Part 8: advanced challenges in resuscitation. Section 3: special challenges in ECC. 3D: anaphylaxis. European Resuscitation Council

The management of anaphylaxis includes early recognition, anticipation of deterioration, and aggressive support of airway, oxygenation, ventilation, and circulation. Prompt, aggressive therapy may be successful even if cardiac arrest develops.     

Clinical 3T MR imaging: mastering the challenges

3T MRI is ready to meet the needs of clinical practice. SAR limitations are minimized by technical advances and surface coils are available for all core applications. With appropriate adjustments to scanning protocols, one can master the challenges of scanning at 3T; studies of the brain, spine, chest, abdomen, pelvis, vasculature, and extremities can be consistently higher in quality than are those obtained at 1.5T. The superior studies that are obtainable at 3T have great appeal to clinicians who are sophisticated about MR technology in areas, such as neurology, orthopedics, vascular surgery, and oncology,and encourage a shift in referrals toward practices that invest in higher field technology. The greater sensitivity to magnetic susceptibility offers unique benefits in functional neuroimaging, and available software/hardware packages enhance clinical setting feasibility, which adds a source of new referrals. The greater overall signal of 3T can be manipulated to make scanning more comfortable and with less motion artifact because scan times could be half as long. Spectacular anatomic delineation that is provided by high-definition scanning at true 1024 resolution can improve preoperative assessment and may improve sensitivity to smaller lesions. 3T provides practices with an advantage that is sought increasingly by high field strength purchasers in a competitive market. Only cost considerations stand in the way of the eventual domination of 3T systems in the high field strength market.     

Suprapubic catheterization: challenges in changing catheters

Suprapubic catheterization of the bladder is used as a short- or long-term alternative to urethral catheterization. As with any indwelling urinary catheter, correct insertion, care and removal are vitally important to minimize problems. A particular problem that affects suprapubic catheters is 'cuffing', which on its own or combined with encrustation can potentially cause a great deal of difficulty on removal or discomfort for the patient. This article discusses the causes of cuffing, and suggests using catheters with integral balloons to reduce the incidence of the problem.     

New challenges in ageing: Home care

Most nations are undergoing two fundamental demographic changes: concentration of their population in cities and accelerated pace of population ageing. The fastest-growing population is that 85 years and over. Morbidity increases with advancing age, functional capacities decrease; this results in decreased performance of activities of daily liver and need for services. The challenge is particularly strong in urban areas. Modern societies seek solutions in maintaining the elderly in their homes through home care programmes for those who are functionally impaired, homebound, and need support in home-making and home nursing. Home care is firmly established in programmes for the elderly. In order to become a scientific discipline home care has to define its boundaries, identify clients by careful multidisciplinary assessment, provide answers regarding its cost-effectiveness, evaluate outcomes of home caring, develop indicators of high-quality care and advise appropriate home care technology, which is affordable and accessible. Home care for the elderly population living in remote rural areas is one of the future challenges.     

End-of-life challenges: honoring autonomy

Patients' end-of-life decisions challenge nurses to improve palliative care, symptom management, and patient advocacy, and examine ethical issues. When terminally ill patients take charge of the last stages of life, they may challenge nurses to reexamine attitudes about lifesaving technology and autonomy and values about preserving life. Staff members can become benevolent and believe that they know what is best despite the patient's independent decisions. When patients unsuccessfully decline continued aggressive, life prolonging strategies, they may decide to hasten dying rather than accept a natural death. Researchers (Breitbart WS et al. JAMA. 2000;284:2907-2911) defined desire for hastened death as a unifying construct underlying requests for assisted suicide, euthanasia, and withdrawal of food and fluids. When a terminally ill patient considers a hastened death, the nurse needs to examine the patient's mental health, symptom management, advance directives, and decision making. Medical and psychological symptoms and spiritual distress often trigger thoughts of hastening death even when pain and symptoms have been treated (Breitbart WS et al. JAMA. 2000;284:2907-2911). Ethical issues and guidelines for management of patients and evaluation of rationality are presented.     

Evaluating analgesia: the challenges

Decisions must be made when assigning analgesics, and such decisions involve comparing efficacy and adverse effects. The rules for assessing efficacy by systematic review and by large clinical trials are becoming clearer all the time. It is known, for instance, that trials that are not randomized, are not double-blind, or are too small will exaggerate efficacy. These rules are relatively easy to apply to drug interventions, although there are glaring exceptions, such as in early intra-articular morphine studies. The rules may also be less easy to apply for analgesics available over-the-counter (OTC) if the drugs have not been studied in trials of high quality or if the OTC-recommended doses are below the doses studied in the trials. When there are at least 500 patients studied in trials of high quality, credible efficacy estimates for effective drugs can be derived; more patients are needed for less effective drugs. The number needed to treat and the number needed to harm can be used to compare the efficacy and safety of a treatment with placebo or with other treatments. A recent meta-analysis comparing the number needed to treat for paracetamol 1000 mg and paracetamol 600-650 mg in moderate to severe postoperative pain indicated that paracetamol 1000 mg is likely to be more effective than lower doses. Large data sets allow investigation into dose response, gender differences, and whether particular drugs work better for particular painful conditions. Purists would argue that databases of patient experience should not be used for these efficacy analyses. The rules on how to collect and use evidence on adverse effects are less clearly formulated than they are for efficacy. For safety at or above therapeutic dose, the rules of evidence-gathering are necessarily different, and randomized trials are rarely an adequate or sufficient source. Databases of patient experience, with all the caveats, may be the most reliable data from which to work.     

Pancreatic cancer: Nursing challenges

Although pancreatic cancer is not a common tumor, the care of the person with pancreatic cancer is complex, particularly when the pancreas is resected. Nursing care can make a difference in a patient's recovery and in rehabilitation. There is a need for more documentation of the needs of this population both from clinicians who care tor persons with pancreatic cancer and from researchers. A particular need for research is in the area of preoperative cognitive and psychomotor assessment of patients undergoing resection, and their postoperative adjustment. Since this tumor is rare, such documentation could best be accomplished by multi-institutional collaboration.     

Hepatitis C: treatment challenges

Hepatitis C is a significant public health problem, yet transmission can be prevented and the disease is treatable. Nurses have a key role in delivering care.