensive needs which are best treated with adequate resources. This is why a multidisciplinary team, commonly managed by a lead consultant, is involved in the burn patient rehabilitation process.

Physiotherapy

  • physiotherapy is focused on the anatomical and physiological factors related to patient rehabilitation, helping in preventing or treating impairments or disabilities
  • physiotherapy promotes exercises aimed at regaining strength, range of motion, and stretching of the scar area
  • physiotherapy may also include chest physio which helps during the healing process, especially in patients who were exposed to smoke inhalation

occupational therapy

  • occupational therapy focuses on the functional aspect of the patient’s ability to participate in the daily activities of life, providing functional training to promote improvement
  • occupational therapy helps prepare the patient for discharge in relation to required support and services, including necessary equipment and environmental adaptations, assessment and provision

Burn Patient Challenges Prevention

Burn patients may experience various challenges during their healing process, some of which may result in disabling and disfiguring contractures. Challenges may include:

  • pain
  • scarring
  • acute and/or chronic oedema
  • muscle wasting (caused by immobilisation and long periods of reduced functionality)
  • psychological pain caused by trauma and body image changes
  • physical, mental and social limitations when compared to pre-injury

There are things we can do or promote as nurses so as to decrease or ideally prevent such challenges. These include:

  • educating, motivating, and empowering the patient through promoting understanding of the healing process
  • positioning the patient in a way as to protect the joints, reduce pressure, immobilise, and decrease oedema
  • splinting to protect, immobilise, prevent contractures and regain range of movement
  • chest physiotherapy helps in secretion removal whilst increasing tidal lung volume
  • promoting passive, active, and active assisted exercises to prevent loss of range whilst strengthening the muscles
  • scar massage, silicone, and pressure garments

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Burn Injury ~ Types of Burns & Treatments in Critical Care Setting

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A burn injury happens when the skin comes into contact with something hot, causing disruption within the skin’s cell structure, resulting in skin cell death.

NOTE: Throughout this blogpost, the various burns listed are classified into burn degrees, however, this method of classification does not indicate the injury depth, and so, focus should be on the type of burn eg. superficial burn, and the percentage of skin area affected using the Lund and Browder Chart (featured further down).

burn injury
Retrieved from https://departments.weber.edu/chpweb/3e/burn/Burn_Severity.html on 20th January 2023

The Zone of Stasis

The Zone of Stasis is the surrounding area of the burn. It is characterised by decreased tissue perfusion. Nonetheless, the skin within this zone is potentially salvageable:

  1. the burn injury dressing should be chosen with the aim of promoting wound moisture
  2. burnt area should be elevated so as to minimise oedema
  3. smoking should be avoided by the patient since it puts the patient at increased risk of poor outcomes and complications
  4. systemic diseases eg. diabetes should be managed; blood sugar levels should be kept stable
burn injury
Retrieved from https://www.rch.org.au/trauma-service/manual/Burns/ on 20th January 2023

Assessing Burn Injury Surface Area

Prior to assessing a burn injury and its depth, DO NOT apply any silver sulfadiazine or any other topical agents, since doing so gives an inaccurate indication of the wound’s depth.

burn injury
Retrieved from https://forensicmed.webnode.page/wounds/burns/burn-area/ on 20th January 2023
Retrieved from https://www.theplasticsfella.com/total-body-surface-area-in-burns/ on 22nd January 2023

Superficial Burn Injury

A superficial burn, also called a 1st degree burn, is characterised by the following features:

  • painful
  • no blisters are present
  • only the epidermis layer is involved
  • erythema (redness) present due to vasodilation
  • complete healing typically takes up to 7 days due to re-epithelialisation
burn injury
1st Degree Superficial Burn – Retrieved from https://www.victoriapointsurgery.com.au/gp/7192-2/ on 20th January 2023

Care of Superficial Burn

  • superficial burns require no dressings
  • patient should be advised to apply emollient cream
  • patient should be advised to apply sunblock and to avoid the sun

Superficial Partial Thickness Burn Injury

A superficial partial thickness burn, also called a 2nd degree burn, is characterised by the following features:

  • very painful
  • pink or red
  • blisters present
  • wet and weepy
  • complete healing with relatively little scarring
burn injury
2nd Degree Superficial Partial Thickness Burn – Retrieved from https://www.compleetfeet.co.uk/tag/foot-2nd-degree-burns/ on 20th January 2023

Care of Superficial Partial thickness Burn

  • if available apply Aquacel (silver dressing) in the 1st 24 hours following injury
  • de-roof and debride the blisters UNLESS they are located on the palms or soles of the feet due to excessive pain as well as superficial nerves, to which debridement may cause irreparable problems
  • assess wound depth
  • apply silver sulfadiazine and cover with non-adherent dressing for the first 3 days following burn injury
  • advise patient that a lot of exudate is expected to come out from the wound
  • advise patient to take regular analgesia for pain management
burn injury
Retrieved from https://www.burnscare.com/burns.html on 21st January 2023

Deep Partial Thickness Burn Injury

A deep partial thickness burn, also called a 3rd degree burn, is characterised by the following features:

  • usually lacks physical sensation
  • red with overlying eschar
  • scarring expected
  • delayed healing potential
burn injury
3rd Degree Deep Partial Thickness Burn – Retrieved from https://www.mayoclinic.org/diseases-conditions/burns/multimedia/third-degree-burn/img-20006133 on 21st January 2023

