Tag Archives: Nursing Assessment

Invasive blood pressure (BP) versus non invasive BP monitoring in ICU patients

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Searches of PubMed, Embase, and CINAHL yielded this one meta-analysis and two systematic reviews.

Kim, Sang-Hyun, et al. “Accuracy and precision of continuous noninvasive arterial pressure monitoring compared with invasive arterial pressure: a systematic review and meta-analysis.” Anesthesiology 120.5 (2014):1080-1097.
Twenty-eight studies with 919 patients were included in this systematic review. “The overall random-effect pooled bias and SD were -1.6 ± 12.2 mmHg (95% limits of agreement -25.5 to 22.2 mmHg) for systolic arterial pressure, 5.3 ± 8.3 mmHg (-11.0 to 21.6 mmHg) for diastolic arterial pressure, and 3.2 ± 8.4 mmHg (-13.4 to 19.7 mmHg) for mean arterial pressure. In 14 studies focusing on currently commercially available devices, bias and SD were -1.8 ± 12.4 mmHg (-26.2 to 22.5 mmHg) for systolic arterial pressure, 6.0 ± 8.6 mmHg (-10.9 to 22.9 mmHg) for diastolic arterial pressure, and 3.9 ± 8.7 mmHg (-13.1 to 21.0 mmHg) for mean arterial pressure.
CONCLUSIONS: The results from this meta-analysis found that inaccuracy and imprecision of continuous noninvasive arterial pressure monitoring devices are larger than what was defined as acceptable. This may have implications for clinical situations where continuous noninvasive arterial pressure is being used for patient care decisions.”

Ben Sivarajan, V, and DesmondBohn. “Monitoring of standard hemodynamic parameters: heart rate, systemic blood pressure, atrial pressure, pulse oximetry, and end-tidal CO2.” Pediatric critical care medicine 12.4 Suppl (2011):S2-S11.
The conclusion of this systematic review states, “literature would suggest that invasive arterial monitoring is the current standard for monitoring in the setting of shock. The use of heart rate, electrocardiography, and atrial pressure monitoring is advantageous in specific clinical scenarios (postoperative cardiac surgery); however, the evidence for this is based on numerous case series only.”

Chatterjee, Arjun, et al. “Results of a survey of blood pressure monitoring by intensivists in critically ill patients: a preliminary study.” Critical care medicine 38.12 (2010):2335-2338.
“Eight hundred eighty individuals received an invitation to complete the survey and 149 responded. We found that 71% (105 of 149) of intensivists estimated the correct cuff size rather than measuring arm circumference directly. In hypotensive patients, 73% of respondents (108 of 149) reported using noninvasive blood pressure measurement measurements for patient management. In patients on a vasopressor medication, 47% (70 of 149) of respondents reported using noninvasive blood pressure measurement for management.”

Should capnography be used in postoperative, unventilated patients?

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There isn’t a consensus on whether capnography should be used in postoperative patients.

Eichhorn, John H. “Review article: practical current issues in perioperative patient safety.” Canadian journal of anesthesia 60.2 (2013):111-118.
The first paragraph of page 116 discusses the lack of consensus on how best to monitor postoperative patients for hypoventilation from postoperative pain medication.

Jarzyna, Donna, et al. “American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression.” Pain management nursing 12.3 (2011):118-145.e10.
Article states, “there is a paucity of information and no consensus about the benefits of technology supported monitoring, such as…capnography.”

Hutchison, Rob, and LesRodriguez. “Capnography and respiratory depression.” American journal of nursing 108.2 (2008):35-39.
This randomized prospective study of 54 postoperative orthopedic patients found a significantly higher rate of respiratory depression in the capnography group, concluding that “capnography may be more appropriate for use with postsurgical high-risk patients taking opioids” and “may have the added advantage of indicating those patients who may be at risk for obstructive sleep apnea.”

What are the best practices on measuring blood pressure (BP)?

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A search of Joanna Briggs Institute identified the following articles:

Measurement Accuracy of Non-invasively Obtained Central Blood Pressure: A Systematic Review and Meta-analysis. Cheng H, Lang D, Pearson A, Worthley S. The JBI Library of Systematic Reviews. 9(52):2166-2214, 2011.

