The use of activated protein C (drotrecogin alfa (activated)) in the treatment of severe sepsis

Advances in intensive care have allowed many critically ill patients to survive their initial insult. These patients may later demonstrate multiple organ dysfunction and failure, the genesis of which appears to be the body's reaction to critical illness, manifested by an imbalance and failure of inflammatory and immune system homeostasis. The manifestation of multiple organ dysfunction in the critically ill has been termed multiple organ dysfunction syndrome (MODS). MODS mortality is high and remains a leading cause of death in intensive care units (ICUs).

The understanding of the pathophysiology of severe sepsis and MODS has moved from a focus on inflammation to include an understanding of the associated anti-inflammatory responses. Loss of homeostasis can manifest as malignant inflammation or immune paralysis. Increased emphasis is emerging on the role of loss of immune homeostasis and disordered coagulation as a cause of organ injury and dysfunction. Treatment of severe sepsis is based upon aggressive resuscitation, source control and support for failing organs. Novel therapies directed at the modifying the inflammatory response have, up to now, not proven beneficial. However, a new agent, drotrecogin alfa (activated) has been shown, in a phase III randomised controlled trial, to be of benefit in the treatment of severe sepsis. This new agent affects both the inflammatory and coagulation dimensions of severe sepsis.

The developing concepts of the pathophysiology of sepsis and the emergence of a new therapy increases the complexity of the already complex demands of providing nursing care for the patient with severe sepsis and MODS. This article reviews pathophysiological processes in sepsis, reviews clinical data on activated protein C and illustrates the utility of this therapy in a case study.     

Exploring the precursors of outcome evaluation in Australia: Linking structure, process and outcome by peer review

Middleton S & Lumby J. International Journal of Nursing Practice 1998; 4: 151–155
Exploring the precursors of outcome evaluation in Australia: Linking structure, process and outcome by peer review
Reviews of the structure of the health system and the processes that contributed to them were the main forms of evaluation within nursing in Australia during the 1970s and 1980s. The documentation of the end result of care, or outcome evaluation, was rarely undertaken until more recent times. The development and implementation of formal assessment tools such as Qualpacs, the Phaneuf Nursing Audit, the Rush Medicus Nursing Process Methodology, Monitor, and Senior Monitor indicated the focus on structure and process evaluation. This paper examines how nursing care delivered to patients during the l970s and 1980s was evaluated, and explores why structure and process review were necessary precursors to outcome evaluation in the nineties. The necessity of linking structure and process analysis is discussed, in order to perform effective outcome evaluation to close the feedback loop between quality assessment and quality improvement. Peer review is one mechanism that can be used to achieve this. How this may also be a form of evidence-based practice which results in health gains for patients is also explored.     

In vitro evaluation of platelet concentrates, prepared from pooled buffy coats, stored for 8 days after filtration

BACKGROUND: Posttransfusion complications can be prevented by pretransfusion removal of donor white cells from platelet concentrate. The filtration used for this removal seems to have little effect on platelet function and activation, but more information is needed on its effect on function during subsequent long-term storage of concentrate. STUDY DESIGN AND METHODS: The effect of prestorage filtration of buffy coat-prepared platelet concentrates (PCs) on platelet function, metabolism, and activation was investigated. A pool of three PCs, each made of four buffy coats, was split into three equal volumes; two were filtered over two different filters and the third served as a control. Variables monitored immediately after filtration and during the subsequent 8-day storage period at 22 degrees C included aggregation upon stimulation with collagen and/or ADP, platelet adhesion capacity to collagen and fibrinogen in flowing blood, nucleotide content of and nucleobase release by the platelets, expression of activation-dependent antigens, and beta-thromboglobulin release by the platelets. RESULTS: No differences were observed between the PCs filtered over two different filters and the nonfiltered control PCs immediately after filtration and during storage, except for a selective removal (20%) of beta-thromboglobulin by one filter. CONCLUSION: PCs prepared from a pool of four buffy coats can be filtered and subsequently stored for 8 days (starting +/− 24 hours after whole blood collection) without detriment to platelet function, metabolism, or activation.     

A randomized trial on the efficacy of an autologous blood drainage and transfusion device in patients undergoing elective knee arthroplasty

The purpose of the study reported here was the determination of the efficacy of a postoperative autologous blood drainage and transfusion device in reducing allogeneic red cell requirements in patients undergoing elective knee arthroplasty. The study was a randomized controlled trial with adult patients undergoing unilateral elective arthroplastic knee surgery. Patients underwent suction drainage, attached to an autologous blood drainage and transfusion device, or standard suction drainage. Allogeneic red cells were given according to strict transfusion guidelines based on blood loss and postoperative hemoglobin values. Outcome measures included the mean number of allogeneic red cell concentrates required and the number of patients in each group who required no transfusion. Patients assigned to standard suction drainage had a mean allogeneic red cell utilization of 1.2 units (SD 1.0), as compared to a mean of 0.4 units (SD 0.8) in the group undergoing drainage with the autologous blood drainage and transfusion device (p = 0.0007). The percentage of patients not requiring allogeneic red cells was significantly higher in the latter group (74.3% vs. 32.5%; p = 0.002). The postoperative drainage and transfusion device was efficacious in reducing the amount of allogeneic red cells required by patients undergoing knee arthroplasty, and its use resulted in a 42 percent reduction in the number of patients requiring allogeneic transfusion.     

Nursing handovers: An integrative review of the different models and processes available

The aim of this study is to explore the different handover models and processes available and their efficacy in improving handover communication within nursing practice. The handover of information is a key nursing responsibility that ensures patient outcomes through continuity of care. This process is widely recognised as an opening for error that may comprise patient safety. This paper is an integrative literature review that employed an inductive exploratory design. A computerised database search was employed including CINAHL, PubMed and Science Direct and a manual citation search with included papers limited to papers published 2005–2016, in English with full text freely available. This included a systematic search strategy, a critical appraisal of the papers utilising the Critical Appraisal Skills Programme, an inductive data extraction and thematic analysis. Sixteen papers were included in this review. The results detailed that there are various handover models in use, yet there is no evidence that any one model displays superior efficacy. The iSoBAR model and its adaptations remain the only model employed across various specialties. More research is warranted to determine if any handover model displays superior efficacy or transferability.     

Family caregiving in dementia in Japan

Family caregivers were interviewed to describe their caregiving experience with their older relatives who were afflicted with Alzheimer's disease at home. Three elements were identified to contribute toward a caregiving career: (a) good prior relationships between caregivers and care recipients, (b) positive interpretations of the relative's condition, and (c) utilization of resources. Some caregivers were identified as high risk: husbands caring for their wives and daughters-in-law caring for their mothers-in-law. Specific interventions for these subgroup caregivers are in order.     

Seclusion and Restraint: What We Need to Know

Seclusion and restraint are controversial, restrictive interventions employed by psychiatric nurses in response to patient violence. While these interventions are used widely, relatively little is known about them. There is little support in the literature for the efficacy of seclusion and restraint. Although it seems impractical to suggest that seclusion and restraint be eliminated, many questions about these processes are unanswered. Nurses are in an ideal position to conduct studies related to patients' behavior and the use of seclusion and restraint. This article presents a review of the literature related to seclusion and restraint and suggests areas for future research.