Care of Deep Partial thickness Burn

  • de-roof and debride blisters (if any) UNLESS they are located on the palms or soles of the feet due to excessive pain as well as superficial nerves, to which debridement may cause irreparable problems
  • assess wound depth
  • apply silver sulfadiazine and cover with light dry dressing
  • inform patient that some exudate should be expected
  • advise patient to take regular analgesia for pain management

Full Thickness Burn Injury

A full thickness burn, also called a 3rd or 4th degree burn, is characterised by the following features:

  • lacks physical sensation
  • white, brown, tan, or black
  • dry and leathery
  • firm non-blanche
  • scarring expected
  • no healing potential

Care of Full Thickness Burn

  • following diagnosis of burn wound stage, refer patient to the Burns Unit
  • apply aquacel
  • elaborate surgical debridement, reconstruction, or amputation, may be indicated, depending on the case

Thermal Burns

The WHO estimates that thermal burns account for around 6.6 million injuries and 300,000 deaths yearly, worldwide. A thermal burn can be experienced through the following:

  • scalding (commonly caused by hot drinks in children)
  • direct contact with hot materials
  • flash and flame burns
  • can be a 1st, 2nd, 3rd or 4th degree burn (most full thickness burns are classified under thermal burns)

Chemical Burns

Chemical burns can be caused by direct contact with, or fumes of a chemical, usually an alkali or a strong acidic substance. Such burns can happen within various settings, including homes, work, or during an assault.

One such commonly used chemical is hydrofluoric acid – a colourless highly corrosive solution containing hydrogen fluoride in water. It is stored in a plastic container and is commonly used in industrial chemistry, glass finishing, and cleaning. Liquid hydrofluoric acid has the potential to interfere with calcium metabolism. It can cause deep skin burns, which though initially painless, may lead to a cardiac arrest and subsequent death, whilst in gas form, it can cause immediate and permanent lung damage, as well as damage to the eyes’ corneas.

burn injury
Acid Attack Victim – Retrieved from https://www.bbc.com/news/uk-40559973 on 22nd January 2023

care of a chemical burn

A chemical burn requires special care and attention so as to stop the substance from spreading within the skin. When caring for a chemical burn:

  • obtain information as to what caused the chemical burn
  • obtain information on how long the area was exposed to the chemical
  • remove any contaminated clothing that the patient may still be wearing
  • wash area to dilute or remove the substance
  • keep the wound under running water for 20 minutes

Smoke Inhalation

Smoke inhalation, which includes inhalation of heat, chemicals, and soot, can lead to a burn injury to the airway. To confirm smoke inhalation, it is important to assess for:

  • burns in mouth area
  • sooty sputum
  • voice change
  • difficult cough

If in doubt one should still provide oxygen therapy following intubation whilst protecting the cervical spine.

TREATMENT

Based on the inhalation severity:

  • patient may be intubated for minimal upper airway swelling
  • if soot is present in large amounts, patient’s airway may need suctioning
  • if the respiratory tract requires support, an aggressive approach should be taken…
  • chest physiotherapy
  • bacteriological surveillance – prophylactic antibiotic is administered
  • administration of The Galvenstone Protocol: inhaled H1 blockers, inhaled heparin, and nebulised acetyl cysteine

Electrical Burns

Electrical burns are caused by exposure to an electric source. They typically have both an entry and an exit site. The extent of such an injury ranges from minimal injury to severe multi-organ involvement.

An electrical burn needs to be evaluated by a medical professional despite the patient’s condition, be it stable or not.

burn injury
Retrieved from https://link.springer.com/article/10.1007/s12262-012-0476-x on 22nd January 2023

Radiological Burns

Radiological burns are caused by the exposure to radiation. Whilst the most common cause of a radiation burn is through UV radiation as sunburn, patients undergoing radiation may present with radiation ulcers following radiotherapy, which unfortunately increases cancer risk and causes cell death.

burn injury
Retrieved from https://www.curriculumnacional.cl/link/http:/mlrd.net/radiation-burn-5b5d.SHTML on 22nd January 2023

Burn Injury Nursing Care

A patient with burns is ideally kept in a positive-pressure room when hospitalised. Positive-pressure rooms have higher air pressure than the adjoining areas, preventing airborne pathogens from entering the room to avoid the air inside becoming contaminated. This reduces the risk of burn patients acquiring infection and causing further complications in their healing process.

Shock and Fluid management

In patients with critical burns, shock causes progressive failure of the circulation, leading to a decrease in oxygen perfusion within the vital organs. Fluid resuscitation aims to:

  • maintain vital organ function especially when it comes to renal function
  • replace fluid lost within the first 8 hours following burn infliction

Fluid Resuscitation Formula – Hartmann’s

4ml x weight x affected Total Body Surface Area (TBSA)

to be administered over the first 24 hrs

(Half of the prescribed volume should be administered over the first 8 hours from burn infliction, with the rest over the following 16 hours)

CRYSTALLOIDS VS COLLOIDS

The most commonly used resuscitation fluid for initial resuscitation is the Ringer’s Lactate (Hartmann’s) or other crystalloids. Crystalloids make up a balanced solution which helps balance electrolytes in large fluid replacements.

When compared to colloids, crystalloids have a less prominent affect of volume expansion, however colloids tend to exacerbate third space losses. In burn patients, colloids (commonly used being albumin) are added to decrease the total volume of resuscitation fluid needed, since these reduce capillary leakage. Albumin is however commonly used as a rescue approach since it increases mortality in critically ill patients. Albumin:

  • reduces fluid creep (fluid overload)
  • tends to cause haemodynamic instability – hypotension, oliguria, and increasing haematocrit

If Albumin is indicated as an adjunct to the fluid resuscitation protocol, it should replace HALF of the crystalloid amount.