Vital Signs. [Recommended Practices], AN: JBI2005, Updated: 02 Dec 2013.

Reviewed by John Nemeth 4/14

For patients on ventilator receiving neuromuscular blockade, how frequently should patient’s response to dose be monitored with peripheral nerve stimulation?

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Bottom line: No published evidence compares monitoring frequency (eg, q4, q8, etc.) to determine what is safest and most effective for monitoring dosage of neuromuscular blocking agents.  Professional recommendations advocate every 2-12 hours.

Summary:  ASA.  Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration.  Anesthesiology.  2009; 110(2): 218-230.
Page 221 begins review of recommendations and evidence for effectiveness of methods for detecting respiratory depression, and on p. 222, recommendation by expert consensus for monitoring after single injection and continuous infusion depend on class of drugs (neuraxial lipophilic opioids v. neuraxial hydrophilic opioids), clinical condition of patient and concurrent medications.

AACN Procedure Manual for Critical Care, 6th ed. [In print at EUH]

Recommends train of four (TOF) testing every 4-8 hours during infusion after patient is stable and after optimal dose for neuromuscular blockade is achieved (p. 310.)  References guidelines (see below.)

Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient.  Crit Care Med.  2002;30:142-156.
In the monitoring section, the guidelines recommend monitoring but do not provide specifics.  They do however, cite a study (Kleinpell) that surveys ICUs about their practices, as well as one prospective study (Strange) that compares TOF to clinical assessment and one retrospective study (Frankel) about implementing standards for monitoring in a surgical unit.

(“Monitoring, Physiologic”[MAJR]) AND “Neuromuscular Blockade”[MAJR] AND (train-of-four OR electric stimulation) AND (prospective study OR observational study OR cohort study OR comparison study)
Here is a PubMed search for comparison and cohort studies evaluating train-of-four.  Some are evaluating specific devices or stimulation methods.  Baumann (2004) and Strange (1997) address the use of the TOF itself.

There is also an RCT by Rudis (1997) that compares clinical assessment to TOF for reduction in dose of neuromuscular nondepolarizing agent to maintain paralysis .

Reviewed by John Nemeth 4/14

Guidelines for Continuous Pulse Oximetry

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Jeffrey J. Pretto, Teanau Roebuck, Lutz Beckert and Garun Hamilton. Clinical use of pulse oximetry: Official guidelines from the Thoracic Society of Australia and New Zealand. Respirology. 2014 Jan;19(1):38-46. doi: 10.1111/resp.12204. Epub 2013 Nov 20.

Pulse Oximetry. [Recommended Practices], 2016.

Dao Le, Long Khanh,. Pulse Oximetry: Clinician Information. {Evidence Summaries]. 2016.

Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration: An updated report by the American Society of Anesthesiologists Task Force on Neuraxial Opioids and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2016 Mar;124(3):535-52. doi: 10.1097/ALN.0000000000000975.

Pedersen T1, Nicholson A, Hovhannisyan K, Møller AM, Smith AF, Lewis SR. Pulse oximetry for perioperative monitoring. Cochrane Database Syst Rev. 2014 Mar 17;(3):CD002013. doi: 10.1002/14651858.CD002013.pub3. PubMed PMID: 24638894 .

I searched PubMed, CINAHL AND Joanna Briggs.   Keywords:  Continuous Pulse Oximetry Guidelines.

Updated Joanna Briggs and Cochrane links, 10/16/2017 ldt

Is there benefit to routinely screening for urinary tract infection (bacteruria) in hospitalized patients without urinary catheters?

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The information below pertains to asymptomatic bacteruria because the assumption is if the patient were symptomatic, diagnostic testing would be administered as standard care for the patient.

Here are guidelines for diagnosing and managing asymptomatic bacteruria.

