Complete Issue Critical Nursing

F E B R U A R Y
2 0 1 5
V O L U M E
3 5
N U M B E R
CriticalCareNurse
T h e j o u r n a l f o r h i g h a c u i t y, p ro g re s s i v e , a n d c r i t i c a l c a re n u r s i n g
CNE
Stroke Volume
Optimization
Therapeutic
Hypothermia
CNE
Delirium
Exertional
Heat Stroke
CNE
ECMO for
Pediatric
Cardiac Arrest
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CriticalCareNurse
The journal for high acuity, progressive, and critical care nursing
Editor
JoAnn Grif Alspach, RN, MSN, EdD

Editorial Board
THOMAS AHRENS, RN, PhD, CCRN, CS

Clinical Specialist/Research Scientist, Nursing Department
Barnes-Jewish Hospital, St Louis, Missouri
BONNIE M. JENNINGS, RN, PhD, FAAN

Professor, Nell Hodgson Woodruff School of Nursing
Emory University, Atlanta, Georgia
SUSAN D. BELL, RN, MS, CNRN, CNP

Nurse Practitioner, Neurosurgery
Ohio State University Medical Center, Columbus, Ohio
SUSAN G. TREVITHICK, RN, MS, CNA

Clinical Support Manager, Specialty Care Center
Salt Lake City Veterans Administration Medical Center, Utah
SUZETTE CARDIN, RN, DNSc, CNAA

Adjunct Assistant Professor, Graduate Nursing Administration
Program UCLA School of Nursing, Los Angeles, California
GLENNA TRAIGER, RN, MSN, CCRN

Clinical Nurse Specialist, Pulmonary Arterial Hypertension
Program Greater LA VA Medical Center, Los Angeles, California
Contributing Editors
Advanced Practice
ANDREA M. KLINE-TILFORD, CPNP-AC/PC, CCRN, FCCM
Bariatric Care
BRENDA K. HIXON VERMILLION, RN, DNP, ACNS-BC,
ANP-BC, CCRN
Basic and Advanced Life Support

PRISCILLA K. GAZARIAN, RN, PhD
Cardiovascular Surgery
KRISTINE CHAISSON, RN, BSN, MS, CCRN
Certification Test Prep
CAROL RAUEN
Cochrane Review Summary
DAPHNE STANNARD, RN, PhD, CCRN, CCNS
Complementary Therapies
DEBRA KRAMLICH, RN, MSN, CCRN
Critical Care Apps
CLAIRE CURRAN, RN, MSN, CCRN
Cultural Diversity
MAJELLA S. VENTURANZA, RN, MA, CCRN
ECGs and Pacemakers
JANE N. MILLER, RN, DNP, CCRN, CCNS
Emergency Department
DOROTHY DUNCAN, RN, DNP, ACNP-BC, CCRN, CEN
End-of-Life Care
KATHLEEN OUIMET PERRIN, RN, PhD, CCRN
Evidence-Based Practice
MARCIA BELCHER, RN, MSN, BBA, CCRN-CSC, CCNS
Family-Centered Care
PATRICIA BROWN, DNP, APN, CNS, CCRN
Gastrointestinal Disorders
ROSEMARY K. LEE, DNP, ARNP, ACNP-BC, CCNS, CCRN
Geriatric Care
SONYA R.HARDIN, RN, PhD, CCRN, ACNS-BC, NP-C
Healthy Work Environments
VIRGINIA C. HALL, BSN, CCRN
Heart Failure
KAREN L. COOPER, RN, MSN, CCRN, CNS
Management/Administration
MARIA CHRISTABELLE CASTRO, RN, MSHA, CCRN, NE-BC
Military Critical Care Nursing: Air Force
BENJAMIN SCHULTZE, RN, ACNP-BC, MEd, MSN
Military Critical Care Nursing: Army
LINDA A. VALDIRI, COL, ANC, USA, RN, MS, CCNS
Military Critical Care Nursing: Navy
CARL GOFORTH, RN, MSN, CCRN
Neonatal Care
RACHEL A. JOSEPH, PhD, CCRN
Neurology/Neurosurgery
GLENN CARLSON, MSN, ACNP-BC, CCRN
Nutrition
COLLEEN OLEARY-KELLEY, RN, PhD, CNE
Pain Management
DIANE GLOWACKI, RN, MSN, CNS, CNRN-CMC
Patient Education and Discharge Planning
FLORENCE M. SIMMONS, RN, MSN, CCRN
Patient Safety
ELIZABETH MATTOX, RN, MSN, ARNP
Patient Transport
MELISSA RACH, RN, BSN, CCRN, CMC
Pediatric Care
JODI E. MULLEN, RN-BC, MS, CCRN, CCNS
Pharmacology
KELLY THOMPSON-BRAZILL, RN, MSN, ACNP, CCRN-CSC, FCCM
Postanesthesia Recovery
TITO D. TUBOG, RN-BC, CRNA, APRN, CCRN-CSC-CMC, CEN
Precepting
LIZ ROGAN, RN, EdD-c, CNE
Progressive Care
MARGARET M. ECKLUND, RN, MS, CCRN, ACNP-BC
Pulmonary Care
DEBRA SIELA, RN, PhD, ACNS-BC, CCNS, CCRN, CNE, RRT
Quality Improvement Reports
JULIE M. STAUSMIRE, RN, MSN, ACNS-BC
Rural Settings
CHARLENE A. WINTERS, PhD, APRN, ACNS-BC
Simulation
KATE MOORE, RN, DNP, CCRN, CEN, AGACNP-BC, AGPCNP-BC
Staff Development
LESLIE SWADENER-CULPEPPER, APRN-CNS, MSN,
CCRN, CCNS
Tele-ICU
PAT JUAREZ, APN, CCRN, CCNS
Toxicology
DANA BARTLETT, RN, MSN, MA, CSPI
Trauma
MICHAEL W. DAY, RN, MSN, CCRN
Editorial Office
President
President-elect
Secretary
Treasurer
Directors
Chief Executive Officer
TERI LYNN KISS, RN, MS, MSSW, CNML, CMSRN

KAREN MCQUILLAN, RN, MS, CNS-BC, CCRN, CNRN, FAAN
LISA RIGGS, RN, MSN, ACNS-BC, CCRN
CHRISTINE S. SCHULMAN, RN, MS, CNS, CCRN
LINDA M. BAY, RN, MSN, ACNS-BC, CCRN, PCCN
MEGAN BRUNSON, RN, MSN, CNL, CCRN-CSC
NANCY FREELAND, RN, MSN, CCRN
KAREN L. JOHNSON, RN, PhD
DEBORAH KLEIN, RN, MSN, ACNS-BC, CCRN, CHFN, FAHA
PAULA S. MCCAULEY, DNP, APRN, ACNP-BC, CNE
RIZA V. MAURICIO, RN, PhD, CCRN, CPNP-PC/AC
KATHLEEN K. PEAVY, RN, MS, CCRN, CNS-BC
MARY ZELLINGER, RN, MN, ANP, CCRN-CSC, CCNS
DANA WOODS
American Association of Critical-Care Nurses

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Vol 35, No. 1, FEBRUARY 2015
CriticalCareNurse
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CNE
Stroke Volume
Optimization:
The New Hemodynamic
Algorithm
Alexander Johnson and Thomas Ahrens
Page 11
OnlineNOW
Abstracts of articles available exclusively

online at www.ccnonline.org
Page 10
Methods Used by Critical Care

Nurses to Verify Feeding Tube
Placement in Clinical Practice
Annette M. Bourgault, Janie Heath, Vallire Hooper,
Mary Lou Sole, and Elizabeth G. NeSmith
Page e1
Cover illustration by Kimberly Martens
CRITICAL CARE NURSE (ISSN 0279-5442, eISSN 1940-8250) is published bimonthly (February, April, June, August, October, December) by the
American Association of Critical-Care Nurses (AACN), 101 Columbia, Aliso Viejo, CA 92656. Telephone: (949) 362-2000. Fax: (949) 362-2049.
E-mail: ccn@aacn.org. Copyright 2015 by AACN. All rights reserved. CRITICAL CARE NURSE is an official publication of AACN. No part of this
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CCN FAST FACTS

Use of a Nursing Checklist to Facilitate
Implementation of Therapeutic
Hypothermia After Cardiac Arrest
Page 38
Nonpharmacological Interventions to
Prevent Delirium: An Evidence-Based
Systematic Review
Page 50
The name and title CRITICAL CARE NURSE are protected through a trademark registration in the US Patent Office. CRITICAL CARE NURSE is indexed in Cumulative Index to Nursing & Allied Health Literature (CINAHL), Medline, and RNdex Top 100 and is a participant in the UMI Article Clearinghouse and
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FEATURES
Use of a Nursing Checklist to
Facilitate Implementation of
Therapeutic Hypothermia After
Cardiac Arrest
COLUMNS
MILITARY CRITICAL CARE
NURSING: NAVY
Exertional Heat Stroke in Navy and
Marine Personnel: A Hot Topic
Carl W. Goforth and Josh B. Kazman
Page
52
Kathleen Ryan Avery, Molly OBrien, Carol Daddio Pierce,

and Priscilla K. Gazarian
CNE
Page 29
PEDIATRIC CARE
Extracorporeal Membrane Oxygenation
for Pediatric Cardiac Arrest
Jennie Ryan
Page
60
CNE
Nonpharmacological Interventions
to Prevent Delirium: An EvidenceBased Systematic Review
Ryan M. Rivosecchi, Pamela L. Smithburger, Susan Svec,
Shauna Campbell, and Sandra L. Kane-Gill
Page 39
DEPARTMENTS
EDITORIAL
Improving Cardiac Arrest Resuscitation
Outcomes: A Valentine Worth Sending
Aortic cannula
JoAnn Grif Alspach, Editor

Page
vena c
Carol Rauen, Kirtley Ceballos, and Steve Risch

Page
71
ASK THE EXPERTS
Aorta
ava
CERTIFICATION TEST PREP

Celebrate and Be Proud!
Constant
mean
erior
Sup
Overestimated
systole
Normal
systole
Venous cannula
Left
atrium
Normal
diastole
Right
atrium
Right
ventricle
Page 60
Left
ventricle
Comparing normal
with underdamped
Page 75
Underestimated
diastole
Page 89
ALSO IN THIS ISSUE
Comparing Blood Pressure Measures:

Does One Measurement Equal Another?
Contributors
Barbara McLean
Page
Corrections
75
Page 5
Page 9
Book Reviews
IN OUR UNIT
Page 89
Implementation of Early Exercise and

Progressive Mobility: Steps to Success
Education Directory
Melody R. Campbell, Julie Fisher,

Lyndsey Anderson, and Erin Kreppel
Page
I Am a Critical Care Nurse
82
CriticalCareNurse
Page 91
Page 92
www.ccnonline.org
Contributors
oauthor of Stroke Volume

Optimization, Thomas Ahrens
is a research scientist, BarnesJewish Hospital, St Louis, Missouri.
Kathleen Ryan Avery, coauthor of
Implementation of Therapeutic
Hypothermia After Cardiac Arrest, is
the clinical educator for the cardiac ICU
at Brigham and Womens Hospital,
Boston, Massachusetts.
Coauthor of Methods Used to Verify
Feeding Tube Placement, Annette M.
Bourgault is an assistant professor at
Georgia Regents University, College of
Nursing, in Augusta.
Shauna Campbell, coauthor of Nonpharmacological Interventions to Prevent
Delirium, is the nursing director of the
medical ICU at the University of Pittsburgh
Medical Center, Presbyterian Hospital.
Priscilla K. Gazarian, coauthor of
Implementation of Therapeutic Hypothermia After Cardiac Arrest, is the nursing
program director for resuscitative clinical
practice at Brigham and Womens Hospital.
Coauthor of Exertional Heat Stroke in
Navy and Marine Personnel, Carl Goforth
is the clinical subject matter expert for the
Marine Corps Combat Development
Command located in Quantico, Virginia.
Janie Heath, coauthor of Methods to
Verify Feeding Tube Placement, is dean of
the College of Nursing at University of
Kentucky in Lexington.
Coauthor of Methods Used to Verify
Feeding Tube Placement, Vallire Hooper
is the manager of nursing research at Mission Hospital in Asheville, North Carolina.
Coauthor of Stroke Volume Optimization, Alexander Johnson is a clinical nurse
specialist, Central DuPage HospitalNorthwestern Medicine, Winfield, Illinois.
Sandra L. Kane-Gill, coauthor of Nonpharmacological Interventions to Prevent
Delirium, is an associate professor of
www.ccnonline.org
AHRENS
AVERY
BOURGAULT
GAZARIAN
GOFORTH
HEATH
HOOPER
JOHNSON
KANE-GILL
pharmacy and therapeutics at the University of

Pittsburgh School of Pharmacy.
Coauthor of Exertional Heat Stroke in Navy
KAZMAN
and Marine Personnel, Josh Kazman is a
research associate with the Consortium for
Health and Military Performance at Uniformed
Services University of the Health Sciences.
Elizabeth G. NeSmith, coauthor of Methods
NeSMITH
Used to Verify Feeding Tube Placement, is an
associate professor and chair of the Department of Physiological and Technological
Nursing at Georgia Regents University, College
of Nursing, in Augusta.
Molly OBrien, coauthor of Implementation
PIERCE
of Therapeutic Hypothermia After Cardiac
Arrest, is the research coordinator in the cardiac ICU at Shapiro Cardiovascular Center at
Brigham and Womens Hospital.
Coauthor of Use of a Nursing Checklist to
RIVOSECCHI
Facilitate Implementation of Therapeutic
Hypothermia After Cardiac Arrest, Carol
Daddio Pierce is the clinical educator in the
medical ICU at Brigham and Womens Hospital.
Ryan M. Rivosecchi, coauthor of NonpharRYAN
macological Interventions to Prevent Delirium,
is a pharmacy resident in critical care at the
University of Pittsburgh Medical Center, Presbyterian Hospital.
Author of Extracorporeal Membrane OxygenaSMITHBURGER
tion for Pediatric Cardiac Arrest, Jennie Ryan
in a nurse practitioner in the ICU at Nemours
Cardiac Center, Wilmington, Delaware.
Coauthor of Nonpharmacological Interventions to Prevent Delirium, Pamela L.
SOLE
Smithburger is an assistant professor of
pharmacy and therapeutics, University of
Pittsburgh School of Pharmacy.
Mary Lou Sole, coauthor of Methods Used to
Verify Feeding Tube Placement, is the Orlando
SVEC
Health Distinguished Professor at University of
Central Florida, College of Nursing.
Coauthor of Nonpharmacological Interventions to
Prevent Delirium, Susan Svec is the clinical director of
the medical ICU, University of Pittsburgh Medical Center, Presbyterian Hospital. CCN
CriticalCareNurse
Editorial
Improving Cardiac Arrest Resuscitation
Outcomes: A Valentine Worth Sending
JoAnn Grif Alspach
Survival Rates Remain Disheartening

Each year nearly 568 500 sudden cardiac
arrests occur in the United States. Of these,
approximately 359400 (63%) are out-of-hospital
cardiac arrests (OHCAs) and 209 000 (37%)
are in-hospital cardiac arrests.1 Of the nearly
360 000 cardiac arrests that happen outside
hospitals, 88% occur in the home.3 If effective
cardiopulmonary resuscitation (CPR) can be
delivered immediately after cardiac arrest, the
victims probability of survival is doubled or
tripled.3 However, despite decades of research,
the instruction of millions of laypersons and
professional heath care providers, countless
public service announcements, and national
programs provided by organizations such as the
AHA and American Red Cross, only 32%3 to 40%
of OHCAs are responded to with bystander CPR.1
Among all OHCA victims, only 8%3 to 9.5%
Definition of Cardiac Arrest
survive to hospital discharge.4
Cardiac arrest is defined as the abrupt loss
A few distinctions between out-of-hospital
of cardiac function in someone who may or
and in-hospital patient populations are worth
may not have a diagnosis of heart disease. It
noting. An OHCA can be defined as cessation
arises instantaneously, often without preceding of cardiac mechanical activity that occurs outsymptoms,2 making it virtually impossible to
side of the hospital setting and is confirmed by
anticipate and challenging to correctly recogthe absence of signs of circulation.5 Although
nize, manage, and reverse before irreversible
it may develop from a variety of noncardiac
and fatal consequences ensue. Although it
etiologies such as trauma or drug overdose, a
may arise from a number of distinct etiologies, substantial majority of OHCAs is attributable
most cases of cardiac arrest are associated with to cardiac causes.5
development of a cardiac arrhythmia, typically
An in-hospital cardiac arrest occurs in a
ventricular fibrillation.1
hospital and typically includes resuscitation
efforts such as defibrillation, chest compressions,
2015 American Association of Critical-Care Nurses
or both.6 As admission to a hospital becomes
doi: http://dx.doi.org/10.4037/ccn2015167
n the United States, February 14 is Valentines
Day, when expressions of love are sent to
those we care about most. The American
Heart Associations (AHAs) designation of
February as American Heart Month reminds
us that we could extend those sentiments
beyond a single day by demonstrating how to
protect our loved ones from cardiac disease,
still ranked as the nations number 1 cause of
death.1 In recognition of the burden that heart
disease represents in our patient populations,
this issue of Critical Care Nurse is devoted to
the topic of cardiac arrest, a challenging condition that teeters its victims between life and
death. One of the particularly vexing and longstanding attributes of this disorder is our limited success in prevailing against its potentially
ominous outcomes.
CriticalCareNurse
www.ccnonline.org
more selective based on need for services, in-hospital

patients who experience cardiac arrest are likely to be
sicker and have more clinically significant comorbidities
compared to their neighbors living at home. As a result,
despite the greater availability of health care professionals to provide CPR, in-patient cardiac arrest victims may
have more clinically advanced systemic disorders that
could limit their ability to benefit from CPR.
During the 1990s, reports of survival to discharge
rates following in-hospital cardiac arrest and CPR ranged
from 7% to 26%.7,8 In the United States, the most recent
in-hospital cardiac arrest statistics from the Resuscitation
Outcomes Consortium Cardiac Epistry and Get With The
Guidelines-Resuscitation data show an overall survival rate
to hospital discharge for adult victims of cardiac arrest of
23.9%.4 For patients in the United Kingdom, the
National Cardiac Arrest Audit found an overall survival
to hospital discharge rate of 18.4%.9 As in the United
States, higher rates of survival to hospital discharge are
found in patients with shockable rhythms (ventricular
fibrillation or pulseless ventricular tachycardia) compared
to those with nonshockable rhythms (asystole or pulseless electrical activity).9
For patients over 70 years, the chance of survival to
hospital discharge following in-hospital CPR ranges at a
lower plateau between 11.6% and 18.7%, with declining
survival associated with increasing age.10 Although some
improvements in cardiac arrest survival can be noted,
the body of research in this area suggests that significant
improvements have not yet been realized. Until those
advances can be identified to influence clinical practice,
critical care nurses might consider making their contributions by pursuing alternative efforts that represent potential inroads toward improving cardiac arrest outcomes.
Critical Care Nurses Can Contribute to

Improved Outcomes
Recent research suggests that 2 of the inroads that
may lead to better cardiac arrest resuscitation outcomes
include doing more and doing less than we are currently
doing in managing this condition.
Doing More
The Doing More strategy recognizes that 92% of the
360 000 Americans who suffer an OHCA each year will
die, that a majority of those deaths might have been
www.ccnonline.org
avoided if timely and effective interventions known

to improve survival from cardiac arrest had been
provided, and that one of those timely and effective
interventions is provision of bystander CPR. As a recent
AHA Science Advisory explained,11 OHCA survival
rates have increased in communities where bystander
CPR participation was expanded. These are especially
important initiatives in poor, nonEnglish-speaking,
Black, and Latino neighborhoods, where few know
how to provide bystander CPR. Instructional and
recruitment programs to inform, involve, and teach
CPR to residents of these neighborhoods could launch
lifesaving efforts with immediate impact.
Doing Less
As in many aspects of life, doing less at times yields
more. Two approaches to doing less with resuscitation
for cardiac arrest suggested by recent literature include
focusing on immediate and effective provision of Basic
Life Support (BLS) rather than delaying or interrupting that to provide Advanced Life Support (ALS) and
teaching laypersons to perform chest compressions-only
CPR rather than standard CPR that includes intermittent breaths.
An intriguing study reported by Sanghavi and
colleagues12 at Harvard University used a nationally
representative sample of Medicare beneficiaries from
nonrural areas of the United States that included 1643
patients managed with BLS and 31 292 managed with
ALS. The researchers concluded that OHCA patients
had higher survival at discharge (BLS 13.1% vs ALS
9.2%, 95% CI, 2.3-5.7), higher survival at 90 days (BLS
8.0% vs 5.4% for ALS; 95% CI, 1.2-4.0), and lower rates
of poor neurological functioning (BLS 21.8% vs ALS
44.8%; 95% CI, 18.6-27.4) when they received only BLS
rather than ALS from emergency medical services.
These results need to be interpreted with caution (the
ALS was provided by emergency medical services staff
rather than hospital physicians or nurses, the timing
of initiation of either form of resuscitation is not
included in data, data rely on billing record rather than
clinical documentation of measures provided, and ALS
is usually preceded by BLS, so it is not clear how those
influences were distinguished to capture measurement
of ALS alone, some patients require the medications,
equipment, and therapies reserved for ALS) to ensure
CriticalCareNurse
that the methodology and analysis are sufficiently vetted

and not found wanting. Despite that customary admonition, the results are thought-provoking and worthy
of further consideration and repeat testing.
A second avenue of Doing Less involves the use of
compression-only CPR in place of traditional CPR
procedures that include intermittent use of mouth-tomouth breaths. Since the AHA updated its CPR guidelines in 2005 to recommend use of chest-compression
CPR by untrained rescuers as well as in dispatcherassisted CPR in an effort to expand the quality and
provision of bystander CPR, a number of reports13,14
have heralded support for compression-only CPR
(hands-only) as an effective form of CPR with survival
outcomes comparable to those of conventional CPR.
Additional studies15 have noted better neurological
outcomes at 1 month with hands-only CPR compared
to conventional CPR when hands-only CPR is combined with public-access automated external defibrillators. More recently, a meta-analysis of studies
including more than 92000 adult patients with OHCAs
further supported the efficacy of hands-only CPR in
producing survival rates comparable to those achieved
with conventional CPR for patients whose arrest was
of cardiac etiology.16
Because nearly 90% of cardiac arrests occur within
the home, most of us will encounter victims who are
family members, close friends, or neighbors, as stated
by the AHA mantra: The life you save with CPR is
mostly likely to be someone you love.3 For those of us
already thoroughly trained and certified to provide
lifesaving resuscitation, our ability to respond to that
emergency is automatic, immediate, and competent.
In addition, critical care nurses could join with colleagues
in home health, school and community health, and
numerous other surrounding organizations to instruct
and empower residents in our neighborhoods, schools,
communities, places of worship or recreation, towns
or cities to serve their own loved ones as bystander-CPR
providers. Sending them a text, e-mail, tweet, card, or
brochure that reads If you love someone, learn how
to save their life and invites them to see the brief video
of how easily and quickly they can learn hands-only
CPR17 can represent the best valentines gift they ever
received. Critical care nurses can do that. We know
you can.
CriticalCareNurse
Join the Conversation

If you can suggest other strategies for improving
patient outcomes following cardiac arrest, please send
them to us at ccn@aacn.org so Critical Care Nurse can
share these with our readers. CCN
JoAnn Grif Alspach, RN, MSN, EdD

Editor, Critical Care Nurse
References
1. Go AS, Mozaffarian D, Roger VL, et al; for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Executive
summary: heart disease and stroke statistics2014 update: a report
from the American Heart Association. Circulation. 2014;129:399-410.
2. American Heart Association. Cardiac Arrest. http://www.heart.org
/HEARTORG/Conditions/More/CardiacArrest/About-CardiacArrest_UCM_307905_Article.jsp. Accessed December 2, 2014.
3. American Heart Association. CPR Statistics. Last updated September 3,
2014. http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR
/CPRFactsandStats/CPR-Statistics_UCM_307542_Article.jsp. Accessed
December 2, 2014.
4. American Heart Association. Cardiac Arrest Statistics. Last updated September 11, 2014. http://www.heart.org/HEARTORG/General/Cardiac
-Arrest-Statistics_UCM_448311_Article.jsp. Accessed December 2, 2014.
5. McNally B, Robb R, Mehta M, et al; Centers for Disease Control and
Prevention. Out-of-hospital cardiac arrest surveillanceCardiac Arrest
Registry to Enhance Survival (CARES), United States, October 1, 2005December 31, 2010. MMWR Surveill Summ. 2011;60(8):1-19.
6. Morrison LJ, Neumar RW, Zimmerman JL, et al; for the American Heart
Association Emergency Cardiovascular Care Committee, Council on
Cardiopulmonary, Critical Care, Perioperative and Resuscitation,
Council on Cardiovascular Nursing, Council on Clinical Cardiology,
and Council on Peripheral Vascular Disease. Strategies for improving
survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American
Heart Association. Circulation. 2013;127:1538-1563.
7. Ebell MH, Becker LA, Barry HC, et al. Survival after in-hospital cardiopulmonary resuscitation: a meta-analysis. J Gen Intern Med. 1998;13:805-816.
8. Tresch D, Heudebert G, Kutty K, et al. Cardiopulmonary resuscitation
in elderly patients hospitalized in the 1990s: a favorable outcome. J Am
Geriatr Soc. 1994;42:137-141.
9. Nolan JP, Soar J, Smith GB, et al. National Cardiac Arrest Audit. Incidence
and outcome of in-hospital cardiac arrest in the United Kingdom National
Cardiac Arrest Audit. Resuscitation. 2014;85(8):987-992.
10. van Gijn MS, Frijns D, van de Glind EM, C van Munster B, Hamaker
ME. The chance of survival and the functional outcome after in-hospital
cardiopulmonary resuscitation in older people: a systematic review. Age
Ageing. 2014;43(4):456-463.
11. Sasson C, Meischke H, Abella BS, et al; for the American Heart Association Council on Quality of Care and Outcomes Research, Emergency
Cardiovascular Care Committee, Council on Cardiopulmonary, Critical
Care, Perioperative and Resuscitation, Council on Clinical Cardiology,
and Council on Cardiovascular Surgery and Anesthesia. Increasing cardiopulmonary resuscitation provision in communities with low
bystander cardiopulmonary resuscitation rates: a science advisory from
the American Heart Association for healthcare providers, policymakers,
public health departments, and community leaders. Circulation.
2013;127:1342-1350.
12. Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after outof-hospital cardiac arrest treated by basic vs advanced life support. JAMA
Intern Med. In press. http://archinte.jamanetwork.com /journal.aspx.
Accessed December 2, 2014.
13. Bohm K, Rosenqvist M, Herlitz J, Hollenberg J, Svensson L. Survival
is similar after standard treatment and chest compression only in
out-of-hospital bystander cardiopulmonary resuscitation. Circulation.
2007;116(25):2908-2912.
www.ccnonline.org
14. Iwami T, Kawamura T, Hiraide A, et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac
arrest. Circulation. 2007;116(25):2900-2907.
15. Iwami T, Kitamura T, Kawamura T, et al. Chest-compression-only cardiopulmonary resuscitation for out-of-hospital cardiac arrest with
public-access defibrillation. Circulation 2012;126:2844-2851. http://
circ.ahajournals.org/content/126/24/2844.full?sid=f1d8c729-f6cc-4041
-8d91-817fde1c97a0. Accessed December 2, 2014.
16. Yao L, Wang P, Zhou L, et al. Compression-only cardiopulmonary resuscitation vs standard cardiopulmonary resuscitation: an updated metaanalysis of observational studies. Am J Emerg Med. 2014;32(6):517-523.
17. American Heart Association. Two Steps to Staying Alive With HandsOnly CPR. http://www.heart.org/HEARTORG/CPRAndECC
/HandsOnlyCPR/Hands-Only-CPR_UCM_440559_SubHomePage.jsp.
Accessed December 2, 2014.
Corrections
In the December article by Chaisson
et al, Improving Patients Readiness for
Coronary Artery Bypass Graft Surgery
(Crit Care Nurse. 2014;34[6]:29-38),
the e-mail address listed for the corresponding author (Kristine Chaisson)
was invalid. The correct e-mail is
krischaisson@gmail.com.
2015 American Association of Critical-Care Nurses doi:
http://dx.doi.org/10.4037/ccn2015359
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OnlineNOW
Critical Care Nurse offers an online publication process that provides current, relevant and useful information about the bedside
care of critically and acutely ill patients in the most timely and efficient manner possible. The abstracts below represent full-text
articles available exclusively on the Critical Care Nurse website, www.ccnonline.org. These OnlineNOW articles are fully peer
reviewed, edited, formatted, and citable. Reprints of the full-text articles are available by calling (800) 899-1712 or (949) 362-2050
(ext 532) or by e-mailing reprints@aacn.org.
Methods Used by Critical Care Nurese to Verify Feeding