URINE OUTPUT

Urine output is vital for indicating successful fluid resuscitation. A urine catheter should be inserted whenever fluid resuscitation is being performed, since in burn patients, the nurse needs to monitor:

  • urine output
  • heart rate
  • blood pressure
  • ABGs
  • pH (patient may experience lactic acidosis)

Expected Urine Output in Patients Undergoing Fluid Resuscitation:

Adults: 0.5ml/kg/hr

Children: 1.0ml/kg/hr

NOTE: fluid resuscitation increases oedema. Fluid formulae should only be used as guidelines, and fluid calculations need to be calculated from the time at which the burn was inflicted. Ideal fluid resuscitation should include the LEAST amount of fluid necessary to maintain tissue perfusion, maintain vital physiological functions, and return physiology to normal as soon as possible.

Retrieved from https://slideplayer.com/slide/13463859/ on 23rd January 2023

THE GASTROINTESTINAL SYSTEM OF A PATIENT WITH BURNS

In burn patients, the liver’s function forms part of the systemic response to the burn injury, excreting glucagon and inflammatory markers.

Secondary Abdominal Compartment Syndrome (SACS) is a common crystalloid resuscitation complication caused by increased intra-abdominal pressure which may cause a secondary organ infarction if ignored. Typically, a patient with SACS has reduced urinary output which may also be bloody.

To avoid SACS, the patient’s intra-abdominal pressure should be measured, either via the patient’s bladder, or by measuring the intra-vesical pressure.

cleaning the burn Injury

  • a new burn is considered to be sterile, thus, it is important to attempt to keep it that way
  • clean thoroughly with an antibacterial wash eg. betadine surgical scrub
  • antibiotics should not be prescribed as prophylaxis, but only if infection is noted (a temperature of up to 38.5°C is considered to be normal in patients with burn injuries)
  • de-roof and debride large blisters UNLESS they are located on the palms or soles of the feet due to excessive pain as well as superficial nerves, to which debridement may cause irreparable problems
  • debride any dead skin to promote healing

Change of Dressings

  • in the initial stage, dressings should be changed daily, especially since at this stage these are usually found soaked
  • once healing starts to progress, change of dressing should be performed every 3-5 days, however, if the wound becomes painful, smelly, or soaked at any time, it should be immediately changed

Further care

  • encourage daily moisturiser application eg. aqueous cream
  • encourage sunblock use over healed areas for 6-12 months
  • advise patient that pruritus is a common problem following burn injury, and that advise should be sought if this becomes problematic
  • provide patient with support and reassurance, without any false hopes

NOTE: unhealed burns lasting 3 weeks should be referred to the Burns Unit.

Renal Failure

Renal failure in a patient with burns is usually a late septic complication, especially since within the acute stage the patient would be receiving aggressive fluid resuscitation. To avoid such complication, haemofiltration is commonly considered in large burn injuries. Renal failure signs include:

  • oliguria of <4o0ml per day
  • a decline in the GFR
  • a rise in Urea and Creatinine

A patient needing kidney relief may be put on the PrismaFlex System.

Patient Education on Burns First Aid Care

  • always aim to stop the burning process by removing the heat source and any affected clothing
  • if clothes catch on fire, “STOP, DROP & ROLL”
  • put burn wound under running water for 20 minutes following a burn injury
  • protect the burn by covering it with a sterile non-adhesive bandage
  • manage pain through analgesia eg. paracetamol
  • DO NOT use ice water since this causes vasoconstriction, leading to burn progression
  • DO NOT apply any creams or ointments to burn injuries since these may cause further complications

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Hypovolaemic Shock

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Shock can be classified into 3 different types: Hypovolaemic Shock, Cardiogenic Shock, and Septic Shock. Whilst the management of shock varies based on the type of shock it is, the resulting effect of all 3 types of shock is the same – decreased tissue perfusion.

Features of a Hypovolaemic Shock

Hypovolaemic shock is the most commonly occurring type of shock, which is also easily reversible if treated in a timely manner. Features of a hypovolaemic shock include:

  • loss of circulating or intravascular volume
  • impaired tissue perfusion
  • inadequate delivery of oxygen and nutrients
  • may be caused by relative and absolute hypovolaemia, or loss of blood or other fluids

Absolute Hypovolaemia

The phrase Absolute Hypovolaemia refers to external loss of fluids from the body. Fluid loss may be that of whole blood (through trauma or major surgery), loss of plasma (through burns) and loss of other fluids such as massive diuresis (through skin loss), severe vomiting, diarrhoea, and dehydration (through diabetes insipidus – a rare condition unrelated to type 1 or 2 diabetes which causes diuresis and polydipsia, diabetic ketoacidosis, and HONK – hyperglycaemic hyperosmolar non-ketotic coma – coma resulting from very high blood glucose levels in a patient with normal ketone levels; very high blood glucose levels combined with high ketone levels may be due to ketoacidosis).

