Randomised Controlled Trial Assessing The Impact Of A Nurse Delivered, Flow Monitored Protocol For Optimisation Of Circulatory Status After Cardiac Surgery Author(s): Moira McKendry, Helen McGloin, Debbie Saberi, Libby Caudwell, Anthony R. Brady and Mervyn Singer Source: BMJ: British Medical Journal, Vol. 329, No. 7460 (Jul. 31, 2004), pp. 258-261 Published by: BMJ Stable URL: http://www.jstor.org/stable/25468787 Accessed: 11-02-2016 12:06 UTC REFERENCES Linked references are available on JSTOR for this article: http://www.jstor.org/stable/25468787?seq=1&cid=pdf-reference#references_tab_contents You may need to log in to JSTOR to access the linked references.
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Svendsen KB, Jensen TS, Bach FW Does the cannabinoid dronabinol reduce central pain inmultiple sclerosis? Randomised double blind pla cebo controlled crossover trial.BMJ 2004;329:253-7. JoyJE, Watson SJ, Besnon JA, eds.Marijuana and medicine.Washington, DC: National Academy Press, 1999. Farquhar-Smith WP, Egertova M, Bradbury EJ,McMahon SB, Rice ASC, Elphick MR. Cannabinoid CB(1) receptor expression in rat spinal cord. Mol CellNeurosci 2000;15:510-21. Tanda G, Goldberg SR. Cannabinoids: reward, dependence, and underly review of recent preclinical data. Psy ing neurochemical mechanisms?a chopharmacology2003;169:115-34. Walker JM, Huang SM, Strangman NM, Tsou K, Sanudo-Pefia MC. Pain modulation by release of the endogenous cannabinoid anandamide. Proc Nail Acad Sci 1999;96:12198-203.
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10.1136/bmj.38168.627292.0B
controlled trial assessing the impact of a Randomised nurse delivered, flow monitored protocol for optimisation of circulatory Helen
Moira McKendry,
Bloomsbury Institute of Intensive Care Medicine, Department of Medicine and Wolfson Institute of Biomedical Research, University College London, Middlesex Hospital, London WIT 3AA Moira McKendry research sister Helen McGloin research sister Debbie Saberi research sister Libby Caudwell research sister Mervyn Singer professor of intensive care continued
over
BMJ 2004;329:258-61
status
after
McGloin,
Debbie
cardiac
surgery
Saberi, Libby Caudwell,
confidence To
Objective monitored
assess
led, flow
for optimising circulatory reduces cardiac surgery
and
shortens
stay
in intensive
care
period
unit
and
were
Patients
unit
cardiothoracic
management
guided by oesophageal maintain
allocated or
a stroke
Doppler
index
to an
often
algorithm
lead
to
a median
of nine
(interquartile
duration
of hospital
stay
was
reduced
from
intensive
delivered
range
13.9
to
status surgery
protocol in the early
may
for postoperative shorten
significandy
can pass hypoperfusion are These after major surgery.1 during and may not for several apparent days, clinically to increased and mortality. morbidity
(pulmonary
26 control patients had postoperative complications (two deaths) compared with 17 (four = deaths) protocol patients (P 0.08). Duration of was significandy hospital stay in the protocol group from
of
Usage
stay.
and
tissue
and
Several
= 7-12) days to seven (7-10 days; P 0.02). The mean
circulatory cardiac
Hypovolemia undetected
Results
reduced
to 47%).
Introduction
to conventional
flowmetry
12%
of
35 ml/m2.
above
after
hospital
trial.
controlled
care
Intensive
haemodynamic
A nurse
optimising
and
a university teaching hospital. 174 patients who had cardiac surgery Participants between April 2000 and January 2003. Interventions
-
interval
Conclusions
hospital.
Design Randomised Setting
Singer
care beds was reduced by 23% (- 8% to 59%).
after
patients
complications
a nurse
whether
protocol in
R Brady, Mervyn
11.4 days, a saving in hospital bed days of 18% (95%
Abstract
status
Anthony
artery
catheterisation)
invasive (oesophageal Doppler technologies
9
to
have
studies
perioperative
optimise
invasive
used or
minimally
flowmetry) monitoring
circulatory
variables,2
and
777/s is the abridged version of an article that was posted on bmj.com on 8 July 2004: http://bmj.com/cgi/doi/10.1136/ bmj.38156.767118.7C
258 BMJ VOLUME
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329
31 JULY 2004
bmj.com
Papers
have
shown
major and
complications Others,
have
however, our
To
outcomes.3
study has
status
reported
investigated cardiac
after
postoperative or hospital.
of
optimisation and
surgery,4
in median
in
improvement one randomised
only
knowledge,
a reduction
care
no
found
specifically
circulatory
in
improvements stay in intensive
this
duration of hospital
previously
a
that
reported
low
stroke
volume
nitrates
care
to intensive
after
cardiac
at four
and
surgery
hours
were the best prognostic factors for the development of subsequent complications.5 We therefore studied the optimisation of circulatory status in patients in the first hours,
to
them
randomising
treatment
receive
guided by oesophageal Doppler flowmetry to achieve a stroke volume index above 35 ml/m2. This trial differs in two the previous study major Firstly, respects.4 was monitored cardiac invasive output using rriinimally nurses the study conducted and, secondly, technology
from
a
using
driven
protocol
approach.
referral
standard
of
over
undergoing
surgery.We
excluded
on
surgery,
under
aged
postoperatively was excessive intra-aortic
bypass
cardiopulmonary
patients undergoing or with
18 years,
if on
admission
bleeding, balloon
unstable
off-pump
relative
to
contraindi
probe,
Doppler
were
Patients
disease.
oesophageal
also
excluded care
intensive
there
a need
arrhythmias, or
counterpulsation,
the aid of an online
with
care
and
and
protocol
was made.
for
delayed Both
an
integral
and
patients were patients unaware of the group
and
sent
a note
reasons,
logistical staff on
the
general intensive
after
was to
wards care
were
assignment
Statistical analysis Patients
were
on
randomised
at
arrival
care.
intensive
We calculated a sample size of 170 patients (85 in each in postoperative group), and tested for differences measurements
and
treatment
between
complications
Overall, 179 patients were recruited between April 2000 and January 2003 (see bmj.com). After exclu sions, there were 89 patients in the protocol group and in the control
85 for
were well matched group. The groups and Parsonnet cardiac risk score,
sex, weight,
age,
cardiac and
postoperative
*Study nurse to consult Intensive care unit consultant or specialist registrar x once three fluid challenges given ?
care
by the intensive as in most UK such
to the
of admission
hours
postoperatively,
care
intensive the
study
and
Doctors
nurses
not
involved
with
and
were
group a hours, Doppler of the endotracheal
ready
for
recording tube.
extubation
was
made
329
31 JULY 2004
or
I *Study nurse to consult intensive care unit TYes consultant or specialist before giving registrar adrenaline (epinephrine) ?
tomaximumI Adrenaline
t
I_Strokeindex>35ml/M2? |