Tube Placement in Clinical Practice
ANNETTE M. BOURGAULT, RN, PhD, CNL
JANIE HEATH, PhD, APRN-BC
VALLIRE HOOPER, RN, PhD, CPAN
MARY LOU SOLE, RN, PhD, CCNS
ELIZABETH G. NeSMITH, PhD, APRN-BC
BACKGROUND The American Association of Critical-Care Nurses practice alert on verification of feeding tube placement makes
evidence-based practice recommendations to guide nursing management of adult patients with blindly inserted feeding tubes.
Many bedside verification methods do not allow detection of improper positioning of a feeding tube within the gastrointestinal
tract, thereby increasing aspiration risk.
OBJECTIVES To determine how the expected practices from the American Association of Critical-Care Nurses practice alert were
implemented by critical care nurses.
METHODS This study was part of a larger national, online survey that was completed by 370 critical care nurses. Descriptive
statistics were used to analyze the data.
RESULTS Seventy-eight percent of nurses used a variety of methods to verify initial placement of feeding tubes, although 14% were
unaware that tube position should be confirmed every 4 hours. Despite the inaccuracy of auscultation methods, only 12% of
nurses avoided this practice all of the time.
CONCLUSIONS Implementation of expected clinical practices from this guideline varied. Nurses are encouraged to implement
expected practices from this evidence-based, peer reviewed practice alert to minimize risk for patient harm. (Critical Care Nurse.
2015;35[1]:e1-e7)
Do you have a QR scanner app on your

iPhone or Android? Scan this QR code with
your phone to access this article instantly.
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Cover
Stroke Volume
Optimization: The New
Hemodynamic Algorithm
ALEXANDER JOHNSON, RN, MSN, ACNP-BC, CCNS, CCRN
THOMAS AHRENS, RN, PhD
Critical care practices have evolved to rely more on physical assessments for monitoring cardiac output
and evaluating fluid volume status because these assessments are less invasive and more convenient to
use than is a pulmonary artery catheter. Despite this trend, level of consciousness, central venous pressure,
urine output, heart rate, and blood pressure remain assessments that are slow to be changed, potentially
misleading, and often manifested as late indications of decreased cardiac output. The hemodynamic
optimization strategy called stroke volume optimization might provide a proactive guide for clinicians to
optimize a patients status before late indications of a worsening condition occur. The evidence supporting
use of the stroke volume optimization algorithm to treat hypovolemia is increasing. Many of the cardiac
output monitor technologies today measure stroke volume, as well as the parameters that comprise stroke
volume: preload, afterload, and contractility. (Critical Care Nurse. 2015;35[1]:11-28)
urses commonly experience scenarios where hemodynamic monitoring is focused

on hypovolemia (see case study) in clinical practice. In this article, we provide
an overview of the use of stroke volume (the amount of blood ejected from the left
ventricle with each beat) for hemodynamic management of critically ill patients.
We also discuss the limitations of conventional assessment parameters, methods
of measuring stroke volume, hemodynamic variables that influence stroke volume, the stroke volume
optimization (SVO) replacement algorithm, supporting literature, and nursing considerations.
Much of the supporting literature (mostly studies in perioperative patients) on stroke volume as a
primary hemodynamic monitoring parameter focuses on the treatment of hypovolemia, as in the case
CNE Continuing Nursing Education

This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article,
which tests your knowledge of the following objectives:
1. Discuss the use of stroke volume optimization in a hypovolemic patient
2. Define corrected flow time, peak velocity, stroke distance, and stroke index
3. State various methods used to obtain blood flow measurement
2015 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2015427
www.ccnonline.org
CriticalCareNurse
11
CASE STUDY
Importance of Occult Hypovolemia
critical care nurse cares for a patient who had

a 3-vessel coronary artery bypass graft approximately 30 minutes earlier. No indications of
bleeding are present, and both cardiac output and urine
output are within the reference limits. However, the
patients systolic arterial blood pressure has decreased
to 77 mm Hg 3 times in the past 20 minutes. Because
the decrease seems to respond to fluid administration,
the nurse begins administering a fourth bottle of 5%
albumin via the rapid infuser in accordance with the surgeons standing orders. Even though the patients central
venous pressure has remained at 3-4 mm Hg since the
patient arrived from surgery, the nurse notes that the
stroke volume has remained between 75 and 80 mL
since the second bottle of albumin. On the basis of the
patients hemodynamic profile and this recent
sequence of events, the nurse calls the surgeon to inquire
about an order to administer a vasoactive agent. In
this case, decreased stroke volume response to fluid
suggests adequate volume expansion even though low
central venous pressure values suggest hypovolemia.
study. In the following section, we review the clinical

importance of hypovolemia that may go undetected
(occult hypovolemia) when conventional assessment
techniques are used.
Table 1
To illustrate the nature of subclinical or occult

hypovolemia and to test the sensitivity of gastrointestinal
tonometry for detecting such hypovolemia, HamiltonDavies et al1 conducted a study on 6 healthy volunteers
in the critical care unit at University College of London
Hospitals, London, England. Each of the volunteers had
a mean of 25% (21%-31%) of their overall blood volume
removed during a 1-hour period, and the volunteers
response was measured. Variables such as heart rate,
blood pressure, serum levels of lactate, and stroke volume
were measured every 30 minutes throughout the study.
After 90 minutes, decreases in gut intramucosal pH were
observed, as well as marked decreases in stroke volume,
by a mean of 16.5 mL (P < .01). Despite this compromised
flow, no clinically significant or consistent postinterventional changes were noted in serum levels of lactate,
arterial blood pressure, heart rate, or arterial blood gases
according to serial measurements obtained throughout
the study period. Retransfusion was started after 90 minutes. The results of this study1 may provide insight into
the reliability of routinely used measurements such as
heart rate and systolic blood pressure as volume depletion progressed in these volunteers.
Hypovolemia (defined as inadequate left ventricular
filling volumes)2 affects the cardiovascular system in a
characteristic sequence of events as the hypovolemia
worsens3-6 (Table 1). First, stroke volume decreases
Classes of shock by Advanced Trauma Life Support (ATLS) designationa
Class 1
Class 2
Class 3
Class 4
Blood loss, %
< 15%
15%-30%
30%-40%
> 40%
Heart rate, beats per minute
< 100
> 100
> 120
> 140
Normal
Normal
Decreased
Decreased
Normal or increased
Decreased
Decreased
Decreased
14-20
20-30
30-40
> 35
Slightly anxious
Mildly anxious
Anxious, confused
Confused, lethargic
Blood pressure, mm Hg
Pulse pressure
Respiratory rate, breaths per minute
Mental status
a Reprinted
from American College of Surgeons,5 with permission.
Authors
Alexander Johnson is a clinical nurse specialist, Central DuPage Hospital, Cadence Health SystemNorthwestern Medicine, Winfield, Illinois.
Thomas Ahrens is a research scientist, Barnes-Jewish Hospital, St Louis, Missouri.
Corresponding author: Alexander Johnson, 4007 Schillinger Dr, Naperville, IL 60564 (e-mail: apjccrn@hotmail.com).
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or
(949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
12
CriticalCareNurse
www.ccnonline.org
because of decreased overall circulating volume (class 1).

Next, heart rate increases and vasoconstriction occurs to
maintain blood pressure and cardiac output (the volume
of blood pumped by the heart per minute)7 (class 2). A
surge of endogenous catecholamines helps shunt blood
from the periphery and splanchnic circulation to the brain
and great vessels to preserve vital organs. Once compensatory mechanisms are exhausted, cellular respiration
begins to change from aerobic metabolism to anaerobic
metabolism, and tissue oxygenation is threatened. Oxygen extraction rates increase, and mixed venous oxygen
saturation (SvO2) and central venous oxygen saturation
(ScvO2) decrease because of decreased cardiac output,
compromised blood flow, and decreased oxygen delivery to tissues (class 3).2,7 Finally, urine output, level of
consciousness, and blood pressure decrease (class 4).3-5
Each event may take minutes to hours. Despite this known
sequence, aggressive intervention often is not implemented
until hypotension occurs.8,9 Traditionally, clinicians are
trained to monitor for early indications of decompensation, and the first hemodynamic monitoring parameter
to decrease in hypovolemia is stroke volume.1-5
Hypovolemia frequently occurs in patients during
surgery and in the critical care unit because of bleeding,
hypoalbuminemia, capillary leak and interstitial edema,
diarrhea, vomiting, and insensible water loss. If the hypovolemia is left untreated (or undertreated), circulatory
hypoxia may develop because of the decreased blood flow
and hypoperfusion. Compensatory diversion of blood
flow centrally, away from the peripheral and splanchnic
circulation, often masks hypoperfusion.2
If not recognized and treated promptly, decreased
circulating volume (particularly at the microvascular level)
leads to diminished oxygen delivery, depletion of intracellular energy reserves, acidosis, anaerobic glycolysis,
and lactate accumulation. Hypovolemia can also lead to
ischemic gastrointestinal complications, including nausea, vomiting, and intolerance of oral intake. Therefore,
diligent monitoring, via accurate assessment of cardiac
output and stroke volume, for hypovolemia is important
for monitoring blood flow.
Limitations of Conventional Assessments

Current conventional assessments such as heart rate,
blood pressure, urine output, central venous pressure
(CVP), and level of consciousness often lack precision as
indicators of changes in a patients status. Although the
www.ccnonline.org
A
BP = CO x SVR
MAP CVP x 80
CO
HR x SV
Preload
Afterload
Contractility
Rhythm
B
CO
SVR
Figure 1 A, Complexity of blood pressure (BP): interrelationship of variables comprising BP. BP is the cardiac
output (CO) multiplied by systemic vascular resistance
(SVR). CO is the product of heart rate (HR) and stroke
volume (SV). SV is influenced by preload, afterload,
contractility, and rhythm. SVR is calculated by dividing
the difference between mean arterial pressure (MAP)
and central venous pressure (CVP) by the CO and then
multiplying by 80. (Derivation of content as described in
Alspach.2) B, CO and SVR coexist in a balanced seesawtype relationship. In general, when one decreases, the other
increases (and vice versa) to maintain normal blood pressure.
values obtained in these assessments somewhat correlate

with hemodynamic variables, the values are slow to
change and the changes are often late indications of a
patients worsening condition.3-5 Several studies10-17 suggest
that using physical assessment to evaluate cardiac output
may yield inaccurate findings. More recent data18-20 suggest that the predictive power of blood lactate levels for
mortality and morbidity are independent of blood pressure and common physiological triage variables (eg,
heart rate, blood pressure, mental status, capillary refill).
Despite these limitations, assessments such as blood
pressure are still considered a standard of care, and current practice mandates use of the assessments. However,
blood pressure itself is a composite of so many factors2-5
(Figure 1) that it is of limited value as an early sign of
hemodynamic derangements such as hypovolemia.
Compensatory mechanisms such as vasoconstriction
and tachycardia influence the cardiovascular system to
keep blood pressure normal,2 making the correlation
between blood pressure and blood flow slow to change
as circulating volume decreases.1-5 The terms compensated
shock and cryptic shock are now being used to define
patient scenarios that meet clinical criteria for shock in
CriticalCareNurse
13
the presence of normal blood pressures.18 Blood pressure

measurements are more useful for conditions that involve
treatment of hypertension rather than treatment of
hypovolemia or shock.21,22 International guidelines such
as the Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure22 help guide care providers in the management of hypertension according to a systematic and
stepwise approach. However, currently no such guidelines
exist for the management of hypotension.
Reconsidering Fluid Replacement

End Points
In an article published in 1996, Connors et al23 suggested that use of a pulmonary artery catheter (PAC) was
associated with an increased likelihood of patient death.
Since then, use of PACs has generally decreased. Although
values obtained via a PAC were once considered the gold
standard for bedside hemodynamic monitoring,24,25 the
precision of a PAC for assessing preload status via filling
pressures is limited. As early as 1971, Forrester et al26
pointed out the inaccuracies of CVP monitoring. In a more
recent systematic review of CVP as a predictor of cardiac
output and fluid responsiveness, Marik et al27 concluded
that CVP should
not be used as a
Ultimately, blood flow is more reliable
basis for clinical
and precise than blood pressures, and
decisions on fluid
blood flow can decrease before blood
management. In
pressures decrease.
fact, Marik et al27
noted that the
28
only published study suggesting CVP could be an accurate
indication of preload was done in horses. Even though
guidelines such as those of the Surviving Sepsis Campaign29
recommend using CVP to monitor preload, no study of
CVP or pulmonary artery occlusive pressure (PAOP) has
shown that these pressures consistently correlate with
blood flow or volume status.30 Early and aggressive use
of fluid replacement to preestablished end points such
as ScvO2 is more likely than the measurement of CVP
itself to provide patients benefit.31,32 The limitations of
CVP are further pointed out in the landmark study on
septic shock by Rivers et al33 published in 2001. These
investigators randomized 263 patients with septic shock
to receive either treatment according to a protocol on
fluid replacement known as early goal-directed therapy
or conventional care (control group). The patients treated
14
CriticalCareNurse
according to the protocol had a 17% reduction in mortality,

even though CVP was used as part of the basis for treatment in both the interventional and the control group.33
PAOP is also an inaccurate predictor of fluid responsiveness in critically ill patients, further indicating that
blood pressures do not correlate with blood flow parameters such as cardiac output and stroke volume.34,35 This
lack of correlation occurs because many factors can
alter the pressure-volume relationship within the heart.
For example, conditions that increase PAOP but not
preload include, but are not limited to, positive-pressure
mechanical ventilation, positive end-expiratory pressure,
and decreased ventricular compliance. Conditions that
alter cardiac compliance include aging, obesity, diabetes,
myocardial ischemia, and sepsis.36 The challenge encountered with interpreting PAOP is further illustrated in
Figure 2; the 3 hearts in the drawing have different cardiomyopathies and various left ventricular end-diastolic volumes (LVEDVs), but each heart has the same PAOP. As a
result, the baseline Frank-Starling pressure-volume
curves for the 3 hearts differ vastly (Figure 3). When
LVEDV increases in normal hearts, pressure increases in
a characteristic curvilinear relationship. However, in conditions such as left ventricular hypertrophy, decreased
wall compliance increases intracardiac pressure without
a concomitant increase in volume. Measurements based
on blood flow, such as stroke volume, help clinicians
avoid incorrect assumptions based on pressure-volume
curves.36 Ultimately, blood flow is more reliable and precise than are blood pressures, and blood flow can decrease
before blood pressures decrease.1,3,5,18
CVP and PAOP were never intended to be used alone;
both are filling pressures meant to guide the optimization of stroke volume.27,32 The fundamental reason to
administer a fluid bolus to a patient is to increase stroke
volume.27,35,37 Although stroke volume monitoring is not
considered a standard of care, as is conventional monitoring of vital signs, plotting or documenting stroke
volume in response to a fluid challenge may be the closest clinicians can come to using the Frank-Starling curve
in routine bedside practice. Stroke volume is more likely
to indicate hypovolemia before other monitoring parameters do because the former is not influenced by most
compensatory mechanisms.1-5 Treatments that include
giving fluids and medications such as drugs that improve
contractility (inotropes) are often administered with the
goal of improving stroke volume. Specifically targeting
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Figure 2 Challenges associated with interpreting pulmonary artery occlusion pressure (PAOP). Left ventricular end-diastolic
volume (LVEDV) can be independent of PAOP. A, PAOP is 22 mm Hg. Normal left ventricle has very high LVEDV. B, PAOP is
22 mm Hg. Dilated right ventricle creates increased juxtacardiac pressure; LVEDV is normal. C, PAOP is 22 mm Hg. Left ventricular hypertrophy with noncompliant myocardium creates decreased space within the left ventricle; LVEDV is low. Use of PAOP
alone to reflect LVEDV may not be accurate.
Based on data from Marik et al27 and Turner.36
Illustration courtesy of Lisa Merry, RN, Merry Studio, Bloomington, Illinois.
Stroke volume, mL
120
100
SV 100 mL
75
SV 75 mL
50
SV 40 mL
25
Pulmonary artery
occlusive pressure
Fluid bolus administered
4 mm Hg
500 mL
12 mm Hg
1000 mL
18 mm Hg
1500 mL
Figure 3 Fluid replacement to optimize stroke volume

(SV) vs cardiac filling pressures as primary end point.
Information in blue is displayed when filling pressures
form the basis for routine bedside preload monitoring.
Patient-specific differences in myocardial compliance
and filling capacity markedly limit ability to estimate enddiastolic volume and thus, SV, on the basis of cardiac filling pressures. Note also the widening of the Doppler
aortic pulse waveform (systolic flow time, or FTc) as preload increases. SV measurements (in red) are the primary
target for fluid in SV optimization. Blood-flow-based technology allows clinicians to estimate SV more directly
along this pressure-volume curve. This approach helps
eliminate guesstimation of blood flow based on cardiac
filling pressures.
stroke volume for hemodynamic management is termed

SVO. Indications for use of SVO include age, heart failure,
www.ccnonline.org
low urine output, bleeding, monitoring of fluid boluses

and vasoactive infusions, cardiac conditions, and risk for
hypoperfusion or organ dysfunction. Awareness of contraindications is just as important: for example, esophageal
Doppler monitoring is contraindicated in patients with
esophageal strictures or varices.
Stroke Volume As the Newest Cardiac

Vital Sign
Assessing for Adequate Perfusion
Using mean arterial pressure to evaluate a patient for
adequate perfusion to the vital organs is a controversial
but important idea for bedside clinicians to consider.38,39
As oxygen supply decreases or oxygen demand increases,
tissue hypoxia can develop. However, exactly when the
hypoxia occurs in an individual patient is unclear. ScvO2
can be a helpful global indicator; however, monitoring
microcirculatory perfusion at the end-organ level is not
readily available yet.40 When compromised perfusion
progresses to the point of eventual acidosis, organ damage most likely is occurring, even when blood pressures
are normal.1
The complexity of these changes defies overreliance
on parameters such as blood pressure. Ongoing fluid
replacement decisions should be based on stroke volume,
variations in pulse pressure, cardiac output derived by
using a minimally invasive method, and passive leg-raising
maneuvers supported by integrated assessment to more
CriticalCareNurse
15
precisely determine the response to the replacement

efforts.32,35,41,42 Methods of actually measuring blood flow
by more direct methods are becoming increasingly
available. These methods can provide true blood-flow
measurements, such as stroke volume, stroke distance,
variation in stroke volume, and systolic flow time.
Methods of Measuring Stroke Volume
Traditionally, echocardiography has been the most
commonly used method to measure stroke volume at the
bedside. However, this method is expensive and technically
difficult and continuous or serial measurements are often
not practical in critical care. Several new technologies
enable ongoing measurement of stroke volume at the
bedside, including noninvasive Doppler imaging
(USCOM), esophageal Doppler imaging (Deltex Medical;
Figure 4), bioimpedance (SonoSite), endotracheally applied
bioimpedance (ConMed Corporation), bioreactance
(Cheetah Medical), pulse contour methods (Edwards
Lifesciences, LidCo Ltd, Pulsion Medical Systems), an
exhaled carbon dioxide method (Philips, Respironics),
and the PAC. All use various methods to calculate stroke
volume, and the results have various degrees of accuracy.
Some devices measure stroke volume directly (eg,
esophageal Doppler imaging) and may be considered
the preferred method because of the high degree of
accuracy of the results.43 Other technologies simply
divide the cardiac output by the heart rate to obtain
stroke volume (eg, PAC). Table 2 provides a more
detailed comparison.44-59
Clinical application of technology is based on
knowledge and experience in obtaining and applying
the information received. If a care provider targets the
wrong hemodynamic end points or interprets a poor
waveform as an
Each technology has a unique profile accurate tracing,
of advantages and limitations, and a
benefits may be
patients situation may dictate which
limited. These
technology is best at a give time.
concerns were
cited in the technology assessment report published by the Agency for
Healthcare Research and Quality60 in 2008 as some of the
most likely reasons studies have collectively suggested
no benefit for monitoring with PACs.
Disagreement may exist about which technology is best
for monitoring stroke volume because none of the technologies is appropriate for all patients in all situations.
16
CriticalCareNurse
Figure 4 Examples of minimally invasive hemodynamic

monitoring. A, Esophageal Doppler monitor: display
allows real-time measurement of preload (flow time, corrected, FTc), contractility (peak velocity, PV), stroke volume (SV), and stroke distance (SD). B, Sagittal view of
esophageal Doppler probe in place to monitor cardiac output variables. Ultrasound transducer measures blood flow
in the descending thoracic aorta.
Images courtesy of Deltex Medical, Inc, West Sussex, England.
Each technology has a unique profile of advantages and

limitations, and a patients situation may dictate which
technology is best at a given time. Regardless of the
technology used, the device will provide measurements
of preload, afterload, and contractility for optimizing
stroke volume.
Hemodynamic Variables That Influence

Stroke Volume
Three variables affect stroke volume: preload,
contractility, and afterload.
Measurement of Preload: Corrected Flow Time
Corrected flow time (FTc) is a measure obtained in
esophageal and noninvasive Doppler imaging via ultrasound technology. The FTc is an estimate of circulating
blood volume based on the amount of red blood cells
www.ccnonline.org
Table 2
Technology
Manufacturer
Technology for measuring stroke volume
Where used
Randomized controlled
trials regarding
patient outcome
Description
External
Doppler
imaging
USCOM, Sydney,
Australia
Anywhere
None
Stroke volume estimate obtained via

ultrasound probe placed at the sternal
notch or parasternally; ultrasound beam
directed at the aortic or pulmonic valve
Esophageal
Doppler
imaging
Deltex Medical, West

Sussex, England
Operating room,
intensive care
unit, emergency
department
Stroke volume estimate directly obtained

9 trials44-52 (2 trials had
via Doppler signal of descending aorta;
conflicts of interest to
disclose) showing reduced typically, patient must be sedated;
inserted similarly to a nasogastric tube
length of stay, complications, use of vasopressors, renal insufficiency,
and mortality and lower
lactate levels
Endotracheal
bioimpedance
ConMed Corporation,
Utica, New York
None
Operating room,
intensive care unit
Transcutaneous
bioimpedance
SonoSite, Bothell,
Washington
Anywhere
Pulse contour
FloTrac, Edwards
Lifesciences, Irvine
California
LidCo Ltd, Cambridge,
United Kingdom
PiCCO, Pulsion
Medical Systems,
Munich, Germany
3 trials (each with conflicts Stroke volume estimated from arterial

Operating room,
pressure waveform via methods such
intensive care unit of interest to disclose)
as lithium infusion, pulse pressure
suggesting decreased
variation, or thermodilution; continucomplications and
ous cardiac output and beat-to-beat
length of stay (LidCO),53
(FloTrac),54 and (PiCCO)55 variability proportional to stroke
volume; changes in systemic vascular
3 trials suggesting unclear
benefit (PiCCO)56 (conflict resistance and arterial pressure necessitate recalibration; dampening, dysof interest disclosed) or
rhythmias, and ventilator triggering
no benefit (FloTrac)57
also limit accuracy
and (PiCCO)58
Bioimpedance technology via endotracheal tube; stroke volume obtained

from impedance signal from ascending
aorta; patient must be intubated
Transcutaneous electrodes placed on
neck and chest; electrical impedance
between electrodes during cardiac
cycle entered into nomogram to compute stroke volume; for best readings,
patient must have normal anatomy
None
Exhaled carbon Philips Respironics,

Operating room,
None
dioxide method Andover, Massachusetts intensive care unit
Exhaled carbon dioxide method, with

Fick equation; needs controlled
mechanical ventilation to work; additional personnel, such as respiratory
therapist, may be required; patient
must be intubated
Pulmonary artery
catheter
Operating room,
Several trials,59,60 with
intensive care unit both pro and con
findings
Measures cardiac output via thermodilution, temperature sensed by the

catheter thermistor; stroke volume
calculated by dividing cardiac output
by heart rate; central venous access
required via catheterization of right
side of heart
Operating room,
None
intensive care unit
Like bioimpedance, uses transcutaneous

electrodes; however, signal acquisition
eliminates impedance errors present
with the first-generation technology
Bioreactance
www.ccnonline.org
Cheetah Medical,
Portland, Oregon
CriticalCareNurse
17
Peak velocity (cm/s)
Velocity, cm/s
Stroke distance (cm)

= area under curve
Flow time, ms
1/3 Systole
2/3 Diastole
1 Cardiac cycle
Figure 5 Waveform components for stroke volume optimization (SVO): aortic pulse waveform from an esophageal Doppler
examination. Corrected flow time (ie, the time spent in systole) corresponds to the width of the pulse waveform and is an index
of preload. Peak velocity corresponds to the height of the wave and is a measure of contractility. Stroke distance represents the
area under the curve and is used to compute stroke volume.
that cross the ultrasound transducer beam through the

aorta during the systolic phase (Figures 4A and 4B). FTc
corresponds to the width of the pulse waveform base
and can be used to estimate preload. For example, a longer
FTc suggests that the left ventricle is pumping forward
an increased amount of blood (ie, increased preload).
The width of the pulse wave is measured in milliseconds
and represents the amount of time spent in systole compared with total cardiac cycle time, and FTc is also corrected for heart rate.61 The correction is based on a heart
rate of 60/min,
The most important value of corrected although the
current heart
flow time is the degree to which it
rate is taken into
changes in response to intraveous
account. If a
administration of fluids.
patients heart
rate is 60/min, then each cardiac cycle will last 1 second,
or 1000 ms. Normal FTc is 330 to 360 ms.61,62 In other
words, for a cardiac cycle lasting 1 second, the systolic flow
period should last approximately 330 to 360 ms, provided
that adequate preload exists. An easy way to remember
the reference range is to remember that the heart is in
diastole two-thirds of the time and that normal FTc
18
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multiplied by 3 equals 1 second, or 1000 ms62 (Figure 5).