Internal Haemorrhage

Internal Haemorrhage may be caused by:

  • fractures
  • GI bleeding
  • organ rupture (eg. spleen, liver, and kidneys)
  • pregnancy complications (eg. ectopic pregnancy or post-partum haemorrhage)

Fluid Loss – from intravascular space to extravascular space – may be caused by:

  • burns
  • pleural effusion
  • peritonitis – inflammation of the peritoneum
  • pancreatitis – inflammation of the pancreas
  • ascites – a condition in which fluid collects in spaces within the abdomen

Pathophysiology of Hypovolaemic Shock

  1. relative or absolute hypovolaemia
  2. decreased circulating volume
  3. decreased venous return (decreased preload)
  4. decreased stroke volume
  5. decreased cardiac output
  6. decreased cellular oxygen supply
  7. impaired tissue perfusion
  8. impaired cellular metabolism

Signs & Symptoms

  • impaired consciousness
  • pale, cool, clammy extremities
  • prolonged capillary refill time
  • increased heart rate
  • increased respiratory rate
  • hypotension (SBP <90mmHg & reduced pulse pressure SBP-DBP)
  • reduced urine output
  • metabolic acidosis
  • signs of bleeding (decreased Haematocrit & Haemoglobin)
hypovolaemic shock
Retrieved from https://twitter.com/misirg1/status/1382458804995035144 on 19th January 2023

Management

  1. Identify & Treat the Underlying Cause
  2. Restore Intravascular Volume & Blood Pressure
  3. Redistribute Fluids to Ensure Perfusion
  4. Prevent Shock Progression
  5. Avoid onset of Cardiogenic Shock
  • stop the bleeding by applying pressure to injured site and prepare patient for surgery
  • administer antiemetics for severe vomiting, antidiarrhoeal agents to treat diarrhoea, insulin for dehydration caused by diabetes, and desmopressin for diabetes insipidus
  • establish good venous access through large peripheral lines and central venous catheters
  • insert a urinary catheter to monitor renal perfusion and fluid balance
  • monitor haemodynamic parameters and the patient’s condition, and titrate fluid administration according to patient’s needs
  • crystalloids are electrolyte solutions such as Isotonic (eg. normal saline or RLactate), Hypertonic (eg. 10% Dextrose) or Hypotonic (eg. 0.45% NaCl – Sodium Chloride); these address both fluid and electrolyte loss
  • colloids include blood and its products such as Fresh Frozen Plasma (FFP), as well as synthetic plasma expanders such as Gelafundin (a colloidal plasma volume substitute in an isotonic balanced whole electrolyte solution that can be used for prophylaxis and therapy of hypovolaemia and shock); ADVANTAGES: colloids remain in the intravascular space, restoring fluids faster and with less volume, while blood restores Hgb; DISADVANTAGES: colloids are expensive, may cause reactions, and may also leak out of damaged capillaries, causing additional problems including cardiac failure and peripheral oedema
  • based on the patient’s blood group and cross match, administer infusions of packed red blood cells to increase circulatory volume and oxygen carrying capacity; fresh frozen plasma, platelets, and cryo precipitate (the insoluble portion, or precipitate, that remains when the liquid portion of the plasma drains away) may also be indicated – blood products are commonly administered through a blood warmer so as to prevent or manage hypothermia
  • during surgical procedures such as cardiothoracic surgery, chest and abdominal trauma, and orthopaedic surgery, the patient can receive own blood through the intra-operative blood salvage machine, which collects lost blood through a filtered tube and readministers it within 4 hours; this reduces the risk of reactions and infections, however, it does carry an increased risk of haemolysis and microemboli formation during the collection and administration period
  • pay attention to any arising complications of fluid administration eg. allergic reactions and infection, electrolyte imbalance, dilution of haemoglobin and clotting factors, and pulmonary oedema (higher risk in older adults, and patients with chronic heart failure or renal failure); monitor patient’s urine output and fluid balance, haemodynamic monitoring, fluid responsiveness, and lung sounds
  • haemorrhagic stroke drug therapy may include inotropes and vasopressors (typically adrenaline or noradrenaline and dobutamine) to increase cardiac output and blood pressure for better perfusion; these however increase oxygen demands; ensure secure airway and administer oxygen if needed to treat hypoxia; antifibrinolytics such as tranexamic acid may be required to prevent the breakdown of fibrin, which is the main protein in a blood clot
Retrieved from https://www.getdoc.com/blood-type-basics-blood/ on 19th January 2023

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Septic Shock

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Shock can be classified into 3 different types: Hypovolaemic Shock, Cardiogenic Shock, and Septic Shock. Whilst the management of shock varies based on the type of shock it is, the resulting effect of all 3 types of shock is the same – decreased tissue perfusion.

Distributive Shock

  • impaired distribution of circulating blood volume
  • vasodilation
  • capillary leaks

Distributive Shock is sub-classified into 3 other types of shock: septic shock, anaphylactic shock and neurogenic shock. In this blogpost we will be focusing on Septic Shock.

Septic Shock

While sepsis is defined as a life-threatening organ dysfunction caused by dysregulated host response to infection, a septic shock is defined as a subset of sepsis in which underlying circulatory, cellular and metabolic abnormalities and profound enough to substantially increase the risk of mortality.

  • microorganism entry into the patient’s body
  • dysregulated host response characterised by excessive peripheral vasodilation, causing maldistribution of blood volume, over-perfused peripheral areas and under-perfused central areas
  • is the major cause of admission in the critical care setting

Septic Shock may originate from the community (>80% of cases) or during a stay in a healthcare facility. Common sites for origin of septic shock include:

  • lung
  • abdomen
  • bloodstream
  • renal
  • gastrointestinal tract
  • bone
  • soft tissue
  • surgical wounds

Infective organisms may include:

  • Gram negative bacteria eg. Klebsiella, Escherichia coli, and Pseudomonas aeruginosa
  • Gram positive bacteria eg. Staphylococcus aureus and Streptococcus pneumoniae
  • Viruses
  • Fungi
  • Parasites

Predisposing Factors

Intrinsic FactorsExtrinsic Factors
age extremesinvasive devices eg. catheter use
malnutritionimmunosuppressing drug therapy eg. steroids
co-existing diseases eg. malignancies, AIDS and Diabetesimmunosuppressive therapy eg. chemotherapy
wounds
surgical or invasive procedures

NOTE: all critically ill patients are at an increased risk of developing septic shock.