  • Infectious Diseases Society of America (IDSA) guideline on diagnosis and treatment of asymptomatic bacteriuria in adults.  Clin Infect Dis 2005 Mar 1;40(5):643.
    • Based on evidence from at least 1 quality RCT in each case, IDSA recommends AGAINST screening premenopausal, nonpregnant women, women with diabetes, elderly institutionalized persons, older persons living in community, patients with spinal cord injury, patients with indwelling urethral catheter.  Also recommends screening pregnant women.
    • IDSA does recommend screening prior to transurethral resection of prostate (based on at least 1 RCT) and before other urologic procedures (based on descriptive studies and expert opinion)
    • IDSA does not make any recommendation about screening renal or other solid organ transplant recipients
  • United States Preventive Services Task Force (USPSTF) recommendation on screening for asymptomatic bacteriuria in adults.  National Guideline Clearinghouse 2008 Aug 4:12619 or Ann Intern Med 2008 Jul 1;149(1):43.
    • Only recommends routine screening for pregnant women.

Guidelines suggest further research is needed to address management of asymptomatic bacteruria in these populations:  chronic kidney disease, indwelling urinary devices other than catheters (eg, urinary stents, nephrostomy tubes), selected immunocompromised patients (eg, neutropenia, transplant recipients), and patients undergoing prosthetic implantation (orthopedic or vascular procedures).

Evidence from the guidelines includes hospitalized and non-hospitalized patients.  Details of the evidence are provided in the guidelines.

Searches of Medline and CINAHL using combinations of these terms did not identify any papers on routine testing of hospitalized patients.

Urine analysis
Routine, screening
Hospitalized, inpatients
Transplant, immunocompromised

What is the risk for transmitting infection by healthcare providers using a stethoscope as he or she moves from patient to patient?

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Bottom line:  Stethoscopes, mostly the earpieces, are a reservoir for bacteria, but there is no evidence directly addressing any association between use of stethoscopes on multiple patients and transmission of the bacteria found on the stethoscope

Halcomb E, et al. Role of MRSA reservoirs in the acute care setting. JBI Library of Systematic Reviews. 2008; 6(16): 633-685.
Identified one observational study of the eartips of stethoscopes dedicated to patients on contact precaution for MRSA.  13 of 78 (17%) eartips examined had potentially pathogenic bacteria on them, but none of the bacteria were the same as the infectious agents in the patients.

Other similar studies were identifed in a PubMed search.   Only the Brook (1997) paper below describes an actual infection (in a nurse) traced to an earpiece of a stethoscope.  The other studies show that most common organisms identified on stethoscopes (mostly earpieces) is S. aureas.

Gopinath KG, et al. Pagers and stethoscopes as vehicles of potential nosocomial pathogens in a tertiary care hospital in a developing country.  Trop Doct. 2011 Jan;41(1):43-5.  PMID: 21109607

Youngster I, et al. The stethoscope as a vector of infectious diseases in the paediatric division.  Acta Paediatr. 2008 Sep;97(9):1253-5.   PMID:18554272

Bernard L, et al.  Bacterial contamination of hospital physicians’ stethoscopes.  Infect Control Hosp Epidemiol. 1999 Sep;20(9):626-8.  PMID:10501265

Brook I.  Bacterial flora of stethoscopes’ earpieces and otitis externa.  Ann Otol Rhinol Laryngol. 1997 Sep;106(9):751-2.  PMID:9302906

Smith MA, et al.  Contaminated stethoscopes revisited.  Arch Intern Med. 1996 Jan 8;156(1):82-4.  PMID:8526701

Wright IM, et al.  Stethoscope contamination in the neonatal intensive care unit.  J Hosp Infect. 1995 Jan;29(1):65-8.  PMID:7738341

Search strategy:
Consulted and evidence summary source:  Searched Joanna Briggs Institute for “stethoscope and infection” – Identified a systematic review, which cited a paper on stethoscopes dedicated to MRSA-infected patients as as reservoirs.
Looked up that reference in PubMed and identified terms for a focused PubMed search:
(“Stethoscopes/microbiology”[MAJR] OR “Equipment contamination”[MAJR]) AND (nosocomial OR “hospital-acquired infection”)

Used QUOSA to identify articles from this set that discuss stethoscopes.