But normal reference ranges are really just reference points,
not necessarily static physiological targets to be used for
all patients. The most important value of FTc is the degree
to which it changes in response to intravenous administration of fluids.62 Increases in FTc in response to volume
challenge help confirm hypovolemia, which is manifested
as a narrow waveform base and a low FTc (Figure 3).
The accuracy of FTc has been questioned.63-65 However,
a complete understanding of the variable is critical before
FTc and be used effectively in clinical practice.66-68 Simply
put, FTc is suggestive of the amount of circulating volume
that passes the tip of the ultrasound probe during systole.36
Therefore, conditions such as bleeding (hypovolemia),
heart failure (low contractility), and high afterload (eg,
vasoconstriction) may contribute to low blood-flow
states and thus low FTc. These influences must be considered before FTc is accepted as a surrogate for preload
in individual patients. Several investigators66,69-72 have
suggested that FTc is as good as or better than PAOP for
indicating changes in preload. Most important, however,
improvement in stroke volume after fluid administration
is what was intended to form the basis on which preload
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responsiveness is ultimately determined (in each of the

outcome trials studying SVO).44-52,73,74 In other words,
FTc (as well as CVP and PAOP) is best used as a decisionmaking aid for optimizing stroke volume.
Measurement of Contractility: Peak Velocity
Peak velocity, a measure of contractility, is indicated
by the amplitude of a Doppler waveform (Figure 5). It
indicates the acceleration of blood flow in the systolic
phase, or the speed at which a pressure wave goes from
baseline to the peak height of contraction. An overall
reference range is 50 to 120 cm/s. Peak velocity can be
age dependent; the expected range for a 20- to 30-yearold is 90 to 120 cm/s, with gradually decreasing expected
peak velocity as a person ages. Patients more than 65
years old are expected to have a peak velocity greater
than 50 cm/s. Values less than 50 cm/s are suggestive
of poor left ventricular contractility, as in heart failure.
However, peak velocity should be evaluated with respect
to a patients baseline values and how those values
respond to treatments. For example, an increase in peak
velocity is expected with administration of an inotrope.
A low stroke volume can occur for 1 of 2 main reasons: hypovolemia or decreased ventricular contractility.
The immediate measured availability of peak velocity
with Doppler techniques provides better information
than do the derived contractility parameters of the PAC
regarding why stroke volume may be low. For example,
if stroke volume is low but peak velocity is normal, the
problem most likely is hypovolemia.21 However, if both
stroke volume and peak velocity are low, the problem
most likely is left ventricular dysfunction.62 A patients
response to medications such as preload reducers, afterload reducers, or inotropes can help differentiate the
cause of the left ventricular dysfunction (eg, fluid overload, high afterload, or low contractility, respectively).
Peak velocity may also help detect acute decompensating systolic heart failure earlier than do other techniques for monitoring cardiac output. In critical illness,
poor left ventricular contractility (low ejection fraction)
may initially lead to a compensatory increase in enddiastolic volume, a change that implies a normal stroke
volume. The ability to monitor peak velocity allows clinicians to recognize this decrease in contractility in real
time and intervene before a decrease in stroke volume
occurs. Further research is needed to better establish
SVO treatment guidelines for patients with heart failure.
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Measurement of Afterload:
Systemic Vascular Resistance
Systemic vascular resistance (SVR) is the resistance
that must be overcome by the ventricles to develop force
and contract, propelling blood into the arterial circulation.2
Most of the newer hemodynamic monitoring technologies (eg, esophageal Doppler imaging, bioimpedance,
pulse contour methods) have the capability to calculate
SVR. However, SVR was not a major parameter in the
algorithms used in any of the SVO trials that showed
improved outcomes in surgical patients.44-52,73,74
Evidence of lack of inclusion suggests that SVR is a
more of a secondary monitoring parameter. Elevated SVR
usually occurs in response to systemic hypertension or
as a compensatory mechanism due to decreased cardiac
output, as in shock states (Figures 1A and 1B). Therefore,
nurses must know why the SVR is elevated. If the value is
elevated in response to low cardiac output, once cardiac
output is improved with treatment (eg, fluid, inotropes),
SVR should decrease because of a decreased need for
compensatory vasoconstriction. If SVR is elevated
because of systemic hypertension, treatment may include
administration of an afterload reducer.2
When SVR decreases, the left ventricular ejection of
blood encounters lower resistance. Low afterload states
may be less problematic when blood pressure and cardiac output are normal (Figure 1A). However, attempts
to increase low SVR generally include administration of
vasopressors.2 ScvO2 and stroke volume should also be
followed as end points to ensure that blood flow and tissue oxygenation improve in response to the vasopressor21
(Figure 6). Titrating the dose of a vasopressor used to
alter ScvO2 and stroke volume allows clinicians to focus
on optimizing blood flow to both the microcirculation
and the macrocirculation. Several studies of fluid replacement protocols that include use of vasopressors suggest
that optimizing ScvO231,33,75 and stroke volume47,76 improve
patients outcomes. However, further research is needed
to better establish how vasopressors and ScvO2 are best
used in SVO protocols.
Stroke Volume, Stroke Index, and
Stroke Distance
Stroke volume is one of the primary end points for
detecting fluid responsiveness and guiding goal-directed
therapy.27,32,62 Stroke index is a standardized parameter in
which a patients body surface area is taken into account.
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19
Stroke volume, mL
75
50
25
Increasing norepinephrine dose, g/min
MAP response to increasing doses of norepinephrine, mm Hg
10
5
50
15
55
20
60
65
Figure 6 Response of stroke volume to norepinephrine. Increasing vasopressor doses to previously established, prescribed
thresholds for mean arterial pressure (MAP) and systemic vascular resistance may in turn decrease stroke volume and overall
blood flow. The case example graph suggests that stroke volume is optimized at 8 g/min of norepinephrine, even though a
MAP of only 55 mm Hg is achieved at that dose. Note: patients responses to norepinephrine dosing may vary.
However, monitoring both stroke volume and stroke index

is generally not necessary, because they use different units
of measure to quantify the same value. Table 3 gives reference ranges for these parameters.21,77-79 However, the
ideal stroke volume value is the one that contributes to
adequate blood flow for tissue oxygenation without
increasing heart rate.
Despite the unique advantages of measuring stroke
volume, available technologies to measure this parameter
at the bedside have some limitations. Even esophageal
Doppler imaging, which provides a highly flow-directed
estimation of stroke volume, uses a calculated estimation
of aortic diameter based on the patients height and
weight.80 Stroke distance may be a more accurate reflection of the Doppler estimation of stroke volume. Stroke
distance is the distance a column of blood moves through
the descending thoracic aorta during each systolic phase.61
Because stroke distance is used to calculate stroke volume, the recommendation is that stroke distance be
evaluated to determine if the measurement of stroke
volume is accurate.
The SVO Algorithm:

Putting It All Together
The Frank-Starling principle states that the strength
of cardiac contraction is directly related to the length of
muscle fibers at end diastole, or preload.81 Administration
of fluid on the basis of stroke volume allows clinicians to
directly apply this principle. Figure 7 displays a standard
20
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Table 3
Reference ranges for

hemodynamic parametersa
Reference
range
Parameter
4-8
Cardiac output, L/min

Stroke volume, mL
50-100
Stroke indexb
25-45
Flow time corrected, ms
330-360
Peak velocity, cm/s
30-120
Stroke distance, cm
10-20
Cardiac
indexc
Systemic vascular resistance, dyne sec
2.8-4.2
cm-5
Saturation of central venous oxyhemoglobin, %

Central venous pressure, mm Hg
Stroke volume variation, %
900-1600
65-80
2-8
< 10-15
a Based
on data from Ahrens,21 Lynn-McHale Wiegand,77 Lynn-McHale

Wiegand and Carlson,78 and Edwards Lifesciences.79
b Calculated as stroke volume in milliliters per heartbeat divided by body
surface area in square meters.
c Calculated as cardiac output in liters per minute divided by body surface
area in square meters.
example of an SVO fluid replacement algorithm, cited by

Schober et al,62 that is based on a synthesis of experimental SVO protocols and literature.44-52,73,74 In this type of
algorithm, determination of fluid responsiveness is used:
fluid boluses are administered as long as stroke volume
continues to improve by 10% or more. When administration of fluid boluses ceases to improve stroke volume by
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If stroke volume or corrected

flow time is low
Give 200 mL of colloid or

500 mL of crystalloid
Is the heart
pumping
enough blood?
Yes
(stroke volume
increased < 10%)
Stop giving fluids;

monitor stroke
volume as indicated
No
(stroke volume
increased > 10%)
Other therapies as appropriate, for example:

High afterload state: dilators ( more fluid) if low corrected
flow time, low peak velocity, and blood pressure acceptable
Low contractility state: inotropic agents if low peak velocity
and blood pressure
Low afterload state: vasopressors if high corrected flow
time, high stroke volume, and low blood pressure
If stroke volume
decreased > 10%
Figure 7 Example of an algorithm for stroke volume optimization.
10% or more, no more fluid is needed. Using this method

of fluid administration can mitigate the risk of pulmonary
edema, and bedside clinicians can be better assured that
the patient is receiving enough fluid to optimize the
macrocirculation but not more fluid than is needed.
SVR and blood pressure are usually not included in
SVO algorithms and are considered secondary monitoring parameters in SVO.44-52 According to the SVO algorithm, SVR and blood pressure are evaluated only after
peak velocity (contractility) and stroke volume are optimized, because SVR and blood pressure are more indirect reflections of cardiac output and are influenced by
other factors (see Figures 1A and 1B). Furthermore,
when blood flow and tissue oxygenation are measured
rather than assumed, doses of vasopressors can be adjusted
to optimize the end points of stroke volume (macrocirculation) and ScvO2 (microcirculation) rather than SVR
and blood pressure (Figure 6). Stroke volume may improve
initially with initiation and escalating doses of vasopressors, but changes in afterload due to further increases in
the medication may impede stroke volume and cardiac
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output.82 Surveillance of ongoing stroke volume and

cardiac output may help clinicians avoid this decrease
in stroke volume and cardiac output.
Challenges to SVO implementation may include incorporating new hemodynamic monitoring technology into
daily practice (eg, esophageal Doppler imaging, pulse
contour method), education of staff members, support
from physicians and leaders, and the paucity of literature
to support use in nonsurgical patients. However, potential
benefits include use of minimally invasive techniques,
allowing earlier detection of unstable hemodynamic status,
and reductions in morbidity, mortality, and length of stay.
More research is needed to determine how values
such as peak velocity and ScvO2 can be incorporated into
the SVO algorithm. The following case studies illustrate
these points and indicate how SVO can be applied in cases
involving alterations in preload, afterload, and contractility.
Case Study 1: Decreased Preload
A 59-year-old man was admitted to the surgical
intensive care unit after having a partial liver lobectomy
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21
Table 4
Interventions used and response of 59-year-old man admitted after a motor vehicle accident
Stroke
Peak
Heart rate, Central venous Central venous
Flow time,
volume,
velocity,
beats
oxygen
pressure,
corrected, ms
mL
cm/s
per minute saturation, %
mm Hg
Intervention
Blood pressure, mean

(SD), mm Hg
Administer 1000-mL
bolus of physiological saline
34
300
96
102
49
100/48 (64)
Administer 1000-mL
48
335
95
100
69
94/55 (68)
Response
49
337
95
99
70
100/60 (73)
after a motor vehicle accident (Table 4). On postoperative day 5, he was evaluated for discharge to a general
care unit. His urine output had decreased during the
preceding 12 hours, suggestive of hypovolemia. The
hypovolemia was evidenced by low stroke volume, low
FTc, and low ScvO2 in the presence of a normal peak
velocity. After injection of a 1000-mL bolus of physiological saline, stroke volume improved from 34 mL to 48
mL, more than a 10% (3.4 mL) improvement. So,
another bolus was given. Satisfactory response to the
bolus was manifested by normal FTc and ScvO2. Stroke
volume improved to 49 mL only with the second bolus
(<10% improvement), indicating the beginning of the
plateau along the Frank-Starling curve where increased
stretching of the ventricular myocytes does not improve
stroke volume. Thus, no further administration of fluid
was indicated.
Table 5
Intervention
Case Study 2: Decreased Preload Leads to

Decreased Afterload
A 55-year-old woman was admitted because of sepsis
(Table 5). The patient had a dangerously reduced stroke
volume, decreased FTc, decreased ScvO2, and a normal
peak velocity, indicating hypovolemia. She was deemed
fluid responsive as indicated by an improvement in
stroke volume from 26 mL to 50 mL, a greater than 10%
(2.6 mL) improvement, after administration of a bolus of
1000 mL of physiological saline. So, another saline bolus
was indicated. However, the patient did not respond to
the second bolus, as evidenced by an improvement in
stroke volume from 50 mL to only 51 mL (<10%), suggesting that the macrocirculation had been optimized. Norepinephrine was started because of the reduced ScvO2
and persistent hypotension despite volume correction.
The patient responded appropriately as evidenced by the
Interventions used and response of 55-year-old woman admitted for sepsis
Stroke
Peak
Heart rate, Central venous Central venous
Flow time,
volume,
velocity,
beats
oxygen
pressure,
corrected, ms
mL
cm/s
per minute saturation, %
mm Hg
Blood pressure, mean

(SD), mm Hg
Administer 1000-mL
bolus of 0.9%
normal saline
26
254
78
107
26
68/36 (47)
Administer 1000-mL
50
341
76
105
48
76/42 (53)
Administer
norepinephrine
10 g/min
51
341
76
105
50
80/44 (59)
Response
55
344
72
106
68
92/62 (72)
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CriticalCareNurse
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increase in ScvO2 to 68%, suggesting normalization of

the microcirculation.
Literature Supporting
Clinical Usefulness of SVO
Before they adopt a new practice, astute clinicians
want to know that the practice is strongly supported in
the literature. Randomized controlled trials are the
highest-level research design, and the number of welldesigned randomized controlled trials is directly correlated
with the level of evidence assigned to a given practice.83-85
The findings of 11 randomized controlled trials,44-52,73,74
including 9 prospective trials,44-52 suggest that SVO results
in improved patient outcomes. Despite a thorough literature review, we were unable to find a fluid replacement
strategy supported by more research. The results of the
9 prospective trials,44-52 which included a total of about
1000 patients, consistently suggested that compared with
conventional fluid replacement, SVO fluid replacement
protocols contribute to decreases in overall hospital length
of stay (by 2 days or more), complication rates, renal
insufficiency, infection, use of vasopressors, blood lactate
levels, and time-to-tolerance of oral intake. Appropriately
implemented SVO programs that replicate these outcomes
may also be associated with decreased costs.86
Notably, the sample in all 11 trials44-52,73,74 included
perioperative patients. Although 2 of these trials44,47 also
focused on postoperative care in the critical care unit,
more research is needed to indicate the efficacy of SVO
in nonsurgical patients. However, in perioperative
patients, the strength of the supporting evidence in
favor of SVO has been substantiated by large-scale systematic literature reviews conducted by the Agency for
Healthcare Research and Quality,87 the National Health
Service,86 and third-party payers such as the Centers for
Medicare and Medicaid Services88 and Aetna.89
In 3 of these studies,86-88 the agencies recommended
SVO protocols be used for monitoring cardiac output of
patients receiving mechanical ventilation in the critical
care unit and for surgical patients who require intraoperative fluid optimization. Esophageal Doppler imaging,88 bioimpedance,90 and PACs91 are all reimbursed by
the Centers for Medicare and Medicaid Services88 on the
basis of systematic literature reviews. However,
esophageal Doppler imaging is the only technology also
supported by the Agency for Healthcare Research and
Quality.87
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Similarly, the Cochrane Collaborative59 and the

Agency for Healthcare Research and Quality60 have published technology assessments based on meta-analyses
of outcomes related to use of PACs. The analyses indicated that the patients studied showed no evidence of
benefit or harm from PACs. Among the reasons cited
for the perceived lack of benefit was clinician-to-clinician
variability in management of hemodynamic data obtained
via PACs. In addition, the authors59,60 questioned the
accuracy of the interpretation of the hemodynamic
information in the studies analyzed and whether or not
patient management strategies based on hemodynamic
data were appropriate. Furthermore, none of the studies
included use of a specific protocol for PAC use. This lack
of a protocol is a key difference between PAC studies and
SVO studies. Each of the 9 randomized control trials44-52
on SVO
included a
Stroke volume may improve initially
protocol for with initiation and escalating doses of
use of SVO. vasopressors, but changes in afterload
Use of a pro- due to further pressor dose increases may
tocol is con- impede stroke volume and cardiac output.
sistent with
other studies of replacement protocols that include
fluid therapy, which can be lifesaving when initiated
early in the course of treatment. Findings from a metaanalysis of hemodynamic optimization by Poeze et al92
also suggest that replacement strategies such as SVO
improve outcomes, including patient mortality, in
high-risk surgical patients.
Nursing Considerations
Nursing considerations associated with incorporating SVO into bedside practice include acquiring and
evaluating hemodynamic data, maintenance of skin
integrity, sedation and analgesia, and nursing research.
Acquisition and Evaluation of
Hemodynamic Information
Clinical proficiency with applying or inserting the
hemodynamic monitoring device and adequate signal
acquisition are key.93 Each device has its own unique signal
acquisition technique and competency requirements.
Inappropriate application of the device may produce inaccurate hemodynamic readings, leading to improper treatment decisions.77,78 Once accurate readings are obtained,
understanding the appropriate application of normal
CriticalCareNurse
23
hemodynamic reference ranges to all patients is crucial.

Tracking trends in hemodynamic values over time is
generally more useful than is monitoring and treating
on the basis of single data points, because transient
changes in values may not be clinically importantly.
When readings are considered accurate and hypovolemia is identified, rapid infusion of a fluid bolus may
optimize a patients response. Fluid infused via a pressure bag often produces a more dramatic increase in
stroke volume than does fluid administered via an intravenous infusion pump. A maximum rate of commonly
used intravenous pumps is 999 mL/h. Because hypovolemia and hypoperfusion are time-sensitive conditions,
the providers judgment and the patients condition may
determine that a more rapid infusion rate is needed.
The latest revision of the Surviving Sepsis Campaign
guidelines also suggests an increased emphasis on earlier
and more aggressive fluid replacement. For example, the
2008 guidelines94 recommended a 20 mL/kg crystalloid
fluid challenge in a 6-hour replacement bundle. In the
2012 revised guideline,29 the recommended amount of
fluid was increased (to 30 mL/kg) in a shorter time (3-hour
bundle). Clinicians must strongly consider strategies to
infuse such a volume rapidly enough, in accordance with
institutional policy as appropriate.
Maintenance of Skin Integrity
Care must be taken to avoid skin breakdown under
and around skin electrodes. With bioimpedance and
bioreactance, signals are acquired transcutaneously, and
skin care should be in accordance with the manufacturers
recommendations and institutional policy. Mouth ulcerations are also possible with monitoring devices such as
those used for esophageal Doppler imaging93 and endotracheally applied bioimpedance. Diligent oral care should
be performed as
needed while
Earlier signals such as stroke volume
allow clinicians to anticipate rather than those devices are
react to changes, improving the likeli- in place. Site care
hood of maintaining a stable metabolic is also important
when caring for
state at the organ and cellular level.
patients monitored with intravenous pulse contour devices or PACs.
Catheter infections can be minimized by using sterile
conditions during insertion and aseptic technique during
dressing changes.77,78
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Sedation and Analgesia

Sedation is sometimes required with techniques such
as the exhaled carbon dioxide method, which requires
controlled mechanical ventilation, and esophageal Doppler
imaging. These techniques may have limited accuracy
when increased respiratory rates or restlessness, respectively, occur. Therefore, sedative agents or analgesics
may be administered as needed.77,78 Although not a major
focus with respect to SVO, pain cannot be overlooked;
it is not only an overall priority but can also influence
hemodynamic readings.
Nurse Research
The implications of patient advocacy extend beyond
routine patient care and include nurses participation in
designing and implementing future research on the clinical usefulness of SVO in critical care. Critical care nurses
monitor and treat hypovolemia daily and have a unique
opportunity to contribute to the existing scientific body
of knowledge through participation in SVO studies in
medical critical care patients.
Summary
The growing body of evidence supporting SVO
suggests that implementation of SVO into daily practice
should be considered.61,62,88 A new era is emerging in
which blood-flow monitoring is taking precedence over
the monitoring of blood pressures. Cardiac pressures
help provide estimates of blood volume; however, normal
cardiac pressures can be observed in a patient in shock
and provide little information about blood flow.30,95-97
Interpretation and treatment of blood pressures incorporate assumptions, whereas stroke volume may be
considered a more precise measure of fluid responsiveness and an earlier warning sign of volume depletion
than are urine output, altered mental status, CVP, heart
rate, and blood pressure.1-5 Earlier signals allow clinicians to anticipate rather than react to changes, improving the likelihood for maintaining a stable metabolic
state at the organ and cellular level. In addition to the
evidence supporting SVO, minimally invasive applications and improvements in accuracy also add to safety
advantages when inherent limitations of the various
methods are considered.
For years, strategies for use of SVO were not feasible
because no practical measurement method for SVO
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existed for bedside clinicians. Fortunately, technology

has improved the hemodynamic monitoring landscape.
Compared with old devices, newer technology is less invasive, safe, evidence based, flow directed, cost-effective,
easier to use, and accurate. Although further research
on SVO and dynamic indices are needed to establish the
clinical efficacy of SVO in critical care units, the current
body of literature indicates that SVO is associated with
fewer complications and reduced hospital lengths of stay,
particularly in patients receiving mechanical ventilation
and in surgical patients. Until more randomized trials
on the impact of SVO protocols on the outcomes of
critical care patients are published, SVO is supported
by more evidence than is use of filling pressures for fluid
replacement in critical care units.27,32,44-52,73,74,86-88 On the
basis of our review of the current available literature, we
suggest that the SVO algorithm for fluid replacement be
considered in place of use of cardiac filling pressures for
patients in critical care, as appropriate, with attention to
outcomes. In the meantime, more research is needed to
evaluate the impact of SVO on patients other than perioperative patients and on nonintubated patients. CCN
Acknowledgments
The authors thank Terry Sears and Julie Stielstra for their contributions. We
also thank the critical care staff, physicians, and leaders at Central DuPage
HospitalNorthwestern Medicine. Without their help and support, this manuscript would have been much more difficult to complete.
Financial Disclosures
Tom Ahrens has lectured for hemodynamic monitoring companies (including
Deltex Medical Inc) and is a hemodynamic monitoring consultant.
Now that youve read the article, create or contribute to an online discussion
about this topic using eLetters. Just visit www.ccnonline.org and select the article
you want to comment on. In the full-text or PDF view of the article, click
Responses in the middle column and then Submit a response.
To learn more about stroke volume optimization, read Stroke