Septic Shock Signs & Symptoms

  • general malaise
  • fever OR hypothermia
  • tachycardia
  • tachypnoea
  • altered mental status
  • hypotension
  • impaired gas exchange
  • mottled skin
  • prolonged capillary refill
  • oliguria – urinary output less than 400 ml per day or less than 20 ml per hour

Investigations

  • CBCs
  • ABGs
  • c-reactive protein
  • clotting profile – prothrombin time and INR
  • urea & electrolytes
  • liver function tests
  • urinary function tests
  • serum lactate – helps identify cryptic septic shock

Septic Shock Diagnosis

Rapid recognition and resuscitation is crucial for survival, and so, deteriorating patients should be investigated for infection in a timely manner.

SepsisSeptic Shock
presence of infectionadequate fluid resuscitation not enough
acute change in SOFA score of 2 points or more from baselinevasopressors required to keep MAP at >65mmHg and Serum Lactate at >2mmol/L

Sequential Organ Failure Assessment Score (SOFA)

SOFA is a bedside tool that helps identify patients with infection at an increased risk of death or prolonged ICU stay. SOFA is considered to be positive when the patient has at least 2 of the following 3 criteria:

  • respiratory rate of >22 breaths/minute
  • altered mental state with a GCS <15
  • systolic blood pressure <100mmHg
septic shock
Retrieved from https://www.crit.cloud/summaries–reviews/the-bat-and-the-sofa-the-3rd-consensus-definitions-for-sepsis-are-out on 20th January 2023

Multiple Organ Dysfunction Syndrome (MODS)

MODS refers to a clinical syndrome characterised by acute potentially reversible dysfunction of two or more organs or organ systems not directly involved in the primary disease process. It is the ultimate complication of Septic Shock.

Airway Support

  • stabilise the patient’s airway
  • maintain oxygen saturation >94% (unless patient has COPD)
  • mechanical ventilation may be required to improve oxygenation and neutralise metabolic acidosis

Identifying Source of Sepsis + Treatment

  • Microbiology – blood, sputum, CSF, urine, wound swab specimens should be sent immediately for Culture & Sensitivity (2 sets of blood cultures should be taken, the 2nd one being with increased sensitivity for detecting bacteraemia); IMPORTANT: take cultures BEFORE antibiotics are administered (even though broad antibiotics should be started within 1 hour)!
  • Radiology – x-ray and CT scan should be performed to check for signs of infection
  • IV Antibiotics – start broad spectrum IV antibiotics within one hour to cover likely causative agents such as resistant organisms like MRSA, VREs and Klebsiella, or endogenous infections by colonising bacteria
  • Adjust Antibiotic Regime – upon identification of specific pathogens
  • Eliminate Sepsis Source within 12 Hours – debride any infected or nectrotic tissue, drain abscesses and secretions, and remove infective invasive devices

Fluid Resuscitation

Fluids are required to counteract absolute hypovolaemia (sweating, diarrhoea, hyperventilation) and relative hypovolaemia (vasodilation and peripheral blood pooling).

  • start crystalloids within one hour using the fluid challenge – 30ml/kg over 3 hours, titrating according to response
  • if necessary, colloids may be administered to patients who had to receive large volumes of crystalloids
  • CAUTION: watch out for fluid and chloride overload

Inotropes and Vasopressors

If fluid administration is unsuccessful in maintaining physiological parameters and adequate perfusion (MAP should be maintained at >65mmHg), or in the case of myocardial dysfunction, inotropes and vasopressors may be required.

  • administer noradrenaline to revere inappropriate vasodilation, lower risk of tachycardia and arrhythmias with less adverse metabolic effects
  • adrenaline may also be added as an adjunct if required
  • dobutamine may also be added if the patient remains unstable; this may also help counteract excessive vasoconstriction, especially within the peripheries

Corticosteroid Use

  • corticosteriods (hydrocortisone 200mg/day) may be indicated due to their anti-inflammatory effects in patients unresponsive to fluids and vasopressors NOTE: corticosteroids should not be discontinued abruptly!

Nutrition

  • nutritional support is particularly important for patients with septic shock since this helps improve their immune response
  • in case of patients with wounds, a high protein diet is recommended since it helps speed up the healing process
  • maintain the patient’s blood glucose level at <10mmol/L but avoid excessive glucose control to prevent hypoglycaemia

General Support

  • maintain temperature control to decrease metabolic demands
  • provide skin care and pressure ulcer prophylactic measures
  • provide prophylactic therapy to prevent venous thromboembolism
  • prevent over-sedation
  • aim to prevent ventilator-acquired pneumonia and infections related to lines/catheter use
  • provide blood transfusions only if the patient’s Hgb is <7mmol/L, or in case of bleeding, myocardial ischaemia, and severe hypoxia
Give high-flow oxygen via non-rebreathe bag. Take blood cultures and consider source control. Give IV antibiotics according to local protocol. Start IV fluid resuscitation Hartmann’s or equivalent. Check lactate. Monitor hourly urine output consider catheterisation. within one hour….plus Critical Care support – Retrieved from https://slideplayer.com/slide/12865670/ on 20th January 2023
septic shock
Retrieved from https://slideplayer.com/slide/17346484/ on 20th January 2023

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Cardiogenic Shock

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Shock can be classified into 3 different types: Hypovolaemic Shock, Cardiogenic Shock, and Septic Shock. Whilst the management of shock varies based on the type of shock it is, the resulting effect of all 3 types of shock is the same – decreased tissue perfusion.

Cardiogenic Shock

  • impaired ability of the heart to pump blood as it should (left or right ventricle dysfunction), causing systemic hypoperfusion and tissue hypoxia
  • may be caused by cardiac injury (eg. cardiac tamponade), cardiopulmonary arrest, following cardiac surgery, dysrhythmias (severe tachycardia or bradycardia), myocardial tissue necrosis following a Myocardial Infarction, or structural problems (eg. valvular damage or regurgitation, pulmonary embolus, acute myocarditis, papillary muscle rupture, intracardiac tumour, and congenital defects
  • compensatory mechanisms may worsen the situation…eg. reduced cardiac output due to myocardium death causes increased contractility which further increases the heart’s workload and oxygen demand; reduced blood pressure causes the release of catecholamines which leads to vasoconstriction, subsequently leading to a further increase in cardiac workload and oxygen demand

Cardiogenic Shock Signs & Symptoms

  • chest pain or chest trauma
  • altered level of consciousness
  • cool, pale moist skin
  • weak thready pulse
  • tachycardia possibly with dysrhythmias
  • tachypnoea
  • SBP <90mmHg and MAP 30mmHg less than normal
  • urine output <30ml/hr
  • jugular venous distension
  • reduced cardiac output and cardiac index
  • increased PAWP (Pulmonary Artery Wedge Pressure), increased RA (right atrium) pressure & increased SVR (systemic vascular resistance)
  • signs of pulmonary oedema eg. hypoxaemia, crackles, and frothy sputum

Management

  1. Treat Underlying Cause to Prevent Further Damage & Preserve Healthy Myocardium
  2. Enhance Pumping Effectiveness by Increasing Cardiac Output
  3. Improve oxygen perfusion in the heart as well as other organs and tissues
  4. Increase oxygen supply and reduce oxygen demand of the heart
  • provide oxygen therapy through supplementary oxygen or mechanical ventilation due to cardiac ischaemia and chest pain
  • administer morphine for analgesia and sedation, and promote rest
  • if patient has pulmonary oedema, administer diuretics eg. furosemide or bumetanide, and oxygen whilst monitoring haemodynamic status and ABGs of the patient; diuretics reduce fluid accumulation which causes a decrease in preload – monitor for fluid and electrolyte imbalance
  • provide mechanical reperfusion through PCI (percutaneous coronary intervention) eg. angioplasty and coronary stents, or a coronary artery bypass graft (CABG)
  • provide thrombolytic therapy through pharmacologic agents eg. streptokinase, urokinase, tissue plasminogen activator TPA, which dissolve clots in coronary artery BEFORE cardiogenic shock sets in; ATTENTION: watch out for bleeding!
  • provide drug therapy that helps improve cardiac output by increasing cardiac contractility, decreasing preload and afterload, and stabilising the heart rate
  • provide fluids with great caution since this increases risk of pulmonary oedema
  • administer inotropes (eg. dobutamine or milrinone) to improve contractility and reduce afterload, and vasopressors (eg. adrenaline or noradrenaline) to increase contractility, vasoconstriction, blood pressure, and heart rate NOTE: inotropes and vasopressors can be given in combination
  • administer vasodilators eg. nitrates to reduce oxygen demands by reducing preload through venous dilation, reducing afterload by arterial dilation due to less resistance, increasing oxygen supply to the myocardium due to coronary vasodilation, but ATTENTION – vasodilators cause hypotension!
  • treat arrhythmias with anti-arrhythmic drugs eg. amiodarone to help increase time for ventricular filling
  • make use of the intra-aortic balloon pump – a long balloon attached to a large bore catheter inserted through the femoral artery to the descending aorta, with the balloon tip placed just below the aortic arch, and the bottom tip above the renal artery; the attached machine helps by inflating the balloon with helium at the start of diastole when the aortic valve closes, and rapidly deflating it at the start of ventricular systole, just before the aortic valve opens; ATTENTION to possible complications eg. dislodgement of clots, limb ischaemia / neuropathy (check pedal pulses), bleeding (check clotting time before insertion and removal), infection, balloon rupture, and improper position
  • if indicated, the Left Ventricular Assist Device may be used – flow pump which is placed across the aortic valve into the left ventricle; it draws blood continuously from the left ventricle to the proximal aorta; may be used prior to transplantation or long term for transplantation-ineligible patients
  • the VA-ECMO is a device through which deoxygenated blood is drained through the central vein; blood is then oxygenated outside of the patient’s body, before being returned through the large artery; it helps improve aortic flow and organ perfusion, however, it may increase afterload and worsen pulmonary oedema; note increased risk of acute kidney injury, severe bleeding, lower limb ischaemia, and stroke
  • if indicated, a patient with cardiogenic shock may undergo surgical interventions such as human heart transplantation, repair of septal, ventricular, or papillary muscle rupture, or valve repair or change
Retrieved from https://www.magonlinelibrary.com/doi/abs/10.12968/bjca.2021.0055?journalCode=bjca on 20th January 2023
cardiogenic shock
Retrieved from https://www.facebook.com/jamajournal/photos/a.10158814898548341/10158814906348341/?type=3&locale=zh_HK on 19th January 2023

Cardiogenic Shock and Intra-aortic Balloon Pump => https://www.youtube.com/watch?v=mADxD7C8jBw


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Shock Nursing Management – Assessment, Diagnosis & Care

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Shock nursing management depends on the accurate and timely identification of shock. This can be obtained through an accurate assessment, thorough investigations, and a proper diagnosis, following which, the right treatment and requirements can be planned and provided to the patient.