Volume Optimization Versus Central Venous Pressure in Fluid
Management by Ahrens in Critical Care Nurse, April 2010;30:7172. Available at www.ccnonline.org.
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17. Celoria G, Steingrub J, Vickers-Lahti M, et al. Clinical assessment of
hemodynamic values in two surgical intensive care units: effects of therapy. Arch Surg. 1990;125(8):1036-1039.
18. Bakker J, Jansen T. Dont take vitals, take a lactate. Intensive Care Med.
2007;33:1863-1865.
19. Howell MD, Donnino M, Clardy P, Talmor D, Shapiro NI. Occult hypoperfusion and mortality in patients with suspected infection. Intensive Care
Med. 2007;33(11):1892-1899.
20. Mikkelsen M, Miltiades A, Gaieski D, et al. Serum lactate is associated
with mortality in severe sepsis independent of organ failure and shock.
Crit Care Med. 2009;37(5):1670-1677.
21. Ahrens T. Hemodynamics in sepsis. AACN Adv Crit Care. 2006;17(4):
435-445.
22. Department of Health and Human Services, National Institutes of
Health, National Heart, Lung, and Blood Institute. The Seventh Report of
the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure. Bethesda MD: National Heart, Lung,
and Blood Institute; August 2004. NIH Publication No. 04-5230.
23. Connors A, Speroff T, Dawson N, et al. The effectiveness of right heart
catheterization in the initial care of critically ill patients. SUPPORT
Investigators. JAMA. 1996;276(11):889-897.
24. Smartt S. The pulmonary artery catheter: gold standard or redundant
relic. J Perianesth Nurs. 2005;20(6):373-379.
25. Pugsley J, Lerner A. Cardiac output monitoring: is there a gold standard
and how do the newer technologies compare? Semin Cardiothorac Vasc
Anesth. 2010;14(4):274-282.
26. Forrester JS, Diamond G, McHugh TJ, Swan HJ. Filling pressures in the
right and left sides of the heart in acute myocardial infarction: a reappraisal
of central-venous-pressure monitoring. N Engl J Med. 1971;285(4):190-193.
27. Marik P, Baram M, Vahid B. Does central venous pressure predict fluid
responsiveness? A systematic review of the literature and the tale of
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28. Magdesian KG, Fielding CL, Rhodes DM, Ruby RE. Changes in central
venous pressure and blood lactate concentration in response to acute
blood loss in horses. J Am Vet Med Assoc. 2006;229(9):1458-1462.
29. Dellinger RP, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign
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30. Ahrens T. Stroke volume optimization vs central venous pressure in
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52.
53.
54.
55.
26
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Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomized controlled trial investigating the influence of intravenous fluid
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administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97(4):820-826.
McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M.
Randomised controlled trial assessing the impact of a nurse delivered,
flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004;329(7460):258-261.
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reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg. 1995;130(4):423-429.
Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral
fracture: randomised controlled trial. BMJ. 1997;315(7113):909-912.
Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P.
Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in
patients with hip fractures. Br J Anaesth. 2002;88(1):65-71.
Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal
Doppler guided fluid management shortens postoperative hospital stay
after major bowel surgery. Br J Anaesth. 2005;95(5):634-642.
Noblett S, Snowden C, Shenton B, Horgan A. Randomized clinical trial
assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93(9):1069-1076.
Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED.
Early goal-directed therapy after major surgery reduces complications
and duration of hospital stay: a randomized, controlled trial
[ISRCTN38797445]. Crit Care. 2005;9(6):R687-R693.
Mayer J, Boldt J, Mengistu AM, Rhm KD, Suttner S. Goal-directed
intraoperative therapy based on autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial. Crit Care. 2010;14(1):R18. doi:10.1186/cc8875.
Goepfert M, Richter H, Eulenburg C, et al. Individually optimized
hemodynamic therapy reduces complications and length of stay in the
intensive care unit: a prospective, randomized controlled trial. Anesthesiology. 2013;119(4):824-836.
CriticalCareNurse
56. Salzwedel C, Puig J, Carstens A, et al. Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and
continuous cardiac index trending reduces postoperative complications
after major abdominal surgery: a multi-center, prospective, randomized
study. Crit Care. 2013;17(5):R191. doi:10.1186/cc12885.
57. Van der Linden PJ, Dierick A, Wilmin S, Bellens B, De Hert SG. A randomized controlled trial comparing an intraoperative goal-directed
strategy with routine clinical practice in patients undergoing peripheral
arterial surgery. Eur J Anaesthesiol. 2010;27(9):788-793.
58. Szakmany T, Toth I, Kovacs Z, et al. Effects of volumetric vs pressureguided fluid therapy on postoperative inflammatory response: a prospective, randomized clinical trial. Intensive Care Med. 2005;31(5):656-663.
59. Rajaram SS, Desai NK, Kalra A, et al. Pulmonary artery catheters for
adult patients in intensive care. Cochrane Database Syst Rev. 2013;2:
CD003408. doi:10.1002/14651858.CD003408.pub3.
60. Balk E, Raman G, Chung M, et al. Evaluation of the Evidence on Benefits
and Harms of Pulmonary Artery Catheter Use in Critical Care Settings.
Rockville, MD: Agency for Healthcare Research and Quality; March 28,
2008. http://www.cms.gov/determinationprocess/downloads/id55TA
.pdf. Accessed October 29, 2014.
61. Roche A, Miller T, Gan T. Goal-directed fluid management with transoesophageal Doppler. Best Pract Res Clin Anaesthesiol. 2009;23(3):327-334.
62. Schober P, Loer S, Schwarte L. Perioperative hemodynamic monitoring
with transesophageal Doppler technology. Anesth Analg. 2009;109:340-353.
63. Chew HC, Devanand A, Phua GC, Loo CM. Oesophageal Doppler ultrasound in the assessment of haemodynamic status of patients admitted
to the medical intensive care unit with septic shock. Ann Acad Med Singapore. 2009;38(8):699-703.
64. Bendjelid K. Assessing fluid responsiveness with esophageal Doppler
dynamic indices: concepts and methods [comment]. Intensive Care Med.
2006;32(7):1088.
65. Monnet X, Pinsky M, Teboul J. FTc is not an accurate predictor of fluid
responsiveness. Intensive Care Med. 2006;32:1090-1091.
66. Johnson A, Schweitzer D. Putting the wedge under pressure [comment].
Ann Acad Med Singapore. 2010;39(10):815.
67. Singer M. The FTc is not an accurate marker of left ventricular preload:
reply to the comment by Chemla and Nitenberg. Intensive Care Med.
2006;32(9):1456-1457.
68. Singer M. The FTc is not an accurate marker of left ventricular preload.
Intensive Care Med. 2006;32(7):1089.
69. Madan AK, UyBarreta VV, Aliabadi-Wahle S, et al. Esophageal Doppler
ultrasound monitor versus pulmonary artery catheter in the hemodynamic management of critically ill surgical patients. J Trauma. 1999;46(4):
607-611.
70. Seoudi H, Perkal M, Hanrahan A, Angood P. The esophageal Doppler
monitor in mechanically ventilated surgical patients: does it work
[abstract]? J Trauma. 1999;47(6):1171.
71. DiCorte CJ, Latham P, Greilich PE, Cooley MV, Grayburn PA, Jessen ME.
Esophageal Doppler monitor determinations of cardiac output and preload during cardiac operations. Ann Thoracic Surg. 2000;69(6):1782-1786.
72. Kincaid H, Fly M, Chang M. Noninvasive measurements of preload
using esophageal Doppler are superior to pressure-based estimates in
critically injured patients [abstract]. Crit Care Med. 1999;27(1):A111.
73. Mark JB, Steinbrook RA, Gugino LD, et al. Continuous noninvasive
monitoring of cardiac output with esophageal Doppler ultrasound during cardiac surgery. Anesth Analg. 1986;65(10):1013-1020.
74. Valtier B, Cholley BP, Belot JP, Coussay JE, Mateo J, Payen DM. Noninvasive monitoring of cardiac output in critically ill patients using transesophageal Doppler. Am J Respir Crit Care Med. 1998;158:77-83.
75. Micek ST, Roubinian N, Heuring T, et al. Before-after study of a standardized hospital order set for the management of septic shock. Crit
Care Med. 2006;34(11):2707-2713.
76. Saberi D, Caudwell L, McGloin H, Singer M. Proactive circulatory management in the first 4 hours postcardiac surgery: interim analysis of a
nurse-led, oesophageal Doppler-guided protocol [abstract]. Intensive
Care Med. 2000;26(3 suppl):S220.
77. Lynn-McHale Wiegand D, ed. AACN Procedure Manual for Critical Care.
6th ed. St Louis, MO: Elsevier Saunders: 2011.
78. Lynn-McHale Wiegand D, Carlson K, eds. AACN Procedure Manual for
Critical Care. 5th ed. St Louis, MO: Elsevier; 2005.
79. Edwards Lifesciences. Advanced hemodynamic monitoring. The FloTrac
sensor: stroke volume variation. http://www.edwards.com/products
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30, 2014.
80. Singer M. Continuous Haemodynamic Monitoring by Oesophageal Doppler
[doctoral dissertation]. London, England: University of London; April 1989.
81. Starling EH. The Linacre Lecture on the Law of the Heart. London, England:
Longmans, Green & Co; 1918.
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82. Ahrens T, Taylor L. Hemodynamic Waveform Analysis. St Louis, MO: WB

Saunders; 1992:432, 444-447.
83. Atkins D, Best D, Briss PA, et al; GRADE Working Group. Grading quality of
evidence and strength of recommendations. BMJ. 2004;328(7454):1490-1498.
84. Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an
American College of Chest Physicians task force. Chest. 2006;129(1):174-181.
85. Schnemann HJ, Jaeschke R, Cook DJ, et al; ATS Documents Development
and Implementation Committee. An official ATS statement: grading the
quality of evidence and strength of recommendations in ATS guidelines
and recommendations. Am J Respir Crit Care Med. 2006;174(5):605-614.
86. Mowatt G, Houston G, Hernndez R, et al. Systematic review of the clinical effectiveness and cost-effectiveness of oesophageal Doppler monitoring in critically ill and high-risk surgical patients. Health Technol Assess.
2009;13(7):iii-iv, ix-xii, 1-95. doi:10.3310/hta13070.
87. Agency for Healthcare Research and Quality. Esophageal Doppler ultrasound-based cardiac output monitoring for real-time therapeutic management of hospitalized patients: a review. http://www.cms.hhs.gov
/determinationprocess/downloads/id45TA.pdf. Published January 16,
2007. Accessed October 30, 2014.
88. Centers for Medicare and Medicaid Services. CMS manual system: pub
100-03 Medicare national coverage determinations. http://www.cms
.hhs.gov/Transmittals/Downloads/R72NCD.pdf. Published August 28,
2007. Accessed October 31, 2014.
89. Aetna Health Insurance. Clinical policy bulletin: esophageal Doppler
monitoring. Publication No. 0793. http://www.aetna.com/cpb/medical
/data/700_799/0793.html. Accessed October 31, 2014.
90. Centers for Medicare and Medicaid Services. CMS manual system: pub
100-03 Medicare national coverage determinations. https://www.cms.gov
/transmittals/downloads/R63NCD.pdf. Published December 15, 2006.
Accessed October 31, 2014.
91. CMS.gov. Billing and coding guidelines. Cardiac catheterization and

coronary angiography. http://downloads.cms.gov/medicare-coverage
-database/lcd_attachments/30719_6/L30719_CV006_CBG_010111
.pdf. Accessed November 24, 2014.
92. Poeze M, Greve J, Ramsay G. Meta-analysis of hemodynamic optimization:
relationship to methodological quality. Critical Care. 2005;9(6):R771-R779.
93. Prentice D, Sona C. Esophageal Doppler monitoring for hemodynamic
assessment. Crit Care Nurs Clin North Am. 2006;18:189-193.
94. Dellinger P, Levy M, Carlet J, et al; International Surviving Sepsis Campaign Guidelines Committee; American Association of Critical-Care
Nurses; American College of Chest Physicians; American College of
Emergency Physicians; Canadian Critical Care Society; European Society
of Clinical Microbiology and Infectious Diseases; European Society of
Intensive Care Medicine; European Respiratory Society; International
Sepsis Forum; Japanese Association for Acute Medicine; Japanese Society of Intensive Care Medicine; Society of Critical Care Medicine; Society
of Hospital Medicine; Surgical Infection Society; World Federation of
Societies of Intensive and Critical Care Medicine. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008 [published correction appears in Crit Care Med.
2008;36(4):1394-1396]. Crit Care Med. 2008;36(1):296-327.
95. Wo CC, Shoemaker WC, Appel PL, Bishop MH, Kram HB, Hardin E.
Unreliability of blood pressure and heart rate to evaluate cardiac output
in emergency resuscitation and critical illness. Crit Care Med. 1993;21(2):
218-223.
96. Shippy C, Appel P, Shoemaker W. Reliability of clinical monitoring to assess
blood volume in critically ill patients. Crit Care Med. 1984;12:107-112.
97. Ferrer R, Artigas A, Suarez D, et al; Edusepsis Study Group. Effectiveness
of treatments for severe sepsis: a prospective, multicenter, observational
study. Am J Respir Crit Care Med. 2009;180(9):861-866.
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CriticalCareNurse
27
CNE Test Test ID C1513: Stroke Volume Optimization: The New Hemodynamic Algorithm
Learning objectives: 1. Discuss the use of stroke volume optimization in a hypovolemic patient 2. Define corrected flow time, peak velocity, stroke distance,
and stroke index 3. State various methods used to obtain blood flow measurement
1. Which of the following hemodynamic values help determine

responsiveness to fluid replacement?
a. Stroke volume within normal values
b. Normal stroke volume with normal filling pressures
c. Adequate blood flow for tissue oxygenation without increasing
heart rate
d. Afterload and preload stabilized
5. Which of the following explains why clinicians prefer blood flow

monitoring versus blood pressure monitoring?
a. Compensatory mechanisms mask hypoperfusion
b. Afterload, preload, and contractility are influenced by medications
c. Blood pressure, MAP, and heart rate are late indicators of hypoperfusion
d. All of the above
6. Which of the following changes is expected in a patient who
received a 1000-mL fluid challenge that confirms hypovolemia?
a. Increase in PAOP
b. Increase in urine output
c. Increase in stroke volume, corrected flow time, and cardiac output
d. Increase in CVP and MAP
2. Which of the following is the first hemodynamic parameter to

decrease in hypovolemia?
a. Pulmonary artery occlusive pressure (PAOP)
b. Central venous pressure (CVP)
c. Cardiac output
d. Stroke volume
7. Volume and vasopressors are often the treatment of choice in a

patient with shock. Which of the following parameters are best used
as end points to guide therapy?
a. Stroke volume, peak velocity, and corrected flow time
b. Stroke volume, systemic vascular resistance, and central venous
oxygen saturation (ScvO2)
c. ScvO2, corrected flow time, and peak velocity
d. ScvO2 and stroke volume
3. After mitral valve replacement, your patients urine output

decreases over 3 hours. The monitor displays sinus tachycardia
with heart rate 108 beats/min, CVP 8 mm Hg, cardiac output 4
L/min, and mean arterial pressure (MAP) 80 mm Hg. The MAP
remains within normal range because of which of the following?
a. Normal cardiac output
b. No change in circulating volume
c. Compensatory mechanisms
d. MAP is an independent parameter
8. Nursing implications in obtaining hemodynamic data include

which of the following?
a. Proficiency in application of monitoring device
b. Application of data obtained to patient population
c. Achieving optimal signal acquisition
d. All of the above
4. Monitoring stroke volume gives the clinician insight into which

of the following?
a. Blood flow and circulating volume
b. Cardiac filling pressures
c. Oxygenation
d. Contractility
9. Mechanical ventilation with positive end-expiratory pressure can

impede blood flow and increase PAOP. How can clinicians determine proper interventions for this patient population?
a. Trend and optimize stroke volume
b. Trend cardiac filling pressures
c. Closely follow pulmonary vascularity on the chest radiograph
d. Trend blood pressure
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. a
b
c
d
2. a
b
c
d
3. a
b
c
d
4. a
b
c
d
5. a
b
c
d
6. a
b
c
d
7. a
b
c
d
8. a
b
c
d
9. a
b
c
d
Test ID: C1513 Form expires: February 1, 2018 Contact hours: 1.0 Pharma hours: 0.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 7 correct (78%)
Synergy CERP Category A Test writer: Carol Ann Brooks, BSN, RN, CCRN-K, CSC
Name
Program evaluation
Yes

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or mail this entire page to:
AACN, 101 Columbia
Aliso Viejo, CA 92656.
Objective 1 was met

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Objective 3 was met
Content was relevant to my
nursing practice

My expectations were met

This method of CNE is effective
for this content

The level of difficulty of this test was:
easy medium difficult
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it took me
hours/minutes.
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The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.
AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN
programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.
Feature
Use of a Nursing Checklist to

Facilitate Implementation of
Therapeutic Hypothermia
After Cardiac Arrest
KATHLEEN RYAN AVERY, RN, MSN, CCRN
MOLLY OBRIEN, MPH
CAROL DADDIO PIERCE, RN, MSN, CCRN
PRISCILLA K. GAZARIAN, RN, PhD
Therapeutic hypothermia has become a widely accepted intervention that is improving neurological outcomes
following return of spontaneous circulation after cardiac arrest. This intervention is highly complex but infrequently used, and prompt implementation of the many steps involved, especially achieving the target body
temperature, can be difficult. A checklist was introduced to guide nurses in implementing the therapeutic
hypothermia protocol during the different phases of the intervention (initiation, maintenance, rewarming, and
normothermia) in an intensive care unit. An interprofessional committee began by developing the protocol, a
template for an order set, and a shivering algorithm. At first, implementation of the protocol was inconsistent,
and a lack of clarity and urgency in managing patients during the different phases of the protocol was apparent.
The nursing checklist has provided all of the intensive care nurses with an easy-to-follow reference to facilitate
compliance with the required steps in the protocol for therapeutic hypothermia. Observations of practice and
feedback from nursing staff in all units confirm the utility of the checklist. Use of the checklist has helped reduce
the time from admission to the unit to reaching the target temperature and the time from admission to continuous
electroencephalographic monitoring in the cardiac intensive care unit. Evaluation of patients outcomes as related
to compliance with the protocol interventions is ongoing. (Critical Care Nurse. 2015;35[1]:29-38)
n the United States, 359 400 people experience an out-of-hospital cardiac arrest each year, and
less than 9.5% of those people survive.1 Out-of-hospital cardiac arrest continues to be associated
with high mortality, and among those patients who do survive the initial cardiac arrest, two-thirds die
as a result of neurological injury.2 Postresuscitation care is increasingly recognized as an integral component
in improving the quality of survival and neurological outcomes. Although advances have been made in
initial resuscitative efforts; anoxic neurological injury remains a major concern after return of spontaneous
circulation (ROSC).2,3 Therapeutic hypothermia improves neurological outcomes after ROSC.3
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CriticalCareNurse
29
Despite recommendations from the American Heart

Association,3 the European Resuscitation Council and
the International Liaison Committee on Resuscitation4
that therapeutic hypothermia be used in comatose survivors following ROSC, challenges to implementation of
therapeutic hypothermia in clinical practice remain.
Therapeutic hypothermia is a complex but uncommon
intervention, and because of this, prompt implementation
of the many steps involved and quickly achieving the
desired temperature goal can be difficult.
Background
In 2002, researchers in 2 studies5,6 reported improved
neurological outcomes and a decrease in mortality with
the use of therapeutic hypothermia after out-of-hospital
cardiac arrest. Recently published guidelines from both
the American Heart Association and the International
Liaison Committee on Resuscitation incorporated evidence from research
The effectiveness of a surgical safety and recommended
that clinicians implechecklist has been documented.
ment therapeutic
hypothermia to increase the likelihood of improved
neurological outcome.3,7 Brain cells die because of several
biochemical processes resulting from cardiac arrest and
the inflammatory process following that injury. Therapeutic hypothermia is believed to be effective because it reduces
cerebral metabolism, decreases cerebral blood flow, and
decreases intracranial pressure.8-10 The neuroprotective
mechanisms of therapeutic hypothermia are now widely

recognized and implemented as a standard of care.3
The American Heart Association recommended that
comatose adult patients with ROSC following out-ofhospital cardiac arrest be cooled to 32C to 34C (90F93F) for 12 to 24 hours, with the strongest evidence of
survival for those patients who had pulseless ventricular
tachycardia or ventricular fibrillation rhythms.3 Less
well understood is how the timing of these therapeutic
hypothermia interventions affects patients outcomes. In
the 2002 studies published by Bernard et al5 and the
Hypothermia After Cardiac Arrest Study Group,6 target
temperature was reached within 8 hours after ROSC.
Although a prospective observational study11 of 986
patients did not reveal an association between the timing
of therapeutic hypothermia and neurological outcomes,
observational evidence demonstrates a 20% increase in
risk of death for every hour delay in initiating therapeutic hypothermia.12 The evidence is not conclusive; however, the American Heart Associations 2010 guidelines
recommended initiating therapeutic hypothermia as
soon as possible after ROSC.3 Our institutions policy
states that therapeutic hypothermia should be initiated
within 6 hours of ROSC with a goal of achieving target
temperature within 4 hours of initiation of therapeutic
hypothermia. Therapeutic hypothermia has few absolute
contraindications. The ultimate decision to initiate therapeutic hypothermia should be based on an assessment
of the potential risks and benefits of hypothermia in
each individual patient while considering the complete
clinical situation and comorbid conditions.9,13
Authors
Kathleen Ryan Avery is the clinical educator for the cardiac intensive
care unit and co-chair of the Therapeutic Hypothermia Committee
at Brigham and Womens Hospital, Boston, Massachusetts.
Molly OBrien is the research coordinator in the cardiac intensive
care unit at Shapiro Cardiovascular Center at Brigham and
Womens Hospital.
Carol Daddio Pierce is the clinical educator in the medical intensive
care unit at Brigham and Womens Hospital.
Priscilla K. Gazarian is the nursing program director for resuscitative clinical practice at Brigham and Womens Hospital and an
associate professor of nursing at Simmons College, Boston,
Massachusetts.
Corresponding author: Priscilla K. Gazarian, RN, PhD, The Center for Nursing Excellence, Brigham and Womens Hospital, 1 Brigham Circle, 4th Floor, Suite 6, Boston
MA 02120 (e-mail: pgazarian@partners.org).
To purchase electronic or print reprints, contact the American Association of CriticalCare Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)
362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
30
CriticalCareNurse
Recommendations for the Use of

Checklists
The implementation of institution-specific standardized protocols, order sets, and a bundled care approach
have proven a successful method in combating the barriers to implementation of therapeutic hypothermia14-20
and were associated with an increased efficiency in
achieving target temperature.21,22
The effectiveness of a surgical safety checklist on rates
of postoperative death and complications was documented
by Haynes et al,23 who reported a decrease in death rate
and complication rate after implementation of a checklist. In addition to decreasing mortality and complication rates, surgical checklists have improved compliance
with safety measures, teamwork, and communication.24
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Local Problem
At our hospital, we have implemented therapeutic
hypothermia in 182 patients in the past 5 years. Until
2009, therapeutic hypothermia was exclusively implemented in the coronary care unit (CCU). Although most
patients who are treated with therapeutic hypothermia
continue to be admitted to the CCU (73%) or the medical
intensive care unit (18%), therapeutic hypothermia is
sometimes provided in the other intensive care units
(ICUs). The number of patients receiving therapeutic
hypothermia has increased steadily each year to a total
of 59 patients in 2013 (Figure 1). Because of the low frequency of therapeutic hypothermia cases and the large
number of nursing staff across different ICUs, months
can pass between case exposures, and each exposure
could be at a different phase of the protocol.
In a review of cases of therapeutic hypothermia at
our institution, we found inconsistencies in the implementation of the protocol and a lack of clarity and urgency in
managing the patients during the different phases of
the protocol (initiation, maintenance, rewarming, and
normothermia). Despite our having a standardized order
template and nursing policy for therapeutic hypothermia,
our data indicated a need for improvement in our implementation of the therapeutic hypothermia protocol.
Intended Improvement
Caring for patients after cardiac arrest in a critical
care unit is a complex, tense, and time-sensitive undertaking. Applying an infrequently used but multifaceted
procedure such as therapeutic hypothermia under these
conditions is challenging and may diminish reliable and
consistent implementation of the intervention. Barriers
to timely implementation exist, including a delayed
decision to implement therapeutic hypothermia, lack of
protocols to guide implementation, the volume of cardiac
www.ccnonline.org
No. of patients
Beginning in 2009, checklists have been adapted and

used to improve patients outcomes in other practice
situations such as in interdisciplinary rounds and
meetings, during shift handoff, and at discharge.25-29
Researchers have documented that tools such as checklists can increase adherence to evidence-based practice
guidelines,30 so we considered adding a checklist to our
therapeutic hypothermia bundle to support the safe,
effective, and efficient implementation of the therapeutic
hypothermia protocol.
40
35
30
25
20
15
10
5
0
2009
2010
2011
2012
2013
Year
CCU
MICU
SICU
Other
Figure 1 Number of patients who had therapeutic hypothermia

by type of intensive care unit.
Abbreviations: CCU, coronary care unit; MICU, medical intensive care unit;
SICU, surgical intensive care unit. Other includes neurological, cardiac surgery,
and thoracic intensive care units.
arrest patients treated, training, and experience of staff.31

Providing therapeutic hypothermia requires an interdisciplinary collaborative approach initiated in the field by
emergency medicine services (EMS) and continued by
the emergency department, catheterization laboratory,
and the ICUs. The different phases of therapeutic
hypothermia cause physiological changes that require
intense assessment, monitoring, and intervention to
manage shifts in hemodynamics (bradycardia, hypotension, hypovolemia), electrolytes (hyper- and hypoglycemia, hypo- and hyperkalemia), achieving desired
temperature,
Caring for patients after cardiac arrest
managing infection, and assessing in a critical care unit is a complex,
tense, and time-sensitive undertaking.
for evidence of
myoclonus and
seizure activity.8,9,32 Successful implementation of the
therapeutic hypothermia protocol requires collaboration
among many disciplines and is a labor-intensive task
that requires continuous monitoring, assessment, and
multitasking by the bedside nurse to rapidly initiate the
many required protocol interventions during the 4 different phases of therapeutic hypothermia in a 3- to 5-day
period.31-33 In addition, nurses are responsible for promoting patients comfort and providing support to
patients families during the tenuous period after cardiac arrest.33-35
Although we were decreasing the time it took to achieve
target temperature, we were not reliably achieving our
CriticalCareNurse
31
Table
Times needed to complete therapeutic hypothermia interventions after admission to coronary care unit
Time, hours:minutes, median (interquartile range)

Before checklist
(n = 60)
After checklist
(n = 61)
Goal time
Start of therapeutic hypothermia to target temperature
7:00 (5:30-8:11)
6:30 (4:32-9:57)
< 4:00
Admission to unit to target temperature
5:47 (4:22-8:03)
4:00 (2:00-6:56)
< 3:00
Time measured
Admission to unit to placement of Arctic Sun

Admission to unit to continuous electroencephalographic
monitoring
target temperature in fewer than 4 hours after the initiation of therapeutic hypothermia (see Table). We proposed
a checklist as an intervention to improve achieving the
desired temperature goal within the recommended 4
hours and to manage the various protocol interventions
and minimize complications.
Since the release of the World Health Organizations
surgical safety checklist study,23 checklists have gained
prominence in clinical care as visual tools for standardizing communiChecklists have been documented as cation, especially
effective tools to improve teamwork during high-risk
processes.24 Because
and communication.
checklists have been
documented as effective tools to improve teamwork
and communication,24 we theorized that a checklist
could improve performance in reaching target temperature during therapeutic hypothermia.
Study Purpose
The purpose of our checklist was to guide ICU nurses
and the health care team in safely, effectively, and efficiently implementing the therapeutic hypothermia
protocol during the different phases of the intervention
in the ICU to decrease the time required to achieve the
target temperature.
Methods
Ethics
Our cardiac arrest registry was reviewed by the
Human Research Committee and was approved as
research limited to health medical records. Data from
the cardiac arrest registry were collected and managed
by using REDCap electronic data capture tools hosted
at Brigham and Womens Hospital. REDCap (Research
32
CriticalCareNurse
1:05 (0:30-2:29)
0:30 (0:30-1:00)
37:27 (15:00-55:27)
14:17 (9:15-22:42)
< 18:00
Electronic Data Capture) is a secure, web-based application designed to support data capture for research
studies.36 All patient identifiers (date of birth, medical
record number) are restricted from data reporting
within REDCap to protect the confidentiality of the data.
Setting
Brigham and Womens Hospital is a 793-bed academic
medical center with 100 adult ICU beds in 6 units and a
total of 436 critical care staff nurses.
Planning the Intervention: Improving
Therapeutic Hypothermia Implementation
With a Checklist
To achieve optimal, consistent standardized care
for patients receiving therapeutic hypothermia in our
hospital, an interprofessional committee on therapeutic
hypothermia was established in 2008 with representation from nursing, pharmacy, cardiology, neurology,
pulmonary critical care, emergency medicine, and
interventional cardiology.37 Our committee began by
developing a protocol in 2009, an order template in
2010, and a shivering algorithm in 2011. These resources
had been developed as we gained experience with the
implementation of therapeutic hypothermia and were
based on current evidence. Nurses received ongoing
education on the therapeutic hypothermia protocol via
in-service training sessions and annual competency sessions. As we gained experience in caring for patients
receiving therapeutic hypothermia and as new data
were published, our hospitals protocol for therapeutic
hypothermia underwent annual revisions.
Based on the positive feedback from the ICU nursing
staff on the 1-page shivering algorithm and building on
the success of the World Health Organizations surgical
www.ccnonline.org
safety checklist,23 the nursing representatives on the