Assessment

When assessing for shock, one should keep in mind that clinical changes are initially quite subtle. Still, the following aspects must be taken into account during an initial patient assessment…

  • patient history
  • level of consciousness
  • signs of internal or external bleeding
  • skin colour and/or moisture
  • respiratory rate and effort
  • heart rate and rhythm
  • body temperature
  • blood pressure
  • urine output
shock nursing management
Retrieved from https://www.grepmed.com/images/4224/types-table-signs-classification-symptoms on 16th January 2023
shock nursing management
Retrieved from https://doctorlib.info/medical/harrisons-manual-medicine/12.html on 16th January 2023

Investigations

Clinical tests should be carried out to confirm shock and identify the patient’s array of needs…

  • CBC – a complete blood count test measures the amount of red blood cells (which carry oxygen) and white blood cells (which fight infection); this test gives a good indication of bleeding and infection.
  • ABGs – an arterial blood gases test measures the acidity (pH) and the levels of oxygen and carbon dioxide in arterial blood; this test determines how well the patient’s lungs are performing gas exchange.
  • Lactate Level – normal blood lactate levels are 1.3 mmol/L; an increase in lactate production is usually caused by impaired tissue oxygenation whereby the lungs switch from performing aerobic to anaerobic respiration.
  • Cross Match – this is done in case the patient is found to be needing a blood transfusion.
  • Electrolytes electrolyte imbalance can be indicative of shock in the progressive phase.
  • Clotting – impaired coagulation and microclots are indicative of shock in the progressive phase.
  • Alcohol Levels – these are tested if the patient suffered from trauma.
  • ECG – an ECG determines whether the patient is suffering from arrhythmias or is heading towards cardiac depression and failure.
  • Cardiac Enzymes – cardiac enzymes a.k.a. cardiac biomarkers are released by the heart in the case of heart damage or stress caused by low oxygen; Troponin and creatinine phosphokinase (CPK) levels rise following a heart attack; elevated heart enzyme levels may also indicate acute coronary syndrome or ischaemia.
  • X-rays, CT scan of the Patient’s Chest, Abdomen and Spine – determines if there is infection, injury, and fluid loss.
shock nursing management
Retrieved from https://oxfordmedicalsimulation.com/learning/blood-gases/normal-blood-gas-sig001us/ on 16th January 2023
Retrieved from https://veteriankey.com/blood-gas-acid-base-analysis-and-electrolyte-abnormalities/ on 16th January 2023

Diagnosis

Clinical manifestations of shock vary according to both the underlying cause and the stage it is at, varying based on the cause of shock as well as the patient’s physiological response.

Typically, a patient is considered to be in shock when the following signs are noted:

  1. a systolic blood pressure of <90mmHg
  2. tachycardia OR bradycardia
  3. altered mental status

Shock Nursing Management

Shock nursing management aims to:

  • RESTORE ADEQUATE TISSUE PERFUSION – this can be achieved through ensuring adequate oxygen delivery to the cells in relation to gas exchange, cardiac output, and haemoglobin, as well as improving oxygen utilisation by the cells
  • PREVENT SHOCK PROGRESSION INTO FURTHER STAGES

Thus, in shock nursing management, the following steps need to be tackled as needed:

  1. improving oxygen supply
  2. administering fluid therapy
  3. administering cardiovascular drugs
  4. providing nutritional support
  5. providing psychosocial care

1. Improving Oxygen Supply

With adequate oxygen supply we aim to:

  • achieve adequate gas exchange – ensure the patient has a patent airway, and improve ventilation and oxygenation by providing supplemental oxygen and mechanical ventilation if required
  • achieve adequate cardiac output – aim to control the patient’s heart rate, preload and afterload, and cardiac contractility through the administration and titration of fluids and cardiovascular drugs

2. Administering Fluid Therapy

Fluid therapy administration is necessary for all types of shock, though the type of fluid administered and the amount and speed of delivery varies with every patient.

Fluids help increase oxygenation since oxygenation is partly affected by circulation. Types of fluids administered include:

  • crystalloids – electrolyte solutions such as Isotonic (eg. normal saline or RLactate), Hypertonic (eg. 10% Dextrose) or Hypotonic (eg. 0.45% NaCl – Sodium Chloride)
  • colloids – types of colloids, which contain large molecules, include blood and its products such as Fresh Frozen Plasma (FFP), as well as synthetic plasma expanders such as Gelafundin (a colloidal plasma volume substitute in an isotonic balanced whole electrolyte solution that can be used for prophylaxis and therapy of hypovolaemia and shock); ADVANTAGES: colloids remain in the intravascular space, restoring fluids faster and with less volume, while blood restores Hgb; DISADVANTAGES: colloids are expensive, may cause reactions, and may also leak out of damaged capillaries, causing additional problems especially within the lungs

fluid administration Complications

Common fluid administration complications include cardiovascular overload and pulmonary oedema.

Patients with increased risk include elderly patients and patients with a history of chronic renal failure or heart failure.