Therapeutic Hypothermia Committee proposed developing a checklist on therapeutic hypothermia for intensive care nurses. The goal of this checklist was to improve
the timeliness of achieving the target temperature within
the recommended 4 hours and to manage the various
interventions at all phases of the therapeutic hypothermia protocol while minimizing complications and maintaining safe and high-quality patient care. Relying on a
standardized protocol improves the quality and outcomes
of an intervention such as therapeutic hypothermia.9,1618,20,22
Checklists have also been used as tools to increase
the quality and safety in many industries and have gained
popularity in health care. Checklists standardize the
tasks that must be completed and provide a transparent
framework to ensure protocol adherence, all while
establishing a process to share information and support
among caregivers.38
Checklist Development
The design of our checklist was motivated by our
desire to shorten the time required to reach the target
temperature and provide direction to managing the many
treatment interventions at each stage of the therapeutic
hypothermia protocol. Our existing guideline and order
template became the key interventions captured on the
checklist. Based on the American Heart Associations
guidelines for postresuscitation care and our guidelines
of care for use of therapeutic hypothermia after cardiac
arrest, we divided interventions into the 4 stages of the
therapeutic hypothermia protocol. The first phase is the
initiation of cooling from 0 to 4 hours. The goal is that
the patient will reach the target temperature of 33C
(91.4F) within 4 hours of initiation of therapeutic
hypothermia. The next phase is maintenance of cooling from 4 to 24 hours. Cooling is maintained for 24
hours from the initiation of therapeutic hypothermia.
Twenty-four hours after the initiation of therapeutic
hypothermia, the rewarming phase begins. Rewarming
is done very slowly at a rate of 0.25C (0.5F) per hour
and takes 12 to 16 hours. Once the patient reaches 37C
(98.6F), the last phase, normothermia, is maintained
for 48 hours. We were now able to identify all of the
interventions that needed to be completed to achieve
our first goal of target temperature within 4 hours.
The checklist is designed as 1 page to be kept at the
bedside. It is a quick, easy, just-in-time resource for
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nurses, includes a box to be checked when each item is

completed, and is used during handoff communication.
The checklist was first pilot tested in the CCU and was
revised on the basis of staff feedback. We incorporated
the checklist into the hospital policy available online,
and we placed hard copies in a reference book on the unit
for nurses to integrate into patient care. This therapeutic
hypothermia checklist (Figure 2) for intensive care nurses
has been in use since September 2012.
Evaluation and Analysis
Data are collected in real time by our research coordinator. An initiation of therapeutic hypothermia report
is generated each time orders for therapeutic hypothermia
are implemented and is sent to all members of the therapeutic hypothermia committee for review. This report
includes patients demographics (eg, age), initial rhythm,
downtime, times from ROSC to arrival in the emergency
department, from emergency department to ICU admission, from ROSC to target temperature, from ICU
admission to target temperature, from ICU admission
to placement of Arctic Sun surface cooling device, and
from ICU admission to electroencephalography. The
reports allow us to accurately track the use of therapeutic hypothermia throughout the hospital and to review
cases both as they occur and over time.
The development and implementation of the therapeutic hypothermia checklist have provided the nursing staff in all ICUs with an easy-to-follow reference to
facilitate compliance with the required interventions in
the therapeutic hypothermia protocol. Since 2009, we
have cared for 183 patients receiving therapeutic hypothermia at our institution. Despite the various systems in
place, the median time
to target temperature
Nurses report that the checklist
from ROSC was 8 hours, helps them prepare, prioritize,
double our desired goal and organize their interventions.
of 4 hours. Since we
began using the checklist, we have reduced our time
from CCU admission to target temperature from a
median time of 5 hours 47 minutes (2009-2011) to 4
hours (2012-2013) in the CCU, where the checklist was
first pilot tested and used consistently. The time from
CCU admission to placement of the Arctic Sun cooling
device has decreased from 1 hour before use of the
checklist to 30 minutes since implementation of the
checklist (see Table).
CriticalCareNurse
33
Patient ID stamp
initiated:________
Date/Time TH
This is intended to be a quick reference onlyRefer to the ADM 1.4.18 and Nursing NCPM ICU-44 policies for details
on patient management of therapeutic hypothermia. This document is not part of the medical record.
Initiation of cooling 0-4 hours

(goal: target temp within
4 hours)
BICS OE template completed

by house staff
EEG ordered in Precipio
Establish 2 sources of
temperature
Monitoring to Arctic Sun
preferred order is Foley,
esophageal, rectal
Place Arctic Sun pads on
admission to ICU
Sedation infusion (propofol or
midazolam)
Analgesia infusion (fentanyl or
hydromorphone)
BIS monitoring
Baseline TOF
Magnesium 4 g IVB over 4
hours
Cover head, hands, feet with
towels/blankets
BSAS every hour
If BSAS 1, follow shivering algorithm
BBG q 1 hour
If Glu > 200, start modified
BHIP
Turn insulin OFF if
Glu < 200
Draw baseline admission labs:
Chem 20, CBC, CK, CK-MB,
cTnt, lactic acid, ABG
____ 4 hours after initiation:
serum GLU, K
Maintenance of cooling
4-24 hours
Rewarming 24-38 hours

Date/time:______
Normothermia x 48 hours
AFTER target temp 98.6F
BIS monitoring
Continue sedation/analgesia
infusions
BSAS q 1 hour
If BSAS 1, follow
shivering algorithm
BBG q 1 hour
If Glu > 200, start modified
BHIP
Turn insulin OFF if Glu < 200
MAP goal > 75 mm Hg
CVP goal > 12 mm Hg
Document hourly: Patient temp,
Arctic Sun flow, water temp
EEG performed
Draw labs q 4 hours after TH
initiation at:
____ 8 hours: Chem 7,
CBC, CK, CK-MB, cTnt,
lactic acid, ABG
____ 12 hours: Glu, K,
cultures: blood, sputum,
urine
____ 16 hours: Chem 7,
lactic acid, ABG
____ 20 hours: Glu, K
____ 24 hours: Chem7,
lactic acid, ABG
Hold K+ replacement 4 hours
prior to rewarming
(unless K < 3.5)
Rewarming begins 24 hours

after initiation of TH
Set Arctic Sun to:
target temp of
98.6F/37C
rewarm at rate of 0.5F
(0.25C) per hour
(it will take 12-16
hours to rewarm)
Refer to directions on
Arctic Sun and in
nursing policy
Continue sedation/analgesia
infusions
Draw labs q 4 hours after TH
initiation at:
BIS monitoring
BSAS q 1 hour
If BSAS 1, follow
shivering algorithm
during rewarming
BBG q 1 hour
If insulin infusion, check
BBG every 30 minutes
Turn insulin OFF if
Glu < 200
Document hourly: Patient
temp, Arctic Sun flow,
water temp
Once target temp of
98.6F/37C achieved:
Normothermia phase
Wean off of sedation
Keep Arctic Sun pads on and

target temp set at
98.6F/37C for 48 hours
Wean/discontinue sedation/
analgesia infusions
If NMBA infusion
D/C NMBA infusion
Assess TOF every hour
When TOF 4/4, wean/
discontinue sedation/
analgesia
Observe for temp spikes and
rigors
Refer to normothermia
section of shivering
algorithm
Document hourly: patient
temp, Arctic Sun flow,
water temp
Target temp (91.4F) achieved

within 4 hours of initiating TH
IF NOTrefer to shivering
algorithm and Arctic Sun
troubleshooting chart/guidelines
Document hourly: Patient
temperature, Arctic Sun flow,
water temperature
Determine time to begin
rewarming
Draw labs every 8 hours x 2:

Glu, K, Mg, Ca
_______
_______
Figure 2 Therapeutic hypothermia (TH) after cardiac arrest: ICU nursing checklist.
Abbreviations: ABG, arterial blood gas analysis; BBG, bedside blood glucose; BHIP, Brigham and Womens Hospital intravenous insulin protocol; BICS OE, Brigham Integrated Computing System order entry; BIS, bispectral index monitoring; BSAS, Bedside Shivering Assessment Scale; Ca, calcium; CBC, complete blood cell count;
CK, creatine kinase; CK-MB, creatine kinaseMB fraction; cTnt, cardiac troponin T; CVP, central venous pressure; D/C, discontinue; EEG, continuous electroencephalographic monitoring; Glu, glucose; ICU, intensive care unit; IVB, intravenous bolus; K, potassium; labs, samples for laboratory tests; MAP, mean arterial pressure; Mg, magnesium; NMBA, neuromuscular blocking agent; q, every; temp, temperature; TOF, train of four.
Courtesy Brigham and Womens Hospital, Boston, Massachusetts.
34
CriticalCareNurse
www.ccnonline.org
CASE STUDY
r C, a 55-year-old man, was out jogging one

evening when he experienced a witnessed ventricular fibrillation cardiac arrest. Bystander
cardiopulmonary resuscitation was initiated, and EMSactivated prompt defibrillation and ROSC were achieved
within 10 minutes. EMS initiated therapeutic hypothermia
with an infusion of iced normal saline (4C) and ice packs
applied to the neck, axillae, and groin. Mr C arrived in the
emergency department at 9:05 PM with a body temperature
of 36.5C (97.8F). Despite Mr Cs history of hypertension
and coronary artery disease (drug-eluting stent to circumflex
artery 5 years earlier), the 12-lead electrocardiogram did
not show evidence of myocardial ischemia or infarction.
An assessment by the emergency departments team and a
neurology consultant confirmed that Mr C met the criteria
for therapeutic hypothermia: he had experienced a ventricular fibrillation cardiac arrest with ROSC after 10 minutes,
he was comatose (no meaningful response to verbal stimuli),
and there were no contraindications for therapeutic hypothermia. The emergency department continued cooling with
ice packs and initiated continuous infusions of propofol
and fentanyl.
Mr C was admitted to the CCU at 12:30 AM with a body
temperature of 35C (95.2F). The CCU nursing staff had
prepared for his arrival and anticipated Mr Cs care needs
by using the therapeutic hypothermia checklist. The physicians had entered the therapeutic hypothermia order set and
the necessary equipment including the Arctic Sun surface
Observations of practice and feedback from the

nursing staff in all the ICUs all support the utility of the
therapeutic hypothermia checklist for intensive care
nurses. The checklist has been implemented in units
other than the CCU where therapeutic hypothermia is
used less often. Nurses have reported that using the
therapeutic hypothermia checklist helps them prepare,
prioritize, and organize their interventions when admitting a critically ill patient. Nurses have reported that the
checklist guides nursing documentation and ensures
that future interventions remain on schedule, while also
supporting teamwork and communication. The checklist helps the nurses to focus on the immediate tasks
and simultaneously view the entire process from beginning to end so that they can anticipate changes as the
patient progresses. We have observed increased use of
the shivering algorithm and nursing documentation of
www.ccnonline.org
cooling device was ready for placement upon Mr Cs arrival

and was started at 12:40 AM. Interventions to prevent shivering and maintain comfort were initiated. Bispectral monitoring was initiated, and a baseline train of 4 was obtained. Blood
samples for laboratory tests were collected per the therapeutic
hypothermia protocol. Mr C did experience some shivering
that was promptly treated by referring to the shivering algorithm from the therapeutic hypothermia checklist and a target
temperature of 32.7C (90.9F) was achieved at 2 AM. Electroencephalographic monitoring was initiated at 9 AM. Cooling
was maintained for 24 hours from the start of therapeutic
hypothermia. The nurse coming on for the next shift was
alerted that Mr C would be due to be rewarmed in 2 hours.
Using the checklist, the nurses reviewed the completed interventions during the maintenance phase. A potassium level of
3.2 mEq/L had been repleted per protocol 2 hours previously.
The glucose levels had remained less than 200 mg/dL, so
insulin had not been initiated during the cooling phase. Mr C
rewarmed at a rate of 0.25C (0.5F) per hour without significant hypotension, hypoglycemia, or hyperkalemia. Normothermia (37C, 98.6F) was achieved in 14 hours and
maintained per protocol for 48 hours. Mr Cs neurological
and cardiac status improved during his 5-day stay in the CCU,
and he was discharged home on day 10 after receiving an
implantable cardioverter defibrillator. He had good neurological recovery as evidenced by a Cerebral Performance Category
score of 1. Mr C returned to work 2 weeks after discharge
from the hospital and resumed his exercise regimen.
the management of shivering. The checklist has provided

an opportunity for case discussions with the clinical nurse
educator and has led to an increased understanding of
the rationale for the different therapeutic hypothermia
interventions, including the early use of electroencephalographic monitoring. We have noted a decrease in time
from CCU admission to initiation of continuous electroencephalographic monitoring from 37.5 hours to 14.25
hours (see Table). The nurses have stated that the therapeutic hypothermia checklist aids in clinical decision
making by providing prompts to assist with maintaining
hemodynamic stability and preventing complications
from therapeutic hypothermia.
Discussion
The use of the therapeutic hypothermia checklist helps
maintain consistent care of patients in the dynamic ICU
CriticalCareNurse
35
environment, where many team members need to collaborate with one another. Further, it supports nursing
practice by decreasing the uncertainty for nurses less
familiar with implementing the protocol in this complex
time-pressured situation.
We have introduced a novel checklist for the implementation of therapeutic hypothermia and demonstrated
further support for the growing body of evidence indicating that checklists and other types of cognitive aids
are effective in improving various complex processes.30
Using a checklist for therapeutic hypothermia has many
implications in addition to the potential to improve
patients outcomes. Given that checklists have been
documented as improving teamwork and communication, their use in therapeutic hypothermia could lead to
improved interdisciplinary collaboration. Further, this
type of support for nursing work increases nurses
autonomy and allows them more time to focus on providing holistic care to patients and patients families.
Limitations
This report of the implementation of an ICU nursing
checklist for therapeutic hypothermia to integrate the
evidence for therapeutic hypothermia into practice is
limited by the lack of control over possible confounding
variables that may have affected the time to achieve the
temperature target. Although our practice has improved,
we cannot conclude that this is solely a result of using
the checklist. Nonetheless, we easily integrated the
checklist into practice, and it can be adapted for use in
other institutions.
Summary
Thus far, the therapeutic hypothermia checklist for
intensive care nurses has helped the CCU improve 2
metrics related to the implementation of evidence-based
practice of therapeutic hypothermia: the time from CCU
admission to achieving the target temperature and the
time from CCU admission to continuous electroencephalographic monitoring.
Our next challenge will be to focus on the processes
within our system to continue the cooling initiated by
EMS and decrease the time from ROSC to ICU admission. Further evaluation of compliance with the therapeutic hypothermia checklist and the effects on
patients outcomes is needed for continuous quality
improvement. CCN
36
CriticalCareNurse
Acknowledgments
The authors thank Annmarie Chase, RN, MSN, CEN ED, clinical flow manager,
Benjamin M. Scirica, MD, MPH (co-chair), and all members of the Therapeutic
Hypothermia Committee at Brigham and Womens Hospital for their guidance
and support in the development of the therapeutic hypothermia checklist for
intensive care nurses and the nursing staff of the CCU and medical ICU for their
feedback on the implementation of the checklist.
None reported.
Now that youve read the article, create or contribute to an online discussion about
this topic using eLetters. Just visit www.ccnonline.org and select the article you
want to comment on. In the full-text or PDF view of the article, click Responses
in the middle column and then Submit a response.
To learn more about therapeutic hypothermia, read Use of Therapeutic Hypothermia in Cocaine-Induced Cardiac Arrest: Further
Evidence by Scantling et al in the American Journal of Critical Care,
January 2014;23:89-92. Available at www.ajcconline.org.
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Nurs Crit Care. 2008;13(6):305-309.
34. Cushman L, Warren ML, Livesay S. Bringing research to the bedside: the
role of induced hypothermia in cardiac arrest. Crit Care Nurs Q.
2007;30(2):143-153.
35. McKean S. Induced moderate hypothermia after cardiac arrest. AACN
Adv Crit Care. 2009;20(4):342-353.
36. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research
electronic data capture (REDCap)a metadata-driven methodology and
workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381.
37. Szumita PM, Baroletti S, Avery KR, et al. Implementation of a hospital-wide
protocol for induced hypothermia following successfully resuscitated
cardiac arrest. Crit Pathw Cardiol. 2010;9(4):216-220.
38. Winters BD, Gurses AP, Lehmann H, Sexton JB, Rampersad CJ, Pronovost
PJ. Clinical review: checkliststranslating evidence into practice. Crit Care.
2009;13(6):210.
www.ccnonline.org
CriticalCareNurse
37
CCN Fast Facts
CriticalCareNurse
Use of a Nursing Checklist to Facilitate

Implementation of Therapeutic Hypothermia
After Cardiac Arrest
Facts
Therapeutic hypothermia has become a widely
accepted intervention that is improving neurological
outcomes following return of spontaneous circulation
(ROSC) after cardiac arrest. This intervention is highly
complex but infrequently used, and prompt implementation of the many steps involved, especially achieving
the target body temperature, can be difficult.
A checklist was introduced to guide nurses in
implementing the therapeutic hypothermia
protocol during the different phases of the intervention (initiation, maintenance, rewarming,
and normothermia) in an intensive care unit.
We divided interventions into the 4 stages of
the therapeutic hypothermia protocol so that we
were able to identify all of the interventions that
needed to be completed to achieve our first goal
of target temperature within 4 hours.
The first phase is the initiation of cooling from
0 to 4 hours. The goal is that the patient will reach
the target temperature of 33C (91.4F) within 4
hours of initiation of therapeutic hypothermia.
The next phase is maintenance of cooling from
4 to 24 hours. Cooling is maintained for 24 hours
from the initiation of therapeutic hypothermia.
Twenty-four hours after the initiation of therapeutic hypothermia, the rewarming phase
begins. Rewarming is done very slowly at a rate of

0.25C (0.5F) per hour and takes 12 to 16 hours.
Once the patient reaches 37C (98.6F), the last
phase, normothermia, is maintained for 48 hours.
The checklist is a quick, easy resource for nurses,
and is used during handoff communication. The
nursing checklist has provided all of the intensive
care nurses with an easy-to-follow reference to
facilitate compliance with the required steps in
the protocol for therapeutic hypothermia.
Using a checklist for therapeutic hypothermia has
many implications in addition to the potential to
improve patients outcomes. Given that checklists
have been documented as improving teamwork
and communication, their use in therapeutic
hypothermia could lead to improved interdisciplinary collaboration. Further, this type of support
for nursing work increases nurses autonomy and
allows them more time to focus on providing
holistic care to patients and patients families.
Use of the checklist has helped reduce the time from
admission to the unit to reaching the target temperature and the time from admission to continuous electroencephalographic monitoring in the
cardiac intensive care unit. Evaluation of patients
outcomes as related to compliance with the protocol interventions is ongoing. CCN
Avery KR, OBrien M, Pierce CD, Gazarian PK. Use of a Nursing Checklist to Facilitate Implementation of Therapeutic Hypothermia After Cardiac Arrest. Critical Care
Nurse. 2015;35(1):29-38.
38
CriticalCareNurse
www.ccnonline.org
Feature
Nonpharmacological
Interventions to Prevent
Delirium: An EvidenceBased Systematic Review
RYAN M. RIVOSECCHI, PharmD
PAMELA L. SMITHBURGER, PharmD, MS, BCPS
SUSAN SVEC, RN, BSN, CCRN
SHAUNA CAMPBELL, RN, BSN
SANDRA L. KANE-GILL, PharmD, MS
Development of delirium in critical care patients is associated with increased length of stay, hospital costs, and
mortality. Delirium occurs across all inpatient settings, although critically ill patients who require mechanical
ventilation are at the highest risk. Overall, evidence to support the use of antipsychotics to either prevent or
treat delirium is lacking, and these medications can have adverse effects. The pain, agitation, and delirium
guidelines of the American College of Critical Care Medicine provide the strongest level of recommendation
for the use of nonpharmacological approaches to prevent delirium, but questions remain about which nonpharmacological interventions are beneficial. (Critical Care Nurse. 2015;35[1]:39-51)
elirium has a substantial impact on health care. This complication is associated with a
15-day increase in hospital length of stay (LOS),1 a financial impact of $4 billion to $16 billion
annually,2 and a 19% increase in 6-month mortality.3 Delirium is common across all patient
settings; the prevalence, however, varies according to acuity of illness. Delirium develops in general
medicine patients at rates ranging from 11% to 42%.4 The highest prevalence of delirium, as high as 87%,
occurs in critically ill patients.5 Understanding the impact of delirium on hospitalized patients makes
prevention and optimal treatment of this complication a priority. Two approaches are used to manage
delirium: use of pharmacological agents and application of nonpharmacological therapies.

1. Describe the nursing literature on nonpharmacological interventions to prevent delirium
2. Discuss nonpharmacological interventions that have been shown to be effective in preventing delirium
3. Explain the tools developed for the measurement of delirium in intensive care unit patients
www.ccnonline.org
CriticalCareNurse
39
The 2013 pain, agitation, and delirium guidelines6 of

the American College of Critical Care Medicine provide
recommendations for the use of pharmacological agents
in the prevention and treatment of delirium. Because of
a lack of compelling data, the guidelines do not provide
a recommendation for a pharmacological protocol or for
a combined nonpharmacological and pharmacological
protocol for prevention of delirium. Furthermore, the
guidelines give a -2C recommendation for pharmacological prevention with either haloperidol or atypical
antipsychotics. The lack of evidence supporting the use
of pharmacological agents creates a void in the effective
management of delirium.
The guidelines6 give the highest grade within the
delirium section (1B) to a nonpharmacological prevention strategy, meaning the recommendation is a strong
one backed by a moderate level of evidence. Unfortunately, most of the literature is on nonpharmacological
interventions used in either general medicine, geriatric,
or perioperative patients.7-16 Although critically ill
patients certainly differ from most of the populations of
Authors
Ryan M. Rivosecchi is a second-year pharmacy resident in critical
care at the University of Pittsburgh Medical Center, Presbyterian
Hospital, Pittsburgh, Pennsylvania.
Pamela L. Smithburger is an assistant professor of pharmacy and
therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh,
Pennsylvania, and a clinical specialist in the medical intensive care
unit at the University of Pittsburgh Medical Center, Presbyterian
Hospital.
Susan Svec is the clinical director of the medical intensive care unit,
University of Pittsburgh Medical Center, Presbyterian Hospital. She
recently graduated from the masters of leadership and administration
program at California University of Pennsylvania, California,
Pennsylvania.
Shauna Campbell is the nursing director of the medical intensive care
unit at the University of Pittsburgh Medical Center, Presbyterian
Hospital.
Sandra L. Kane-Gill is an associate professor of pharmacy and
therapeutics at the University of Pittsburgh School of Pharmacy.
She has secondary appointments in the School of Medicine in the
Clinical Translational Science Institute, Department of Critical
Care Medicine, and the Department of Biomedical Informatics.
She is also the critical care medication safety pharmacist at the University of Pittsburgh Medical Center in the Department of Pharmacy.
Corresponding author: Sandra Kane-Gill, 918 Salk Hall, 3501 Terrace St, Pittsburgh,
PA 15261 (e-mail: slk54@pitt.edu).
To purchase electronic or print reprints, contact the American Association of CriticalCare Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)
362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
40
CriticalCareNurse
patients studied, one can reasonably assume that critically

ill patients, who are at the highest risk for delirium, would
also benefit from nonpharmacological interventions. Large
randomized controlled trials with a multi-interventional
approach that includes pharmacological and nonpharmacological approaches to prevent delirium are needed.17
Any appropriate attempt at such a study requires a strong
understanding of nonpharmacological approaches. The
purpose of this systematic review is to summarize the
available literature on nonpharmacological management
of delirium among all populations of patients. The ultimate goal is to identify which strategies are beneficial to
facilitate the development of a nonpharmacological protocol that could be implemented for critically ill patients.
Methods
A literature search was completed by using MEDLINE
and EMBASE. With PubMed, the following terms were
used to search MEDLINE for material from 1946 to
October 15, 2013: delirium AND (critically ill, intensive
care, ICU, intensive care unit, OR critical illness), AND
(treatment, prevention, prophylaxis, adjunctive therapy,
OR adjunct therapy). Additional searches in MEDLINE
were then performed with the terms (mobility, animation,
exercise, rehabilitation, physical therapy, OR bicycle),
(light, window, curtains, shades, OR blinds), (earplugs,
ear, noise, OR hearing aid), (sleep, sleep hygiene, OR
sleep deprivation), (eyeglasses, glasses, OR magnifying
lens), orientation, and hydration, each combined with
AND delirium, AND (critically ill, intensive care, ICU,
intensive care unit, OR critical illness). EMBASE was
searched by using the same strategy. The search was
restricted to studies conducted in humans and reported
in English. A second reviewer independently performed
the same search for validation. The titles of all citations
retrieved from the search were reviewed for relevance.
On the basis of the relevance of the title, articles were
selected to be reviewed at the abstract level. Abstracts were
considered for full-text review if delirium was measured
as an outcome (incidence or severity), and the screening
for delirium was completed by using a standardized screening tool. No further review of an abstract was done if the
study covered was not original research, addressed exclusively pharmacological approaches, or used a combination
of pharmacological and nonpharmacological approaches.
If, after review, the abstract was still deemed applicable,
a full-text review was done in which the same inclusion
www.ccnonline.org
and exclusion criteria were applied

to the text of the article. No inclusion
restrictions were placed on the study
setting or population of patients
(critically ill or not critically ill).
Studies with mixed nonpharmacological interventions, including nonpharmacological protocols with
many interventions, were included.
The exclusion of any involvement of
pharmaceuticals was necessary to
evaluate the true benefit of a nonpharmacological protocol and minimize confounding variables. The
references of the included articles
were reviewed to ensure a comprehensive assessment.
EMBASE
1540 citations
MEDLINE
1104 citations
Limit to English
and humans 821
Titles screened for relevance
89 Selected for further
review of abstract
References
reviewed for
inclusion
54 Selected
for full-text
review
10 Included
7 Included
Results
Abstracts screened outcomes,

delirium screening, and pharmacological
interventions
44 Excluded
24 were not original research
6 did not measure delirium or did not
use standard delirium measurement
5 contained pharmacological intervention
5 were not full-text articles
4 did not involve an intervention
17 Included
in review
All Studies
A total of 17 articles7-24 met the
inclusion criteria and were selected
Figure Breakdown of articles selected in literature search.
for review (see Figure and Tables 1
and 2). Seven studies18-24 were done
in critically ill patients, 5 in geriatric
nonpharmacological intervention. Additionally, among
9-13
14-16
general medicine patients, 3 in postoperative patients,
the 6 evaluations7-10,13,18 of the severity of delirium, all but
7,8
and 2 in patients who had a hip fracture. A total of 13
1 study9 indicated a reduction in severity. Patients LOS
of the studies were prospective investigations,7-11,13,15,16,18,21-24
was examined in 6 studies.7,8,11,18-20 Of the 6 studies, the
14-16,24
and 4 were randomized control trials.
The Confusion
results of 2 revealed a decrease in LOS.11,19 Among the 3
Assessment Method or the Confusion Assessment Method
studies18-20
Delirium is associated with multiple negative
for the Intensive Care Unit (CAM-ICU) was the most fredone in the
consequences, including increased length
quently used tool and was used in 10 studies.7-10,13,19-23 The
ICU, only 1
of stay, higher health care costs, and even
Neelon and Champagne Confusion Scale was used in 4
indicated a
increased mortality.
evaluations,14-16,24 and the Intensive Care Delirium Screenreduction in
18
19
ing Checklist, the Diagnostic and Statistical Manual of
LOS. When
12
Mental Disorders (Fourth Edition; DSM-IV), and the
any outcome related to delirium (incidence, duration,
Delirium Screening Scale12 were each used once. The
severity) was examined, only 2 studies11,19 did not show
frequency of delirium screening ranged from less than
any benefit from the addition of a nonpharmacological
daily to 3 times per day.
intervention.
The incidence of delirium was determined in 12
A total of 28 unique nonpharmacological intervenstudies.7-15,18-21 Among these, 9 revealed a benefit of the
tions were used in the clinical studies. The most comnonpharmacological intervention.8-10,12-15,20,21 Table 3 gives
mon interventions associated with any clinical benefit
the interventions used in the individual studies. Among
were mobilization,8,10,20-23 reorientation,9,10,13,18,21 education
the interventions that were beneficial, the mean reducof nurses,7,10,12,18,23 and music therapy.9,16,18,20,21 A single
tion in the incidence of delirium was 24.7%, with a
nonpharmacological intervention was examined in 5
7,8,10,11,22,23
the durarange of 9.7% to 31.8%. In 6 studies,
studies,12,14-16,24 and multiple nonpharmacological intertion of delirium decreased after the addition of the
ventions were examined in 12 investigations.7-10,11,13,18-23
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CriticalCareNurse
41
Table 1
Reference,
year
Milisen et al,
2001
Design
Studies included that involved patients who were not critically ill
Screening tool
used (frequency)
Population (N)
Notable exclusions
Nonpharmacological interventions
Prospective
CAM, modified CAM Hip fracture,

emergency
department/
trauma, (26)
Marcantonio
et al,8 2001
Prospective,
randomized,
double-blind
CAM (daily)
Hip fracture,
65 years old
(126)
Metastatic cancer,
life expectancy
< 6 months
Module: dehydration, dentures, nutrition

supplements, mobilization (physical/occupational therapy), glasses, hearing aids,
clock, calendar, family presence
Inouye et al,9
1999
Prospective,
individual
matching
CAM (daily)
General medicine,
> 70 years old
(852)
Inability to complete
interview, low risk
for delirium
Protocol: orientation with care-team names

and days schedule, cognitive stimulation
activities, sleep protocol (warm drink,
relaxing music, back massage, noise
reduction, medication reschedule),
mobilization, visual aids, adaptive equipment,
hearing aids, hydration
Vidn et al,10
2009
Prospective,
controlled
CAM (daily)
Geriatric unit, age