To avoid fluid administration complications, the nurse should:

  • monitor and document urine output and fluid intake
  • monitor for changes in the patient’s vital signs
  • check for lung sounds
  • perform haemodynamic monitoring

3. Administering Cardiovascular Drugs

Anti-dysrhythmic agents

  • anti-dysrhythmic agents such as Amiodarone prevent or treat abnormal heart rates and rhythms

Vasodilators

  • vasodilators such as nitrates cause arterial dilation by decreasing the afterload following decreased resistance to blood ejection, leading to an increase of cardiac output without increased oxygen demands
  • vasodilators also cause venous dilation by reducing the preload and subsequently reducing the filling pressure on the failing heart

NOTE: Vasodilators REDUCE BLOOD PRESSURE! Monitor patient at all times whilst on vasodilators!

Inotropes and Vasoconstrictors

  • inotropes and vasoconstrictors increase myocardial contractility leading to an increase in cardiac output
  • inotropes stimulate adrenergic receptors, causing similar effects to the fight or flight reaction; types of sympathomimetic agents include naturally occurring catecholamines eg. adrenaline, noradrenaline and dopamine; synthetic cathecolamines eg. dobutamine

NOTE: Vasoconstrictors INCREASE BLOOD PRESSURE!

ADRENALINE (EPINEPHRINE)

  1. binds to beta 1 and beta 2 receptors
  2. cause an increase in heart rate, cardiac contractility, vasodilation, and cardiac output
  3. with an increasing rate of infusion also comes an increase in alpha receptors, which result in increased blood pressure and vascular resistance through vasoconstriction
  4. the heart now needs to work harder and so, its oxygen demand increases too

NORADRENALINE

  1. binds to beta 1 receptors only
  2. does not cause an increase in heart rate
  3. a low dose of noradrenaline increases cardiac contractility, leading to an increase in cardiac output
  4. higher doses tend to limit effect due to alpha stimulation which causes massive vasoconstriction
  5. whilst this causes an increase in blood pressure, it compromises peripheral circulation and increases the workload of the heart

DOPAMINE

  1. dopamine is the chemical precursor of noradrenaline
  2. a low dose of dopamine stimulates dopaminergic receptors, causing renal and mesentric vasodilation, leading to a good urine output
  3. a moderate dose of dopamine stimulates beta 1 receptors, causing an increase in cardiac contractility and cardiac output
  4. a high dose of dopamine stimulates alpha receptors, causing massive vasoconstriction, an increase in blood pressure, and an increase in the workload of the heart

DOBUTAMINE

  1. dobutamine causes no dopaminergic effects
  2. dobutamine mainly stimulates beta 1 receptors, causing an increase in cardiac contractility and cardiac output; dobutamine may also stimulate beta 2 receptors, causing mild vasodilation, causing a reduction the the preload, afterload, and stress on the heart
  3. dobutamine is helpful in treating heart failure, especially in hypotensive patients who are unable to tolerate vasodilators
  4. dobutamine may also be used as an adjunct therapy to adrenaline or noradrenaline and dopamine to reduce vasoconstriction effect

ADMINISTRATION OF INOTROPES:

  • correct dilution of inotropes is of utmost importance
  • inotropes are administrated as infusions through electronic pumps so that consistent administration is ensured
  • administration of inotropes is done through a central line
  • careful haemodynamic monitoring is very important especially since it help in the titrating process of inotropes dosage as needed
  • inotropes should NOT replace fluid and electrolyte balance
  • inotropes should be weaned off slowly

EFFECTS OF ADRENERGIC RECEPTORS

RECEPTORLOCATIONRESPONSE
ALPHAskin, muscles, kidneys, and intestinesconstrict peripheral arterioles
BETA 1cardiac tissueincrease heart rate and cardiac contractility
BETA 2vascular and bronchial smooth muscledilates peripheral arterioles; increases heart rate; causes bronchodilation

4. Providing Nutritional Support

Shock causes increased metabolic rates, which in return increase the patient’s energy requirements. Catecholamines (adrenaline and noradrenaline) deplete glycogen stores in 8-10 hours, after which the body starts breaking down skeletal muscle for energy. This prolongs recovery period unless it is prevented.

Typically, a patient in shock may require >3000kcal daily, however, the patient is usually unable to eat due to intubation, sedation, and anxiety. For this reason, enteral or parenteral nutrition should be initiated within 48 hours, and increased to full nutrition by day 3-7, if the patient is haemodynamically stable (excessive nutrient intake should be avoided in the early phase of critical illness).

NOTE: patients diagnosed with shock are also prone to develop pressure ulcers.

5. Providing Psychosocial Care

Psychological care should be provided throughout the whole course of hospitalisation, especially within the critical care environment. Liaise with other healthcare professionals as needed.

Whilst adopting an empathic approach, provide information and reassurance to both the patient (if conscious; if unconscious still talk to your patient as if he/she is listening, making him/her aware of what is going on in relation to care) and relatives, as this reduces anxiety. Communicate with the patient’s relatives about the patient’s condition as well as procedures being performed.

Shock Nursing Management Additional Interventions

  • ensure good vascular access for fluid administration, central venous pressure (CVP) monitoring, and to draw blood for investigations
  • insert a NGT (or OGT if patient has facial trauma) so that emesis (vomiting) and aspiration are prevented
  • insert a urinary catheter to monitor urine output and fluid balance accordingly
  • monitor the patient’s temperature and ensure maintenance of normal body temperature
  • reposition patient frequently to prevent pressure ulcer formation
  • provide frequent mouth and eye care
  • assess for pain and administer analgesics as needed
  • ensure continuous monitoring and documentation

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