> 70 years (542)
Expected hospital
stay <48 hours
Staff education
Poster in units
Orientation: clock, calendar, reason for
admission, date, place, family letter
Glasses, hearing aids
Sleep: warm drink, reschedule medications
and procedures
Mobilization: out of bed, catheter removal,
change positions, avoid restraints
Hydration: schedule water if ratio of blood urea
nitrogen to serum level of creatinine > 40
Nutrition
Lundstrm
et al,11 2005
Prospective
DSM-IV criteria
(days 1, 3, and 7)
Age > 70 years,

None
geriatric unit (400)
Tabet et al,12
2005
Case-control,
single-blind
Patient not present

Delirium Rating Scale Age > 70 years,
geriatric unit (250) on unit during
assessment
Medical team education
Age > 70 years,

Severe dementia
CAM (every
geriatric unit (37) Discharged within 48
other day)
hours
MDAS for severity if
CAM positive
Reorientation
Cognitive stimulation activities
Feeding assistance
Hydration
Vision protocol
Hearing protocol
Prospective
Caplan and
Harper,13 2007
Ono et al,14
2011
Randomized,
NEECHAM (no com- Esophagectomy
randomized
ment on how often) (22)
controlled trial
NEECHAM
Taguchi et al,15 Prospective,
randomized
(twice a day)
2007
controlled trial
McCaffrey,16
2009
Prospective,
NEECHAM
randomized
(daily for 3 days)
controlled trial
Nursing education
Poster in units
Medical team education

Reorganization of nursing staff
Bright light therapy
Esophagectomy
(11)
Bright light therapy
Hip or knee
surgery, > 75
years old (22)
Music therapy
Abbreviations: CAM, Confusion Assessment Method; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition); LOS, length of stay;
MDAS, Memorial Delirium Assessment Scale; NEECHAM, Neelon and Champagne Confusion Scale.
42
CriticalCareNurse
www.ccnonline.org
Outcomes
Comments
Antipsychotic use
No difference in incidence
3-day reduction in duration
Reduction in the severity (2.94 points)
No difference in LOS
Used resource study nurses

Screened only patients with CAM if NEECHAM identified them as
high risk
Screened only on days 1, 3, 5, and 8
Not reported
18% reduction in incidence

17% reduction in severity
1.2-day reduction in duration
No difference in LOS
Recommendations by geriatric consultant based on module

Recommendations not made if team was already doing them
Yes
5.1% reduction in incidence

56 fewer days delirious
28 fewer episodes
No difference in severity
No difference in recurrence
Less than 50% screened met inclusion criteria

Used research nurses
Geared intervention against risk factors
Same medical team provided care to both groups
Not reported

0.4 decrease in severity
2.5-hour reduction in duration
No difference in recurrence
No difference in functional decline
No difference in death
Must have risk factor for inclusion

Disposition to either geriatric or general medicine decided by
emergency department physician
Baseline characteristics not very similar
Note intervention more helpful in intermediate risk
Not reported
No difference in prevalence at 24 and 72 hours

4-day reduction in LOS
Extensive nursing training for the intervention
Not reported
9.7% reduction in point prevalence of delirium
Investigators had no role in day-to-day management

Use of daytime assessment and point prevalence could be
underestimated
Not reported

3.9-point reduction in MDAS score
Patient must have 1 risk factor for enrollment

Mean intervention time 14-19 h/wk
Very small sample size
Cost analysis
Not reported
31.7% reduction in prevalence
Mean LOS 24.8 days

Two dropped out because light was too bright
All male population
Screening stopped on postoperative day 5
Not reported
34% reduction in incidence at day 3
All male population
Not reported
Decrease in delirium each of the 3 days
All patients received standard pain, mobilization protocol

Music set to play 4 times a day for 1 hour; patients could do
more if they wished to
Not reported
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CriticalCareNurse
43
Table 2
Reference,
year
Design
Skrobik et al,
2010
18
Prospective
Arenson et al,19 Randomized,

cohort
2013
Studies included that involved patients who were critically ill
Screening tool
used (frequency)
Population (N)
Notable exclusions
Nonpharmacological interventions
ICDSC
(3 times a day)
Medical-surgical
ICU (1133)
Nursing education
Radio or compact disc player, reorientation
CAM, CAM-ICU
(3 times a day)
Cardiac surgery
(ICU/medicine)
(1010)
Private room, no barriers

Inpatient death,
preexisting structural Windows
brain disease
Visual or hearing
impairment
Kamdar et al,20
2013
Observational,
pre-post
design
CAM-ICU
(2 times a day)
Medical ICU (300)
Colombo
et al,21 2012
Prospective,
observational,
2 stage
CAM-ICU
(2 times a day)
Medical-surgical
ICU (314)
Schweickert
et al,22 2009
Prospective,
randomized
CAM-ICU (daily)
Medical ICU (104)
Mobilization, physical/occupational therapy

Absent limbs,
6-month mortality Passive range-of-motion exercises
<50%, cardiac arrest
Needham
et al,23 2010
Prospective
CAM-ICU (daily)
Medical ICU (57)
No exclusions
Mobilization, physical/occupational therapy

Nursing education
Van Rompaey
et al,24 2012
Prospective,
NEECHAM (daily)
randomized
controlled trial
ICU (136)
Minimum score of
10 on Glasgow
Coma Scale
Hearing impairment
Sedation
Ear plugs
Sleep: minimize overhead page, turn off

television, dim hallway, group care activities
Open blinds
Prevent napping
Mobilization
Minimize caffeine before bed
Sleep: earplugs, eye mask, music
Reorientation: follow mnemonicuse first
name, give information about location, LOS,
and illness
Clock
Read paper or book, music, radio
Reduction of night noise
Abbreviations: CABG, coronary artery bypass graft; CAM, Confusion Assessment Method; ICDSC, Intensive Care Delirium Screening Checklist; ICU, intensive care unit;
LOS, length of stay; NEECHAM, Neelon and Champagne Confusion Scale; RASS, Richmond Agitation-Sedation Scale.
In 6 of those studies,8-10,13,20,21 the interventions were

incorporated into a protocol. The mean number of
interventions used per study was 4.1.
ICU Studies
Of the 7 studies18-24 (Table 2) conducted in ICU patients,
6 investigations18,20-24 indicated a benefit in at least 1
delirium-related outcome, including incidence, duration,
or severity. In the remaining study,19 a 0.6-day reduction
in ICU LOS occurred. Only 1 study18 indicated a reduction
in subsyndromal delirium. In all but 1 study,24 more than
1 nonpharmacological intervention was used; mobilization, a noise-reduction protocol, and a sleep protocol
44
CriticalCareNurse
were used most often. All studies20-24 that included either

mobilization or noise-reduction or sleep protocols indicated a statistically significant benefit in at least 1 deliriumrelated outcome.
Discussion
ICU delirium is associated with numerous adverse
consequences, ranging from increased cost to mortality.3,5
As in a multitude of other ailments, prevention is the optimal strategy, especially when effective treatment options
are unavailable. Haloperidol has been studied for prevention and treatment of ICU delirium, but the results have
been inconclusive.25,26 Because of the unconvincing evidence
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Outcomes
Comments
Antipsychotic use
No difference in rate of delirium

8.7% reduction in ICDSC score = 0
8.4% reduction in subsyndromal delirium
No difference in LOS (patients with delirium)
Hospital does not provide cardiac surgery or trauma care

Nurses could give haldoperidol if ICDSC score > 3
No difference in antipsychotic administered
Yes
No difference between environments

Day 3 median day of onset
0.6-day reduction in ICU LOS
Same anesthetic used

63.9% underwent CABG, 71.7% men
6.2% delirium in < 65-year-olds vs 21.4% in > 65-year-olds
Baseline characteristics very different
Not reported
5% increase in delirium-free or coma-free days

20% reduction in incidence of delirium or coma
No difference in ICU mortality
No difference in ICU LOS
Primary outcome delirium-coma combination according to

CAM/RASS
Delirium secondary outcome
Compared ICU with post-ICU
Primarily respiratory failure patients
Primary outcome of sleep quality: no difference
Yes

Mean onset on day 2
Delirium increased ICU LOS by 2 days
Used research nurses

Standardized sedation protocol
All treatment haloperidol or olanzapine
Medical ICU significantly higher rates of delirium
Midazolam use hazard ratio of 2.145
Yes
2-day reduction in ICU delirium days

24% decrease in ICU time with delirium
13% decrease in hospital days with delirium
All patients received mechanical ventilation

Less than 10% of patients in medical ICU included
Delirium a secondary outcome
Yes
8% reduction in days delirious

32% increase in days not delirious
24% decrease in days unable to assess
Inclusion was mechanical ventilation 4 days

Routine delirium screening not part of standard care before
project started
No delirium assessments on 15 (pre) and 28 (post) patient days
Not reported
2-point reduction on NEECHAM score

25% reduction when delirium and mild confusion
grouped together
NEECHAM scorer blinded to use of ear plugs

Lowest NEECHAM score used for calculation of incidence
Not reported
for pharmacological management of delirium, nonpharmacological strategies need to be further evaluated.

The nonpharmacological intervention specifically
discussed in the pain, agitation, and delirium guidelines6
of the American College of Critical Care Medicine is
early mobilization. Our review fully supports this recommendation, and we think early mobilization should be
included, when feasible, in any nonpharmacological
prevention protocols implemented across all practice
settings. Some type of mobilization was used in 6 studies,8,10,20-23 and 4 of the types8,10,20,21 were included in protocols with many interventions. The 2 studies22,23 in which
mobilization was not part of a protocol were conducted
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in medical ICU patients receiving mechanical ventilation,

and the results showed benefits for all outcomes evaluated.
The onus then switches to the development of a
nonpharmacological protocol to prevent delirium, but
the ideal protocol has not yet been developed. One starting point would be to use the known risk factors for
delirium and target interventions to patients who have
these risk factors. This strategy was used by Inouye et al,9
who created a standardized protocol to combat 6 risk
factors: cognitive impairment, sleep deprivation, immobility, visual impairment, auditory impairment, and
dehydration. The observational PRE-DELIRIC (PREdiction of DELIRium in ICu patients) study27 was done in
CriticalCareNurse
45
10
20
21
22
X
#
#
#
X
X
X
#
23
12
13
#
X
14
15
24
16
a Key:
X, trial in patients who were not critically ill; #, trial in critically ill patients.
an ICU, and multivariate logistic regression analysis

indicated that 10 of the 25 risk factors evaluated were
predictive of delirium. Unfortunately, the majority of
the predictors, such as age and scores on the Acute
Physiology and Chronic Health Evaluation II, were
characteristics
that could not
Implementation of the appropriate
be altered by
recommendations for each patient
resulted in one of the largest reductions use of a
in both incidence and severity of delirium. nonpharmacological intervention. Although creation of a protocol based on risk
factors is an excellent starting point, efforts must be
directed toward modifiable health careassociated
exposures and not nonmodifiable susceptibilities.
Protocols with many interventions would be needed
in order to include the many risk factors for delirium
identified through the literature and to combat each factor appropriately. Marcantonio et al8 attempted to devise
such a protocol. They developed a geriatric consultation
46
X
#
Minimization of caffeine before bed
Open blinds
Avoidance of restraints
Catheter removal
Dim hallways at night
Eye mask
Adaptive equipment
Medication/procedure reschedule
Noise reduction
Light therapy
Back massage
Family
Warm drink
Calendar
Cognitive stimulation
Clock
Music
Hearing protocol
Reorientation
Eye protocol
X
#
Interventions showing benefita
Daily schedule
18
Mobility
Nutrition
Visual displays
Dentures
Nursing education
Hydration
Reference
Table 3
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that encompassed 10 modules with at least 2 recommendations to be made for each module. Collectively, 31
recommendations potentially could have been used.
Implementation of the appropriate recommendations
for each patient resulted in one of the largest reductions
in both incidence and severity of delirium. Vidn et al10
also used a multicomponent intervention and had results
similar to those of Marcantonio et al.8 The inevitable
follow-up question becomes, Is a certain aspect of these
multicomponent interventions leading to the positive
results, and, if so, what aspect?
The importance of a protocol that includes multiple
interventions is evident when the outcomes of studies with
2 or fewer interventions7,11,12,14-16,18,19,22-24 are compared with
the outcomes of studies with many interventions.8-10,13,20,21
For incidence of delirium, the multi-interventional protocols resulted in a 15.9% mean reduction, whereas those
with 2 or fewer interventions showed an 11% reduction.
The 11% reduction is slightly misleading because 4 of the
11 studies7,11,18,19 with 2 or fewer interventions did not
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indicate any difference in the incidence of delirium,

whereas all 6 of the multi-interventional studies8-10,13,20,21
indicated a reduction in incidence of at least 5.1%.
Another strategy, included in 6 studies,7,10-12,18,23 was
extensive education of nurses. The specifics of the education were typically not reported, but the material tended
to focus on the effects of delirium, screening for delirium,
and, at times, implementation of the investigators protocol. This strategy was used as the sole intervention in
2 studies.11,12 Milisen et al7 used education of nurses and
prominent display of educational material, both of which
resulted in no difference in the incidence of delirium or
the LOS, but a positive reduction in both the duration
and the severity of delirium. Tabet et al12 concentrated
on an education-only strategy for both nurses and
physicians and reported a 9.7% reduction in the pointprevalence of delirium. However, the investigators used
the Delirium Rating Scale, a screening tool that is not
recommended in the guidelines6 of the American College
of Critical Care Medicine. Whether or not the results
would be the same if either the Intensive Care Delirium
Screening Checklist or the CAM-ICU were used is not
clear. Last, Lundstrm et al11 used a similar strategy but
also included a reorganization of the nursing staff. These
investigators noted no difference in the prevalence of
delirium at 24 or 72 hours. Patients in the study were
tested for delirium by using the DSM-IV on hospital days
1, 3, and 7. Because the DSM-IV is a set of diagnostic
criteria and not a delirium screening tool, whether or
not these results can reliably be compared with the
results of other studies in which screening for delirium
was used is unclear.12
We would be remiss if we did not address the notion
that perhaps the best protocol simply involves high-level
nursing care. Most of the unique interventions used in
the studies reviewed could be easily incorporated into
everyday nursing for every patient regardless of the
patients risk factors for delirium. Notable exceptions
would be early mobility, nutrition, and catheter removal.
An inability to determine if certain aspects of a newly
implemented protocol were already routine nursing
practice before the protocols were implemented is a limitation of most published studies of nonpharmacological
interventions. Unfortunately, a study that could indicate
a true level of the benefit of each intervention would not
be feasible, because such a study would require nurses
to stop providing standard care. Additionally, any future
www.ccnonline.org
studies must include use of a standardized screening

tool, preferably either the CAM-ICU or the Intensive
Care Delirium Screening Checklist, to allow accurate
interpretation of the impact of any future interventions
or protocol.
Implications for Critical Care Nurses

Although we reviewed of studies of both critically ill
and noncritically ill patients, we think that a variety of
interventions that benefit patients who are not critically
ill would still be useful in an ICU. The evidence shows
that targeting interventions to prevent or treat known
risk factors for delirium have the greatest benefit (eg,
cognitive stimulation, reorientation), and a great deal
of overlap exists between risk factors for both critically
and noncritically ill patients. A wide variety of patients
are treated in ICUs, and the variety of specialized ICUs
can be as unique as the patients treated within the units.
For these reasons, strong consideration should be given
to having ICUs implement nonpharmacological interventions that have been beneficial for patients who were
not critically ill.
Multicomponent intervention protocols to combat
delirium have proved beneficial. On the basis of guideline
recommendations and the strength of literature, these
protocols should include early mobilization, education
of nurses, and cognitive stimulation with reorientation.
Depending on the severity of a patients illness, a variety
of ways can
All studies that included mobilization,
be used to
accomplish noise-reduction, or sleep protocols displayed
early mobi- a benefit in the reduction of delirium.
lization.
Mobilization can be as complete as full physical or occupational therapy treatments or merely passive range-ofmotion exercises. Bedside nurses and other members of
the medical team work together to decide the level of
mobilization a patient can complete. Additionally, nurses
can advocate for removal of tubes, catheters, or restraints
that may prevent early mobilization.
Second, education of nurses is an essential component
of the success of any new intervention or initiative. The
literature describes a variety of strategies for educating
nurses, including didactic lectures, visual displays, and
one-on-one sessions. In order to include the potentially
large number of nurses who need to be educated, education should be directed at all types of learners.28,29 Last,
CriticalCareNurse
47
cognitive stimulation and reorientation is a rather broad

term that allows each nurse to develop a strategy that
works for him or her. Still, each nurses intervention
should incorporate a few key components, such as
determining how the patient would like to be addressed,
frequent reorientation to date and time, providing updates
on the patients schedule and clinical status, and conversing with the patient in a manner that requires memory
recall by the patient.
The implementation of a new intervention or initiative
is often met with resistance to change. In order to minimize this resistance, obtaining nurses acceptance of and
willingness to support the change becomes imperative.
One strategy to eliminate high levels of resistance is to
educate nurses about the dangers and implications of
the development of delirium while stressing that patients
become increasingly difficult to care for once delirium
occurs. Another frequent reason for resistance is an
overall lack
Multicomponent protocols targeting
of time during
known risk factors for delirium appear to the nursing
have benefits over single interventions.
shift to add
additional
tasks to be completed; however, most interventions we
have mentioned in this review could be worked into a
nurse-implemented protocol that would require no more
than 5 to 10 minutes per nursing shift to accomplish.
Assembling a multidisciplinary team (physician, nurse,
pharmacist, and respiratory therapist) to determine
which nonpharmacological interventions are feasible
within each specific unit is important. Ultimately the
success of a nonpharmacological protocol to prevent
delirium lies with the bedside nurses, who have the
most frequent contact with patients.
Conclusion
Use of nonpharmacological interventions is essential
for the prevention of delirium. These interventions can
be a low-risk, low-cost strategy that has shown a benefit
in most studies. Nonpharmacological therapy also has
the potential to decrease the off-label use of antipsychotics
for the treatment of delirium. The largest challenge in
developing a nonpharmacological protocol is determining what interventions to include. Although a one-sizefits-all protocol may not be available, a strong body of
evidence supports the inclusion of education of the medical team, reorientation with cognitive stimulation, and
48
CriticalCareNurse
early mobility in any protocol created. ICU staff should

assemble a multidisciplinary team to review interventions of known benefit to determine which ones can be
implemented within the staff s specific unit. CCN
None reported.
To learn more about caring for patients with delirium, read

Impact of a Delirium Screening Tool and Multifaceted Education
on Nurses Knowledge of Delirium and Ability to Evaluate It
Correctly by Gesin et al in the American Journal of Critical Care,
January 2012;21:e1-e11. Available at www.ajcconline.org.
References
1. Salluh JI, Soares M, Teles JM, et al; Delirium Epidemiology in Critical
Care Study Group. Delirium epidemiology in critical care (DECCA):
an international study. Crit Care. 2010;14(6):R210. doi:10.1186/cc9333.
2. Pun BT, Ely EW. The importance of diagnosing and managing ICU
delirium. Chest. 2007;132(2):624-636.
3. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA.
2004;291(14):1753-1762.
4. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium
in medical in-patients: a systematic literature review. Age Ageing. 2006;
35(4):350-364.
5. Balas MC, Rice M, Chaperon C, Smith H, Disbot M, Fuchs B. Management
of delirium in critically ill older adults. Crit Care Nurse. 2012;32(4):15-26.
6. Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation,
and delirium in adult patients in the intensive care unit. Crit Care Med.
2013;41(1):263-306.
7. Milisen K, Foreman MD, Abraham IL, et al. A nurse-led interdisciplinary
intervention program for delirium in elderly hip-fracture patients. J Am
Geriatr Soc. 2001;49(5):523-532.
8. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium
after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49(5):516-522.
9. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent
intervention to prevent delirium in hospitalized older adults. N Engl J
Med. 1999;340(9):669-676.
10. Vidn MT, Snchez E, Alonso M, Montero B, Ortiz J, Serra JA. An intervention integrated into daily clinical practice reduces the incidence of
delirium during hospitalization in elderly patients. J Am Geriatr Soc.
2009;57(11):2029-2036.
11. Lundstrm M, Edlund A, Karlsson S, Brnnstrm B, Bucht G,
Gustafson Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious
patients. J Am Geriatr Soc. 2005;53(4):622-628.
12. Tabet N, Hudson S, Sweeney V, et al. An educational intervention can
prevent delirium on acute medical wards. Age Ageing. 2005;34(2):152-156.
13. Caplan GA, Harper EL. Recruitment of volunteers to improve vitality in
the elderly: the REVIVE study. Intern Med J. 2007;37(2):95-100.
14. Ono H, Taguchi T, Kido Y, Fujino Y, Doki Y. The usefulness of bright
light therapy for patients after oesophagectomy. Intensive Crit Care Nurs.
2011;27(3):158-166.
15. Taguchi T, Yano M, Kido Y. Influence of bright light therapy on postoperative patients: a pilot study. Intensive Crit Care Nurs. 2007;23(5):289-297.
16. McCaffrey R. The effect of music on acute confusion in older adults
after hip or knee surgery. Appl Nurs Res. 2009;22:107-112.
17. Khan BA, Zawahiri M, Campbell NL, et al. Delirium in hospitalized
patients: implications of current evidence on clinical practice and future
avenues for researcha systematic evidence review. J Hosp Med. 2012;
7(7):580-589.
www.ccnonline.org
18. Skrobik Y, Ahern S, Leblanc M, Marquis F, Awissi DK, Kavanagh BP.

Protocolized intensive care unit management of analgesia, sedation,
and delirium improves analgesia and subsyndromal delirium rates
[published correction appears in Anesth Analg. 2012;115(1):169]. Anesth
Analg. 2010;111(2):451-463.
19. Arenson BG, MacDonald LA, Grocott HP, Heibert BM, Arora RC. Effect
of intensive care unit environment on in-hospital delirium after cardiac
surgery. J Thorac Cardiovasc Surg. 2013;146(1):172-178.
20. Kamdar BB, Yang J, King LM, et al. Developing, implementing, and
evaluating a multifaceted quality improvement intervention to promote
sleep in an ICU. Am J Med Qual. 2014;29(6):546-554.
21. Colombo R, Corona A, Praga F, et al. A reorientation strategy for reducing
delirium in the critically ill: results of an interventional study. Minerva
Anestesiol. 2012;78(9):1026-1033.
22. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and
occupational therapy in mechanically ventilated, critically ill patients: a
randomised controlled trial. Lancet. 2009;373(9678):1874-1882.
23. Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine
and rehabilitation for patients with acute respiratory failure: a quality
improvement project. Arch Phys Med Rehabil. 2010;91(4):536-542.
24. Van Rompaey B, Elseviers MM, Van Drom W, Fromont V, Jorens PG.
www.ccnonline.org
25.
26.
27.
28.
29.
The effect of earplugs during the night on the onset of delirium and
sleep perception: a randomized controlled trial in intensive care patients.
Crit Care. 2012;16(3):R73.
Wang W, Li HL, Wang DX, et al. Haloperidol prophylaxis decreases
delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial. Crit Care Med. 2012;40(3):731-739.
Page VJ, Ely EW, Gates S, et al. Effect of intravenous haloperidol on the
duration of delirium and coma in critically ill patients (Hope-ICU): a
randomised, double-blind, placebo-controlled trial. Lancet Respir Med.
2013;1(7):515-523.
van den Boogaard M, Pickkers P, Slooter AJ, et al. Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients)
delirium prediction model for intensive care patients: observational
multicentre study. BMJ. 2012;344:e420.
Devlin JW, Marquis F, Riker RR, et al. Combined didactic and scenariobased education improves the ability of intensive care unit staff to recognize delirium at the bedside. Crit Care. 2008;12(1):R19.
Gesin G, Russell BB, Lin AP, Norton HJ, Evans SL, Devlin JW. Impact of
a delirium screening tool and multifaceted education on nurses knowledge of delirium and ability to evaluate it correctly. Am J Crit Care. 2012;
21(1):e1-e11.
CriticalCareNurse
49
CCN Fast Facts
CriticalCareNurse
Nonpharmacological Interventions to
Prevent Delirium: An Evidence-Based
Systematic Review
Facts
Development of delirium in critical care patients is
associated with increased length of stay, hospital costs,
and mortality. The pain, agitation, and delirium guidelines of the American College of Critical Care Medicine
provide the strongest level of recommendation for the
use of nonpharmacological approaches to prevent
delirium, but questions remain about which nonpharmacological interventions are beneficial.
Prevention is the optimal strategy, especially
when effective treatment options are unavailable.
Haloperidol has been studied for prevention and
treatment of intensive care unit (ICU) delirium,
but the results have been inconclusive.
A variety of interventions that benefit patients
who are not critically ill would still be useful in
an ICU. The evidence shows that targeting interventions to prevent or treat known risk factors
for delirium have the greatest benefit (eg, cognitive stimulation, reorientation), and a great deal
of overlap exists between risk factors for both
critically and noncritically ill patients.
Multicomponent intervention protocols to
combat delirium have proved beneficial. These
protocols should include early mobilization,
education of nurses, and cognitive stimulation
with reorientation.
Mobilization can be as complete as full physical
or occupational therapy treatments or merely
passive range-of-motion exercises. Bedside nurses
and other members of the medical team work
together to decide the level of mobilization a
patient can complete. Additionally, nurses can advocate for removal of tubes, catheters, or restraints that
may prevent early mobilization.
Education of nurses is an essential component of the
success of any new intervention. In order to include
the potentially large number of nurses who need to
be educated, education should be directed at all
types of learners.
Cognitive stimulation and reorientation is a broad
term that allows each nurse to develop an individual
strategy. Still, each nurses intervention should
incorporate a few key components, such as determining how the patient would like to be addressed,
frequent reorientation to date and time, providing
updates on the patients schedule and clinical status,
and conversing with the patient in a manner that
requires memory recall by the patient.
Obtaining nurses acceptance of and willingness to
support the new intervention is imperative.
One reason for resistance is a lack of time during the
nursing shift to add additional tasks. Assembling a
multidisciplinary team (physician, nurse, pharmacist, respiratory therapist) to determine which nonpharmacological interventions are feasible within
each specific unit is important.
Ultimately the success of a nonpharmacological protocol
to prevent delirium lies with the bedside nurses, who
have the most frequent contact with patients. CCN
Rivosecchi RM, Smithburger PL, Svec S, Campbell S, Kane-Gill SL. Nonpharmacological Interventions to Prevent Delirium: An Evidence-Based Systematic Review.
Critical Care Nurse. 2015;35(1):39-51.
50
CriticalCareNurse
www.ccnonline.org
CNE Test Test ID C1512: Nonpharmacological Interventions to Prevent Delirium: An Evidence-Based Systematic Review
Learning objectives: 1. Describe the nursing literature on nonpharmacological interventions to prevent delirium 2. Discuss nonpharmacological interventions that have been shown to be effective in preventing delirium 3. Explain the tools developed for the measurement of delirium in intensive care unit patients
7. Which of the following is the nonpharmacological intervention specifically
discussed in the pain, agitation, and delirium guidelines of the American
College of Critical Care Medicine?
a. Music therapy
b. Reorientation
c. Nursing education
d. Early mobilization
1. The highest prevalence of delirium occurs in which of the following

patient populations?
a. Nursing home patients
b. Critically ill patients
c. General medicine patients
d. Perioperative patients
2. Exclusion criteria of the research described in this manuscript include
a. Not original research
b. Delirium measured as an outcome
c. Screening for delirium using a standardized screening tool
d. Incidence or severity of delirium was an outcome measure
8. Which of the following is used to allow accurate interpretation of the

impact of future interventions to reduce delirium?
a. Biostatistics
b. Multiple regression analysis
c. Bonferroni multiple comparison test
d. Standardized screening tool
3. Excluding any manuscripts involved with pharmaceuticals was necessary

to evaluate the true benefit of a nonpharmacological protocol and to minimize
a. Validity and reliability issues
b. Hierarchies of evidence
c. Confounding variables
d. Cleaning and coding data
9. The evidence-based literature supports which of the following nonpharmacological interventions to combat delirium?
a. Nursing education, mobility, and cognitive stimulation with reorientation
b. Nursing education, mobility, and art therapy
c. Mobility, cognitive stimulation with reorientation, and art therapy
d. Mobility, exercise therapy, and cognitive stimulation with reorientation
4. Which of the following tools was used most frequently in the delirium
research?
a. Delirium Screening Scale
b. Neelon and Champagne Confusion Scale
c. Intensive Care Delirium Screening Checklist
d. Confusion Assessment Method for the Intensive Care Unit
10. Which of the following nonpharmacological interventions allows each

nurse to develop a strategy that works for him or her?
a. Mobilization
b. Nursing education
c. Cognitive stimulation and reorientation
d. Music therapy
5. In several studies, the duration of delirium decreased after the addition

of which of the following?
a. Nonpharmacological interventions
b. Pharamacological interventions
c. Haloperidol
d. Lorazepam
11. Which of the following is a strategy for educating nurses about nonpharmacological interventions that help reduce delirium?
a. Visual displays
b. Case study analysis
c. Excel spread sheet
d. PowerPoint self-learning modules
6. Which of the following factors were examined in outcomes related to

delirium?
a. Incidence, duration, and severity
b. Decreasing length of stay
c. Mobility
d. Reorientation
12. Which of the following is essential for the prevention of delirium?

a. Pharmacological therapy
b. Nonpharmacological interventions
c. Occupational therapy
d. Speech therapy
1. a
b
c
d
2. a
b
c
d
3. a
b
c
d
4. a
b
c
d
5. a
b
c
d
6. a
b
c
d
7. a
b
c
d
8. a
b
c
d
9. a
b
c
d
10. a
b
c
d
11. a
b
c
d
12. a
b
c
d
Synergy CERP Category A Test writer: Lynn C. Simko, PhD, RN, CCRN
Name
Program evaluation
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AACN, 101 Columbia
Objective 1 was met

Objective 2 was met
Objective 3 was met
nursing practice


for this content

it took me
hours/minutes.
No

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Military Critical Care Nursing: Navy
Exertional Heat Stroke in

Navy and Marine Personnel:
A Hot Topic
CARL W. GOFORTH, RN, PhD, CCRN
JOSH B. KAZMAN, MS
Although exertional heat stroke is considered a preventable condition, this life-threatening emergency affects
hundreds of military personnel annually. Because heat stroke is preventable, it is important that Navy critical
care nurses rapidly recognize and treat heat stroke casualties. Combined intrinsic and extrinsic risk factors
can quickly lead to heat stroke if not recognized by deployed critical care nurses and other first responders.
In addition to initial critical care nursing interventions, such as establishing intravenous access, determining
body core temperature, and assessing hemodynamic status, aggressive cooling measures should be initiated
immediately. The most important determinant in heat stroke outcome is the amount of time that patients
sustain hyperthermia. Heat stroke survival approaches 100% when evidence-based cooling guidelines are followed, but mortality from heat stroke is a significant risk when care is delayed. Navy critical care and other
military nurses should be aware of targeted assessments and cooling interventions when heat stroke is suspected during military operations. (Critical Care Nurse. 2015;35[1]:52-59)
eat stroke is a persistent problem among firefighters,1 athletes,2 and military

personnel,3 all of whom have occupations that require physical exertion in
humid or hot environments. Military occupations in particular involve physically
demanding tasks, such as carrying heavy loads for extended periods, often with
unpredictable rest periods.4 When protective equipment such as body armor is
worn, heat dissipation is further blocked.5 These extreme conditions place US military personnel
and the military nurses who care for them at risk for heat injuries.6
Heat stress is determined by environmental (ie, radiant and ambient temperature, air movement,
and humidity) and behavioral (eg, ergogenic agents, work intensity, and protective clothing) factors.7,8
Just a few of these risk factors combined can quickly lead to an exertional heat injury. The less severe
conditions can be treated on site with the person resuming normal activities the same day. Conversely,
exertional heat stroke (EHS) is a life-threatening emergency, and rapid cooling must be administered
immediately to ensure survival.9 The high incidence of heat illnesses3 in the US military might indicate
that rapid recognition of heat injury and use of sound clinical nursing practices are not being applied
consistently from ship to ship or unit to unit. Because EHS morbidity and mortality are preventable,
it is important that critical care nurses in the Navy and other branches of the military rapidly recognize
52
CriticalCareNurse
www.ccnonline.org
Table 1
Clinical condition
Definitiona
Heat-related illness criteria
Core temperature
Related signs
Related symptoms
Postural syncope with rapid

recovery once supine
Heat syncope
Dizziness or fainting in a hot

environment due to postural blood pooling in lower
extremities
Normal
Generalized weakness,
syncope
Heat cramps
Painful muscle spasms

during exercise in the heat
Normal or elevated
but < 40C (104F)
Affected muscles are stiff

Painful muscle contracand tender to palpation
tions (commonly in calf,
quadriceps, or abdominal
muscles)
Heat exhaustion
Diminished physical activity

in the heat due to cardiovascular compromise
37C-40C
(98.6F-104F)
Fatigue, nausea, vomiting,

headache
Classic heat stroke
Severe hyperthermia primarily > 40C (104F)

due to heat exposure
Heat exhaustion symptoms Hot skin with or without

sweating, mental status
present before mental
changes (disorientation,
status changes
ataxia, loss of consciousness); can develop slowly
over several days
Exertional heat stroke Severe hyperthermia primarily > 40C (104F)

due to strenuous exercise
Heat exhaustion symptoms Hot skin with or without

sweating, mental status
present before mental
changes (disorientation,
status changes
ataxia, loss of consciousness); rapid onset
Flushed, profuse sweating

with or without clammy
skin, normal mental status
Definitions from Pryor et al9 and Epstein and Roberts.13
and treat patients with potential EHS during military

operations. Previous military reviews have focused on
organizational practices and the onus of responsibility
for EHS up the chain of command.10 For critical care military nurses, however, it is crucial to rapidly recognize
and treat heat stroke in the field. Therefore, the aim of
this column is to discuss the definition, risk factors,
treatment, and nursing implications of EHS.
Authors
Carl Goforth is the clinical subject matter expert for the Marine Corps
Combat Development Command located in Quantico, Virginia.
He has more than 20 years of combined Navy and Marine service
and has deployed as a critical care and flight nurse attached to US
Marine units overseas.
Josh Kazman is a research associate with the Consortium for Health
and Military Performance at Uniformed Services University of the
Health Sciences. He has worked on a variety of projects and publications related to health disparities, heat tolerance, cardiovascular
disease, and injury prevention.
Corresponding author: CDR Carl Goforth, Combat Development & Integration,
HQMC, 3300 Russell Road, Quantico, VA 22134-5001 (e-mail: carl.goforth@
usmc.mil).
To purchase electronic or print reprints, contact the American Association of CriticalCare Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or
www.ccnonline.org
Definition of Heat Stroke

Heat stroke is a life-threatening emergency characterized by a rapid increase in the bodys core temperature
(Tcore) to greater than 40C (104F), multiple organ dysfunction,9 and central nervous system abnormalities (eg,
delirium, confusion, agitation),11 with a mortality rate as
high as 18% in military populations.12 Exertional heat
stroke, especially when combined with strenuous activity,
can occur during exposure to hot or mild climates. Conversely, classic heat stroke occurs only in hot climates.
The heat injury spectrum is listed in Table 1.
Incidence of Exertional Heat Stroke

EHS mortality is significant in athletes and certain
occupations, such as agricultural workers.14 Among
athletes, EHS is the third leading cause of mortality.15
Moreover, among athletes and military personnel, the
frequency of EHS continues to increase despite safety
measures.12,15-18 Despite knowledge of EHS risk factors,
the incidence of heat stroke or heat exhaustion in the
US military has not decreased in the past 5 years, estimated in 2013 at 0.25 and 1.57 per 1000 person years,
respectively.3 Highly motivated individuals might be
tempted to ignore heat safety rules, especially during
CriticalCareNurse
53
Table 2
Risk factors for heat illnessa
Intrinsic
(internal) factors
Extrinsic
(environmental) factors
History of heat-related event
Level of exertion
Age (< 15 or > 65 years)
Excess clothing or protective

equipment
Alcohol consumption
Existing medical conditions
(ie, respiratory, hematologic,
or cardiovascular)
Dehydration
Table 3
Medications implicated in exertional

heat illnessa
Effect
Type of medication
Reduces rate of sweating
Antihistamines
Anticholinergics
Alters skin blood flow
Calcium channel blockers

Female reproductive hormones
Capsaicin
Lowers cardiac contractility
-Blocking medications
Calcium channel blockers
Lack of water
Temperature (ambient)
Humidity
Wet bulb globe temperature
Sleep deprivation
Medications or supplements
Obesity
Overmotivation
Inadequate acclimatization, poor
aerobic conditioning, or both
Sympathomimetics
Increases heat production
Amphetamines
(ergogenic), hypothalamic set
Ephedra
point, or both
1,3-dimethylamyamine
(sympathomimetic
properties)
Salicylates (supratherapeutic
doses)
a Based
on information from Howe and Boden,11 Seto et al,25 Kao et al,26 Lee,27
Lopez and Casa,28 Fink et al,29 Oh et al,30 and Eliason et al.31
Recent illness
Sickle cell trait
a Based
on information from Armstrong et al,2 Epstein et al,10 Casa et al,17

Glahn et al,20 and Wallace et al.21
dangerous operations, placing them at even greater risk

of EHS.10 Military units awareness of heat injury is also
important. One military unit or ship might place greater
emphasis on work/rest cycles, environmental monitoring, and so on than another unit.
Risk Factors
Recognizing inherent risk factors can help Navy critical care nurses make informed clinical decisions during
training and deployments. Additionally, US Navy medical
missions, such as
disaster response,
Exertional heat stroke develops as a
usually include the
result of many complex factors and
care of diverse, vulcan vary from person to person.
nerable populations, such as the young and the elderly.19 EHS risk factors
(Table 2) are commonly classified into 1 of 2 areas:
intrinsic (related to the individual) and extrinsic (environmental, task-related, or contextual).
Intrinsic Risk Factors
In addition to a history of heat illness, intrinsic risk
factors can range from sickle cell trait to high motivation.6,16,22,23 Military training includes the indoctrination
of military culture, such as mission first, which can
54
CriticalCareNurse
lead motivated persons to ignore important physiological warning signs. Other data from the US military show
that overweight military personnel have a higher risk
for sustaining heat injuries.22 Low aerobic fitness has
been cited as a predisposing factor for EHS.24 Poorly
conditioned athletes must work harder to keep up with
fit teammates and thus may ignore warning signs such
as dehydration, tachycardia, or sweating cessation.
Numerous classes of medications have also been implicated in heat stroke (Table 3).
The mechanism by which common medications
contribute to heat stroke depends on the class of drug.
Anticholinergics (antihistamines, antidepressants, or
antipsychotics) decrease production of sweat.11 Cardiovascular agents, such as antihypertensives or diuretics,
decrease the natural physiological responses to dehydration and hyperthermia.25 Of special concern to
young, healthy populations is the recent increase in
use of dietary supplements.
Recent publications indicate that US Marines are
among the highest military users of dietary supplements.26
Ergogenic stimulants, such as amphetamines or ephedra,
increase heat production. Ephedra, from the Chinese plant
ma-huang,27 along with 1,3-dimethylamyamine (DMAA),
is associated with serious heat injury in athletes28,29 and
with EHS30 and death31 in the military. Although the exact
mechanism underlying heat injury in many ergogenic
aids is not fully characterized, published reports clearly
www.ccnonline.org
indicate that US Navy and other critical care nurses should

screen EHS patients for recently used medications or
ingestion of dietary supplement.
of the central nervous system and multiorgan dysfunction are typical of EHS (Figure 1). More extensive reviews
are available.13
Extrinsic Risk Factors

Professions in the US Armed Forces are particularly
hazardous, with constant exposure to strenuous physical
exertion and climate extremes. For instance, summer
temperatures in Afghanistan routinely reach 51C (124F).32
During military operations, personnel perform tasks while
wearing body armor, which weighs a mean of 12.3 kg
(27 lbs),33 often without sufficient rest. Because of the
nature of military operations, these factors are difficult to
modify and might place military personnel in scenarios
that exceed their physical capacity. Therefore, these individuals are at increased risk when subjected to individual
and environmental factors that predispose them to EHS.
It is clear from the evidence that EHS develops as a
result of many complex factors and can vary from person to person. However, hyperthermia is always the
common denominator underlying any risk factor.6
Clinical Management
The extent and severity of EHS might not be readily apparent in the chaos of military operations.
Because mild forms of heat illness, if not recognized,
might rapidly progress to EHS, immediate evaluation
is necessary to assess the severity of symptoms and, if
needed, to initiate cooling rapidly. When cooling is
provided immediately, survival is near 100%.18 Reducing Tcore to less than 40.5C in less than 30 minutes is
the current recommendation.9
Hyperthermia
Hyperthermia is an increase in Tcore above the bodys
natural set point.6 Human homeostasis requires a narrow
operating temperature around 37C.34 To accomplish this,
a thermoregulatory system composed of compensatory
and noncompensatory systems communicate together for
thermoregulation when Tcore fluctuates.35 During strenuous physical activity, body temperature increases in
healthy persons, but as metabolic processes and/or environmental conditions exceed cardiovascular and central
nervous system compensation, hyperthermia (Tcore >
40C) ensues13 and the risk of EHS increases.10
Temperatures as high as 46.5C (116F) have been
reported in patients who have recovered from heat stroke,36
but survival at such an extreme Tcore is rare. The severity
of tissue injury due to hyperthermia depends on the critical thermal maximum,37 defined as the maximum intensity and duration of tissue heating before cellular death
occurs.38 At extreme core temperatures, thermoregulatory
mechanisms are overwhelmed, cellular proteins begin
denaturing, and apoptosis (programmed cellular death)
can occur within 5 minutes.39,40 Failure to promptly recognize and treat hyperthermia can lead to EHS within
minutes, a life-threatening medical emergency. The integrated effects of hyperthermia leading to derangement
www.ccnonline.org
Supportive Interventions
The initial priorities most relevant to EHS are
hemodynamic status, Tcore, and mental status. Upon
presentation of EHS, critical care nursing staff must
assess and stabilize vital signs, correctly recognize
signs and symptoms of EHS, and begin cooling. The
hallmark of EHS is altered function of the central
nervous system, such as confusion and combativeness.
Nursing management for EHS starts with assessing airway, breathing,
and circulation
Central nervous system abnormalities
(ABCs). Baseline
such as confusion and agitation often
consciousness
are the first signs of heat stroke.
should also be
immediately established, along with an initial score on
the Glasgow Coma Scale. Additional assessments
include, when possible, medical history, medications,
and/or dietary supplements used, body temperature at
admission and maximum known temperature, clinical
features apparent at admission, and vital signs. Critical
care nursing interventions also include advanced
hemodynamic monitoring and initiating fluid resuscitation with crystalloid intravenous solutions per the institutions protocol, preferably chilled (4C) 0.9% sodium
chloride solution.41 Lactated Ringer solution is not
used, because liver function can be suppressed by overheated tissues, leading to unmetabolized lactate and
worsening lactic acidosis.20 Numerous studies42-44 have
demonstrated that axillary, aural (tympanic), oral, and
skin temperatures often indicate a falsely low Tcore,
especially after intense exercise in the heat. Rectal temperature remains the reference standard for assessment
CriticalCareNurse
55
Intrinsic factors
Heat stress
Extrinsic factors
Compensatory
Increased metabolic rate
Sweat
Core temperature increase
Noncompensatory
Cardiac output increase
Hypovolemia
Central venous pressure

decreases
Systemic inflammation
Core temperature
increase
ATP depletion
Blood brain barrier

breakdown
Circulatory collapse
Cellular anoxia
Core temperature
increase
CNS derangement
Heat stroke
*Liver dysfunction
*Renal failure
*Coagulopathy (DIC)
*Cardiac dysrythmia
*Myoglobin release
*Intestinal permeability
Death
Figure 1 The event sequence leading to heat stroke and death from the compensatory to the uncompensable phase. Physical
activity, especially during hot conditions, initiates a compensable thermoregulatory response (above the dashed horizontal line).
When individual ability to compensate is surpassed, central venous pressure decreases, core temperature increases leading to
thermoregulatory failure if prompt treatment is not initiated. This thermoregulatory failure triggers cellular death, intracellular
imbalance (energy depletion), and circulatory failure. The multiple body system failures, if not immediately treated, lead to death.
Abbreviations: ATP, adenosine triphosphate; CNS, central nervous system; DIC, dissemiated intravascular coagulation.
Adapted with permission from Epstein and Roberts,13 2011, John Wiley and Sons A/S.
of Tcore in a potential EHS patient and the end point is

a Tcore less than 39C (102F).
Cooling
Once hyperthermia is confirmed by rectal temperature,
or if a high suspicion of hyperthermia exists while one is
waiting for positive confirmation, cooling measures should
begin without delay. Effective heat dissipation relies on
the rapid transfer of heat from the bodys core to the skin
and from the skin to the environment.9
The most important determinant in an EHS outcome is the amount of time that patients core body
56
CriticalCareNurse
temperature is above the threshold (38.6C) for cellular

damage.45 Reducing the Tcore to less than 40C within
30 minutes or less is critical.6 When in doubt, the maxim
cool first, transport second should be employed to ensure
rapid treatment.
The fastest way to decrease Tcore is to remove restrictive
clothing and equipment and immerse the body (trunk
and extremities) in a pool or tub of cold water (approximately 1C-14C, or 35F-57.2F).46 Once the patient is
immersed in cold water, aggressive stirring or continuous water motion will replace warmed water at the skin
with cold water. Additionally, wrapping a cold, wet towel
www.ccnonline.org
0.40
0.30
0.25
0.20
Unacceptable Acceptable Optimal
Mean cooling rate, C/min
0.35
0.15
0.10
0.05
0.00
et
ge
ies
ies
nly
ion
ion
ion
ion
ion
lank
ers
ers
ers
ers
ers
lava
rter
rter
re o
b
a
a
c
m
m
m
m
m
u
i
t
r
r
g
r
a
m
t
im
im
im
im
jo
in
ajo
per
re i
ma
Gas
ool
ter
ter
ter
ater
at m
tem
ratu
Cc
-wa
-wa
-wa
s
s at
e
e-w
d
d
d
4
k
k
l
l
l
p
m
c
c
c
I
o
o
o
c
c
pa
pa
tem
-roo
Cc
8C
2C
ice
Ice
IVF
20
oom
r
re,
u
r
t
e
a
wat
per
tem
and
F
m
V
I
-roo
lled
IVF
Chi
Figure 2 Relative cooling rates by heat stroke nursing intervention. Optimal cooling rates (> 0.155C/min), acceptable cooling
rate (> 0.079C/min and < 0.154C/min), or unacceptable cooling rates (< 0.078C/min).
Abbreviation: IVF, intravenous fluids.
Adapted with permission from Pryor et al,9 2013 with permission from Elsevier.
around the top of the head will enhance rapid cooling

further.45 It is recognized that cold water is not always
available in remote areas. One alternative, when resources
are limited, is to douse the victim with immediately
available water. This method can reach a cooling rate of
0.1C to 0.2C per minute.47 Cooling rates for the most
common cooling methods are presented in Figure 2.9
Civilian Nursing Implications

Heat exposure is one of the most deadly natural
hazards in the United States. The Centers for Disease
Control and Prevention48 estimates that between 1992
and 2006, heat stroke claimed the lives of 423 Americans,
more than hurricanes, lightning, floods, tornados, and
earthquakes combined. These injuries require aggressive
clinical treatments consisting of rapid cooling and supportive nursing care, such as fluid resuscitation to preserve
organ function. Therefore, although this article is focused
on Navy critical care nursing, the concepts of rapid recognition and cooling are universal and apply to any critical
care nurse caring for a heat stroke victim.
www.ccnonline.org
Conclusion
EHS requiring critical care nursing intervention represents a substantial risk of morbidity and mortality to
Navy and Marine Corps personnel. With military EHS
rates at high levels despite scientific advances, never
before has it been so clinically important to recognize
and rapidly treat potential EHS casualties. EHS rates in
the Marine Corps, for instance, were more than 5 times
higher than the rates in other military branches in
2011.49 Data also suggest that military heat stroke survivors have twice the mortality risk from cardiovascular,
kidney, and liver failure within 30 years of initial hospitalization compared with military survivors of nonheat
injuries.21 According to the best evidence available, icewater or cold-water immersion is the most effective cooling treatment and is recommended as the definitive
treatment.46 If this method is unavailable, case reports
demonstrate that continual water dousing combined
with fanning is a practical alternative until advanced treatment is available. Practical resources for the implementation of EHS prevention and emergency procedures can
CriticalCareNurse
57
Table 4
Military and civilian resources for exertional heat illness guidelines
Resource
Website
Description
Uniformed Services University, Consortium

for Health and Military Performance
http://champ.usuhs.mil
Clinical consultation for exertional heat illness

and related conditions such as exertional
rhabdomyolysis
US Army Research Institute of

Environmental Medicine
http://www.usariem.army.mil
Army clinical and educational resources regarding

heat physiology, acclimation, and related
operational issues
US Army Medical Department
http://www.cs.amedd.army.mil
Provides a link to Medical Aspects of Harsh

Environments, Volume 1
American College of Sports Medicine
www.acsm.org
Civilian guidelines and consensus regarding

exertional heat illness
US Marine Corps Heat Injury Prevention

Program
http://www.imef.marines.mil/portals
/68/Docs/IMEF/Surgeon/MCO_
6200.1E_W_CH_1_Heat_Injury
_Prevention.pdf
Marine Corps resource for the prevention of heat

injury guidance per MCO 6200.1E, including
acclimatization and work-rest cycles
be found in multiple locations (Table 4). The evidence

underscores the need for prompt identification of potential EHS victims and aggressive cooling measures in the
field as key critical care nursing actions. CCN
Acknowledgments
The views expressed are those of the authors and do not reflect the official
policy or position of the US Marine Corps, the Uniformed Services University
of the Health Sciences, the Department of Defense, or the US government.
Work on this manuscript was funded by the Office of Naval Research, grant
no. N0001411MP20023.
Now that youve read the article, create or contribute to an online discussion about
this topic using eLetters. Just visit www.ccnonline.org and select the article you
want to comment on. In the full-text or PDF view of the article, click Responses
in the middle column and then Submit a response.
To learn more about military critical care nursing, read Tales From
the Sea: Critical Care Nurses Serving Aboard the USNS Comfort
and USNS Mercy by Faulk and Hanly in Critical Care Nurse,
August 2013;33:61-67. Available at www.ccnonline.org.
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25. Seto C, Way D, OConnor N. Environmental illness in athletes. Clin Sports

Med. 2005;24(3):695-718.
26. Kao T-C, Deuster PA, Burnett D, Stephens M. Health behaviors associated
with use of body building, weight loss, and performance enhancing
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28. Lopez R, Casa D. The influence of nutritional ergogenic aids on exercise heat
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Pediatr Emerg Care. 2006;22(7):510-513.
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/afghan/afghan-narrative.html. Accessed November 11, 2014.
33. Konitzer L, Fargo M, Brininger T, Lim Reed M. Association between
back, neck, and upper extremity musculoskeletal pain and the individual
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PA: Saunders: Elsevier; 2011.
35. Ha S, Talbott E, Kan H, Prins CA, Xu X. The effects of heat stress and its
effect modifiers on stroke hospitalizations in Allegheny County, Pennsylvania. Int Arch Occup Environ Health. 2014;87(5):557-565.
36. Ghaznawi H, Ibrahim M. Heat stroke and heat exhaustion in pilgrims
performing the Haj (annual pilgrimage) in Saudi Arabia. Ann Saudi Med.
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37. Sherwood SC, Huber M. An adaptability limit to climate change due to
heat stress. Proc Natl Acad Sci U S A. 2010;107(21):9552-9555.

38. Lutterschmidt WI, Hutchison VH. The critical thermal maximum: history
and critique. Can J Zool. 1997;75(10):1561-1574.
39. Bouchama A, Knochel J. Heat stroke. N Engl J Med. 2002;346(25):1978-1988.
40. Leon L, Helwig B. Heat stroke: role of the systemic inflammatory response.
J Appl Physiol. 2010;109(6):1980-1988.
41. Badjatia N. Hyperthermia and fever control in brain injury. Crit Care Med.
2009;37(7):S250-S257.
42. Casa DJ, Becker SM, Ganio MS, et al. Validity of devices that assess body
temperature during outdoor exercise in the heat. J Athl Train. 2007;
42(3):333-342.
43. Ganio MS, Brown CM, Casa DJ, et al. Validity and reliability of devices
that assess body temperature during indoor exercise in the heat. J Athl
Train. 2009;44(2):124-135.
44. Ronneberg K, Roberts W, McBean A, Center B. Temporal artery temperature measurements do not detect hyperthermic marathon runners.
Med Sci Sports Exerc. 2008;40(8):1373-1375.
45. Gagnon D, Lemire BB, Casa DJ, Kenny GP. Cold-water immersion and
the treatment of hyperthermia: using 38.6C as a safe rectal temperature
cooling limit. J Athl Train. 2010;45(5):439-444.
46. McDermott BP, Casa DJ, Ganio MS, et al. Acute whole-body cooling for
exercise-induced hyperthermia: a systematic review. J Athl Train. 2009;
44(1):84-93.
47. Rav-Acha M, Hadad E, Epstein Y, Heled Y, Moran D. Fatal exertional
heat stroke: a case series. Am J Med Sci. 2004;328(2):84-87.
48. Centers for Disease Control and Prevention. Preventing heat-related
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MSMR. 2012;19(3):14-16.
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59
Pediatric Care
Extracorporeal
Membrane Oxygenation
for Pediatric Cardiac Arrest
JENNIE RYAN, MS, CPNP-AC
Extracorporeal cardiopulmonary resuscitation (ECPR) remains a promising treatment for pediatric patients
in cardiac arrest unresponsive to traditional cardiopulmonary resuscitation. With veno-arterial extracorporeal
support, blood is drained from the right atrium, oxygenated through the extracorporeal circuit, and transfused
back to the body, bypassing the heart and lungs. The use of artificial oxygenation and perfusion thus provides
the body a period of hemodynamic stability, while allowing resolution of underlying disease processes. Survival
rates for ECPR patients are higher than those for traditional cardiopulmonary resuscitation (CPR), although
neurological outcomes require further investigation. The impact of duration of CPR and length of treatment
with extracorporeal membrane oxygenation vary in published reports. Furthermore, current guidelines for
the initiation and use of ECPR are limited and may lead to confusion about appropriate use of this support.
Many ethical concerns arise with this advanced form of life support. More often than not, the dilemma is not
whether to withhold ECPR, but rather when to withdraw it. Although clinicians must decide if ECPR is
appropriate and when further intervention is futile, the ultimate burden of choice is left to the patients caregivers. Offering support and guidance to the patients family as well as the patient is essential. (Critical Care
Nurse. 2015;35[1]:60-70)
t is only fitting that the first neonate to be supported by extracorporeal membrane

oxygenation (ECMO) was named Esperanza, which when translated from Spanish
means hope.1 Indeed, to the more than 50 000 patients who have survived because of ECMO,
this revolutionary treatment has provided hope where there was none before.2 In the past 5
decades, the use of artificial oxygenation and perfusion has revolutionized the care of critically
ill patients, both in the operating room and in the intensive care unit. Use of artificial oxygenation and
perfusion has evolved from bypass during cardiac surgery to advanced life support, to complex extracorporeal cardiopulmonary resuscitation (ECPR). Within the past 20 years, ECPR has been initiated when
traditional resuscitation methods have failed and has proven its effectiveness with a survival to discharge
rate of approximately 40%.3-13 However, the appropriate use of this therapy and delineated criteria for
initiating and withdrawing this therapy have yet to be defined. Furthermore, implementation of this

1. Determine the difference between venovenous and venoarterial extracorporeal membrane oxygenation (ECMO)
2. Describe the benefits of extracorporeal cardiopulmonary resuscitation
3. Discuss the ethical considerations related to management of patients undergoing ECMO
60
CriticalCareNurse
www.ccnonline.org
Venous cannula
vena c
ava
Extracorporeal
Cardiopulmonary
Resuscitation
Aortic cannula
erior
Sup
extraordinary therapy introduces

many ethical dilemmas concerning
advanced life support. This article
addresses the use of ECMO during
CPR, as well as the ethical problems
we face with the continued advancement of end-of-life care.
Aorta
Left
atrium
ECPR is considered the initiation

of ECMO, following refractory cardiac
Right
atrium
arrest unresponsive to conventional
cardiopulmonary resuscitation (CPR).
Left
Right
ventricle
ventricle
During the initiation of ECPR, traditional resuscitation measures are continued, including chest compressions
and emergency administration of
medication. Practitioners initiating
Figure Venoarterial extracorporeal support for extracorporeal cardiopulmonary
this treatment should aim to maxiresuscitation.
mize cardiac output and flow to optimize outcomes. While traditional
is returned to the aorta, bypassing both the lungs and
resuscitation continues, surgeons place the ECMO cannuheart (see Figure). Placement of the cannulas is dependlas in large arterial and venous vessels. Location of canent on the ease of access and the size of the patient.14 If
nula placement is based on the type of ECMO that the
access to intracardiac placement is available, such as
patient will receive. There are 2 forms of ECMO, venovewith postoperative cardiac patients, this method is usunous and venoarterial. During venovenous ECMO, blood
ally preferable, with direct cannulation of the right atrium
is drained from the right atrium, oxygenated through the
and aorta. Other methods include the cannulation of the
circuit, then perfused back into the right atrium where the
femoral artery and vein. However, this use is restricted
heart pumps it to the rest of the body, bypassing only the
to adolescents and adults because the size of their vessels
lungs. However, this form of ECMO requires adequate
is large enough to support adequate drainage and reinfucardiac function, which is always severely impaired or
14
sion.14 Still, the most common method of cannulation is
absent in ECPR patients. Therefore, venoarterial extravenous access through the internal jugular vein directly
corporeal support is initiated for ECPR patients. In this
into the right atrium and arterial access through the
technique, 1 cannula is placed for venous drainage,
right carotid artery into the aorta.3
similar to venovenous ECMO, but the oxygenated blood
Once a patient is successfully cannulated, the patient
is immediately connected to the ECMO circuit. For this
Author
reason, most centers have developed a rapid deployment
Jennie Ryan in a nurse practitioner in the intensive care unit at
system, in which a circuit is preprimed with a crystalloid
Nemours Cardiac Center. She is also a per diem faculty member in
solution or is able to be primed with blood products within
the Helene Fuld Pavillion Simulation Lab at the University of
a very short period, usually 10 to 20 minutes.15 Although
Pennsylvania, School of Nursing, in Philadelphia.
Corresponding author: Jennie Ryan, MS, CPNP-AC, Nemours Cardiac Center,
a large immediate infusion of crystalloid solution can be
A. I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803
tolerated by older children and adolescents, some centers
(e-mail: jennie.ryan@nemours.org).
are reluctant to administer such an infusion to a neonate
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or
because of the significant hemodilution.15 However, the
www.ccnonline.org
CriticalCareNurse
61
benefits of immediate end-organ perfusion often outweigh

the risks of low hematocrit, which can be resolved with
blood transfusions once the circuit has been established.15
The Benefits of ECPR

The postresuscitation phase in pediatric patients
remains a high-risk period, complicated by significant
myocardial dysfunction, hyperthermia, hyperglycemia,
impaired autoregulation of blood pressure, and ischemia/
reperfusion response.14-16 Upon return of spontaneous
circulation and reperfusion, a decrease in contractility
of the heart, known as myocardial stunning, often occurs.
Decreased function of the heart can lead to hypotensive
shock, with further damage arising from increased production of inflammatory mediators and nitric oxide.16
Treatment of hypotension and myocardial dysfunction
often requires aggressive hemodynamic support with
fluid resuscitation and vasoactive agents including epinephrine, dobutamine, and dopamine.16
In contrast, mechanical circulation via ECMO
allows the body a period of hemodynamic stability
and the possibility of resolution of underlying disease
processes.15,16
Mechanical circulation via extracorporeal
Perfusion of
membrane oxygenation allows the body
organs with
a period of hemodynamic stability and
fully oxygenated
the possibility of resolution of underlying
blood via the
disease processes.
ECMO circuit
allows decreased myocardial oxygen demand, generally without the use of high-dose vasoconstrictors and
inotropic agents.15 This stability in the postresuscitation period may further improve survival rates.17
Large, multi-institutional studies16-18 show that overall
survival to discharge rates in pediatric patients resuscitated with conventional CPR remains at approximately
25% to 27%. However, survival statistics for ECPR are
more encouraging, with a general rate of success of near
40% to 60%.2-5,7-13,19-26 Multi-institutional data obtained in
2012 from the Extracorporeal Life Support Organization
(ELSO), an international registry and database of ECMO
treatment, demonstrated that ECPR was successful for
934 out of 2236 neonatal and pediatric patients, with
survival to discharge of 39% for neonates and 40% for
children. Other retrospective, single-institution studies
have shown survival rates as high as 72% to 80%.25,27-29
The Table provides more detailed information from the
current studies of ECPR in pediatric patients. Critical
62
CriticalCareNurse
analysis of this information is imperative when determining the utility of ECPR.

Most studies rate ECPRs success solely on survival to
discharge statistics; only a few studies address neurological outcome. A void remains in the literature as far as
addressing quality of life after ECPR. Furthermore, good
neurological outcome is often a subjective measure,
with terminology varying among researchers. Some
studies have shown that ECPR patients have an increased
likelihood of central nervous system complications
developing compared with patients treated with ECMO
without CPR.4 Other studies examining ECPR patients
have shown favorable neurological outcomes, as measured by the Pediatric Cerebral Performance Category
Scale, with a score of 2 or less in most patients.8,9,19,20,32
Further investigation into long-term neurological sequelae is needed and should be included in future studies.
When to Initiate Therapy?

In 2005, the American Heart Association recommended the use of ECPR for in-hospital patients in cardiac arrest when the duration of no-flow arrest is brief
and the condition leading to the cardiac arrest is
reversible.35 This broad recommendation does not offer a
definition of brief, nor does it differentiate between
time of no-flow arrest and duration of traditional CPR.
More recent recommendations from the 2010 International Consensus on Cardiopulmonary Resuscitation36
specifies that ECPR is appropriate for patients with heart
disease that is amenable to treatment or heart transplantation, where the cardiac arrest occurs in the intensive care unit in a facility with the personnel, equipment,
and training to provide ECPR. Use of ECPR is indicated
in only 1 situation after out-of-hospital cardiac arrest,
which is in cases of environmentally induced severe
hypothermia (< 30C), again, only if the appropriate
equipment and expertise are available.36 Medical institutions providing ECPR should have established protocols
for its implementation and use. Often centers lacking
these resources are unable to offer ECPR at all.
The advantages of ECPR after prolonged conventional resuscitation remain a source of controversy.
Despite the large number of studies performed regarding
ECPR use, no criteria or guidelines for timing of initiation of this therapy have been clearly established. The
International Consensus on Cardiopulmonary Resuscitation recognizes that evidence is insufficient for establishing
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Table
Retrospective pediatric studies of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary resuscitation
Population of
patients
Reference
No. of
patients
No. (%) of
Duration of
survivors to cardiopulmonary
discharge
resuscitation, min
Duration of
ECMO therapy
Aharon et al28
Postoperative,
cardiac
10
8 (80)
Mean (range),
42 (5-110)
> 30 min associated
with poor survival
Not reported
Alsoufi et al21
Postoperative,
cardiac
48
23 (46)
Not reported
Not reported
Alsoufi et al30
ICU and cardiac
80
27 (34)
Median (range)
4 days for both survivors and
Survivors: 46 (14-95)
nonsurvivors
Nonsurvivors: 41 (19-110)
Cengiz et al4
ELSO registry
161
64 (40)
Not reported
Mean (SD)
Survivors: 4.7 (3.5) days
Nonsurvivors: 4.4 (6.4) days
Chan et al5
ELSO registry of
cardiac patients
492
208 (42)
Not reported
Median (IQR)
Survivors: 87 (51-137) hours
Nonsurvivors: 87 (37-171) hours
40
30 (75)
Median (IQR)
Median (IQR)
Not reported
Not reported
Chrysostomous et al29 Cardiac
Conrad et al3
ELSO registry
de Mos et al10
ICU
151
Neonatal
282
Pediatric
Neonatal:
65 (43)
Pediatric:
111 (39)
2 (40)
Range
All: 31-77
Survivors: 35-48
Not reported
Cardiac
11
6 (55)
Mean (SD): 65 (9)
Mean (SD): 112 (18) hours
Delmo Walter et al
ICU
42
17 (40.4)
Mean (SD)
Survivors: 35 (1.3)
Nonsurvivors: 46 (4.2)
Mean (SD)
Survivors: 4.0 (2.2) days
Nonsurvivors: 6.0 (0.9) days
Duncan et al22
Cardiac
11
6 (55)
Median (range)
55 (20-103)
Not reported
Huang et al13
Pediatric
54
25 (46)
Mean (SD)
Survivors: 39 (17)
Nonsurvivors: 52 (45)
Not reported
Huang et al9
Pediatric
27
11 (41)
Median (IQR)
Median (IQR), range

Survivors: 102 (68-135), 43419 hours
Nonsurvivors: 89.2 (26.9-221),
6-637 hours
Joffe et al19
Meta-analysis
762
361 (49)
Not reported
Not reported
Kane et al
Cardiac
172
88 (51)
Kelly and Harrison31
Pediatric
and cardiac
31
7 (23)
Kumar et al12
Postoperative,
cardiac
29
12 (41)
Del Nido23
11
20
Median (interquartile range) Median (interquartile range)

Nonsurvivors: 36 (21-45) Nonsurvivors: 119 (57-183)
hours
Median
Survivors: 40
Nonsurvivors: 47
Mean
Survivors: 4 days
Nonsurvivors: 6 days
Mean (SD)
Survivors: 42 (8)
Nonsurvivors: 51 (10)
Not reported
Continued
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63
Table
No. of
patients
Continued
No. (%) of
Duration of
survivors to cardiopulmonary
discharge
resuscitation, min
Reference
Population of
patients
Morris et al32
ICU
Paden et al2
ELSO registry
Polimenakos et al26
Cardiac single
ventricle,
neonates
14
8 (57)
Prodhan et al27
ICU, cardiac
32
Raymond et al8
AHA/NRCPR
Shah et al33
64
Median (range)
Median (range)
Not reported
Not reported in ECPR group
Mean (SD)
Survivors: 38.6 (6.3)
Nonsurvivors: 42.1 (7.7)
Median (IQR)
Survivors: 4 (3-6.5) days
Nonsurvivors: 8 (5-11.5) days
24 (72)
Median (range)
Median (range)
hours
199
87 (44)
Median (range)
Not reported
Cardiac
27
9 (33)
Not reported
Mean (SD)
Survivors: 79.3 (40.7) hours
Nonsurvivors: 128.6 (193.3)
hours
Sivarajan et al34
Cardiac
37
14 (38)
Median
Survivors: 15
Nonsurvivors: 40
Not reported
Thiagarajan et al6
ELSO registry
682
261 (38)
Not reported
Median (interquartile range)

hours
Tajik and Cardarelli7
Meta-analysis
288
114 (39.6)
Not reported
Median (range)
4.3 (0.03-90) days
Wolf et al24
Cardiac
90
50 (55.5)
Median (range)
Survivors: 3 (1-20) days
Nonsurvivors: 5 (1-21) days
Thourani et al25
Cardiac
15
11 (73.3)
Not reported
Median (range)
66 (18-179)
Neonatal:
784
Pediatric:
1562
21 (33)
Duration of
ECMO therapy
Neonatal:
304 (39)
Pediatric:
630 (40)
Abbreviations: AHA/NRCPR, American Heart Association/National Registry of Cardiopulmonary Resuscitation; ELSO, Extracorporeal Life Support Organization; ICU,
intensive care unit; IQR, interquartile range.
any specific threshold for CPR duration beyond which

survival is unlikely.36
A substantial amount of debate can be found in published reports about when ECPR should be initiated and
when further intervention would be futile. Several pediatric studies have shown increased mortality rates for
patients cannulated after 30 minutes of conventional
CPR.7,11,28,34 However, other retrospective studies8-10,12,20,26,27,29,31,32
of pediatric patients have shown positive outcomes with
median CPR duration of 30 to 50 minutes. Even more
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interesting are the multiple case reports24,27,30,32,37 of successful cannulation and survival to discharge in patients
receiving CPR of up to 90 to 220 minutes.
Other research has focused on parameters that may
act as predictors for positive outcome. ECPR patients
with a preexisting diagnosis of cardiac illness have
shown improved survival outcomes, when compared
with patients with noncardiac illnesses.5,6,8,30,32 Perhaps
patients with cardiac illness have less multiorgan dysfunction before cardiac arrest and therefore are more likely to
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survive after treatment with ECPR.8 Few published data

support preexisting measurements as indicators for survival. Arterial blood gas values have been postulated to
be predictive variables in several studies, with pH less
than 7.2 associated with higher mortality.4,19,20,34 However,
Thiagarajan et al6 noted that although pre-ECMO arterial
pH less than 6.9 was strongly associated with negative
outcome, 12% of children who survived after ECPR use
had a pre-ECMO pH less than 6.9.6 Multiple studies5,6,8,9,19,20
have shown that preexisting renal insufficiency and
metabolic electrolyte abnormalities are associated with
worse survival to discharge.
This discordance in published results is of extreme
importance to practitioners initiating ECPR in pediatric
patients. The absence of clearly defined parameters and
inconsistencies in published reports may lead some clinicians to initiate ECPR when attempts may be futile,
but also may inhibit its use when there is the possibility
of success.
When to Withdraw ECMO?

Transition from ECPR to standard ECMO care occurs
once the child is cannulated and placed on the ECMO
circuit. Further management of the patient focuses on
treatment of underlying disease processes. The use of
artificial oxygenation and perfusion in this time allows
the child a period of hemodynamic stability and decreased
myocardial oxygen demand, during which vital organ
function may return. However, the precise amount of
time it takes the organs to regain adequate function to
support the body remains unknown. Several studies4,5,30
of duration of ECMO after CPR show similar amounts of
time on the circuit for both survivors and nonsurvivors.
Historically, data in pediatric patients indicate that
ECMO for cardiac failure after cardiothoracic surgery
continued beyond 3 to 6 days results in poor outcomes,
and ECMO beyond 2 weeks may not improve respiratory
failure.33 However, a recent review38 of ELSO data in cardiac ECMO patients shows no significant difference in
survival to discharge between patients who receive
ECMO for 14 to 20.9 days (25% survival) and patients
who received ECMO for 21 to 27.9 days (23% survival);
but, survival decreased significantly after 28 days to
13%.38 In pediatric patients receiving ECMO for acute
respiratory failure, review of ELSO data showed survival
rates were inversely related to duration of ECMO.
Patients receiving ECMO support for 3 weeks or longer
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had a survival to discharge rate of 38%, significantly

decreased from the rate of survival of patients who
received ECMO support for 2 weeks or less (61%).39
If separation from the ECMO circuit is not possible
because of ongoing cardiac or pulmonary failure, then
transition to other modes of mechanical support may be
an option. Patients with prolonged pulmonary failure
but recovery of cardiac function may be transitioned to
venovenous extracorporeal support, potentially decreasing the risk of oxygenator-associated thrombi. Patients
with continued cardiac dysfunction may be converted to
a ventricular assist device to act as a bridge for transplant.
To date, only 2 ventricular assist devices are approved
for pediatric use, the Berlin Heart and HeartWare. However, no current research supports the use of a ventricular assist device in children after cardiac arrest.
The only clear indicator for withdrawal of ECMO
support is neurological devastation evidenced by brain
death, in which termination of all life support is warranted. Other clear criteria for withdraw of ECMO
include hemorrhagic stroke or intraventricular hemorrhage in which anticoagulation must be discontinued to
prevent worsening intracra- The use of artificial oxygenation and
nial bleeding. perfusion allows a period of hemodynamic
Other indica- stability, during which vital organ function
tors for termi- may return. However, the amount of time
nation of
it takes the organs to regain adequate
ECMO
function remains unknown.
include worsening end-organ dysfunction. Renal insufficiency following ECPR is a poor prognostic factor.5,6,8,9,19 Acute renal
injury can occur during cardiac arrest and resuscitation
as a result of hypoperfusion of the kidneys. Again, the
question of how long it will take for these organs to recover,
or if recovery is possible at all, has yet to be answered.
Ethical Considerations
The judicious use of ECPR in pediatric critical care is
complicated by a vast number of factors, including the
high cost of care, questionable effectiveness, and intensified emotions of families and providers caring for a critically ill child. ECPR is an advanced form of life support,
so its use in patient care must be in accordance with the
principles of medical ethics. The first principle is beneficence, which requires that practitioners offer care that
is beneficial to their patients.40 Unnecessary surgical
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65
procedures and unauthorized research are common

problems that arise when addressing beneficence.41 The
second principle is nonmaleficence, meaning do no
harm. This principle requires that the benefits of a treatment must outweigh the potential negative aspects such
as overburdensome pain and unavoidable suffering.40
When discussing the continued use of ECMO, practitioners must decide if prolonged therapy to enhance the
possibility of survival prevails over the risk of unnecessary discomfort and extended suffering of the child. The
third ethical principle is autonomy, which refers to the
patients right to decide what is appropriate in their
care. In critically ill pediatric patients, a dependent
childs autonomy is delegated to the surrogate decision
maker, most often the parents.40 Their values and judgments must be respected by practitioners and incorporated into decision making at every level.
The fourth principle is justice, which is often a source
of controversy in modern medicine.40 This principle
demands that therapies be provided equally to all
patients despite differences in socioeconomic status,
race, gender, and
The ethical dilemma of ECPR is most so on. However,
often not whether to withhold support, medical resources
are not limitless,
but when to withdraw it.
and societies must
strive to ensure appropriate distribution of health care.40
Median hospital charges of ECPR patients has been
quoted at $310824, which is significantly greater than
charges for propensity-matched conventional CPR
patients, which are $147817.42 Financial burdens of
ECMO support may far exceed reimbursement from
insurance companies and may place the hospital at
financial risk.40,43 Offering excess treatment in one
patient may conceivably lead to a decrease in resources
for another patient.43
Taking into account the ethical principles of medicine,
practitioners in the intensive care unit must be acutely
aware of the potential for benefit and the medically
futility of the therapies they provide. Most often, such
awareness means that advanced life support is initiated
and removed appropriately depending on the patients
chance of survival and the desires of the patients family.
These concepts are more commonly known as initiating,
withholding, and withdrawing treatment.
Ethical guidelines have determined that, withholding
and withdrawing life support are no different.44,45 However,
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many professionals recognize that a psychological difference clearly exists.44 Based on this assumption, the Presidents Commission on Ethical Problems in Medicine
concluded that, contrary to widespread feelings on the
matter, withdrawing treatment was preferable to withholding treatment for 2 reasons.45,46 Primarily, withdrawing allows a time-limited trial of therapy in which the
patients status can be reassessed and prognosis determined.45,46 Second, a traditional reluctance to withdraw
treatment had led many practitioners to forgo lifesaving
therapies altogether for fear of eventual failure.44 For
this reason, most intensivists now offer advanced life
support to their patients with the hope that therapies
will be successful, or at the very least buy some time.44
Withholding ECPR is often a debate between physicians involved in the patients care. Most families are not
aware of ECPR and would not know to request that their
child be treated with ECPR. Often ECPR is recommended
by a physician, and therefore withholding ECPR may
come to mean simply not offering it. Withholding ECPR
often becomes an intraprofessional dilemma, where the
effectiveness of treatment is controversial. As discussed
previously, the lack of parameters to guide physicians is
detrimental to evidence-based practice, and decisions in
this scenario are often based on personal reasoning,
experience, and values. In these difficult situations, practitioners most often decide to treat, possibly against their
better judgment.44 Solomon et al44 examined perceptions
of physicians and nurses caring for critically ill children
and reported that 80% of critical care attending physicians
agreed that sometimes I feel we are saving children who
should not be saved, whereas only 8% agreed that
sometimes I feel we give up on children too soon.
The ethical dilemma of ECPR is therefore most often
not whether to withhold it, but when to withdraw it.
Again, the literature does not support a definitive
timetable for withdrawal of ECMO. Obviously, neurological devastation as evidenced by brain death is a definitive indicator for withdrawal of treatment. But no other
parameters exist, and the decision to withdraw is often
at the recommendation of the provider.40,47 Maintaining
ethical principles at this time is essential for practitioners
as they address the medical futility of further treatment.40
There must be a level of assurance that prolonged time
on ECMO will enhance patients outcomes and that this
possibility outweighs the risks of further suffering and
discomfort for the child.47
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The Final Decision

Although clinicians must decide if ECMO is appropriate and when further intervention is futile, the ultimate
burden of choice is left to the patients parents. As practitioners, we must be aware of, and respect, the tremendous
responsibility of this decision. ECPR is initiated as the
most advanced form of life support available to patients,
when death without ECMO is most certainly imminent.
Furthermore, many patients remain alive purely through
the use of ECMO and cannot be supported with traditional
medicine. Removal of the pump often equates to death.
In 2003, Curley and Meyer48 examined parental
experiences with ECMO and reported that 61% of parents felt that they had no other choice but to consent to
treatment, since death was the only other option. In the
study, most parents understood that ECMO was an
extraordinary intervention, even in the technologically
dominant intensive care unit environment.
As practitioners, we must be aware of our communication with parents in this very difficult and anxious time.
Honesty concerning the many complications and uncertainties of ECMO is paramount to effective discussions.48
Furthermore, when a decision is made to treat a child
with ECMO, parents must be cautioned that its use
involves a time-limited trial.48 Reasonable expectations of
length of duration and outcome must be clear to parents.47 Finally, all members of the team must be prepared
to answer questions and provide support throughout the
use of ECMO.47 The importance of offering support and
guidance can never be underestimated in this setting,
where parents are very aware that every moment with
their child may be their last.
Nursing Implications
The use of ECMO during CPR is a technologically
advanced and complex treatment that requires extensive
knowledge from every member of the health care team.
Bedside nurses should be well educated on the physiology of the patient, as well as the mechanical aspects of
the ECMO pump. Centers providing this treatment must
offer educational programs to train nurses in rapid
deployment of the ECMO circuit. Familiarity with the
circuit and experience with the cannulation procedure
will ensure a smooth transition from cardiopulmonary
resuscitation to artificial circulation.
Once the patient is cannulated, highly skilled nurses
are needed to manage daily treatment. Nursing care of
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ECMO patients is both physically and mentally demanding. These patients require frequent laboratory and
physical assessments, as well as frequent neurological
checks. Neurological injury is common in ECMO patients
owing to the acuity of their illness and the risk of cerebral
vascular injury from stroke or hemorrhage. Daily ultrasound imaging of the head are routine in most centers,
and continuous electroencephalographic monitoring is
also implemented with concerns for subclinical seizure
activity. Because
of the immense The importance of offering support and
workload associ- guidance can never be underestimated
ated with ECMO in this setting, where parents are very
aware that every moment with their
patients, 2
nurses are gener- child may be their last.
ally needed to
care for these acutely ill children. One nurse is tasked
with the care of the patient, while the other nurse tends
to the needs of the ECMO pump. Most centers have
implemented the use of perfusionists and specially
trained respiratory therapists to manage the ECMO circuit in an effort to reduce the strain on nursing staffing.
Furthermore, the bedside nurse is often depended on
to provide support to patients families. This responsibility is difficult and challenging, and it requires a large
amount of dedication. Most intensive care nurses are well
versed in end-of-life care and must continue to use this
skill during ECMO trials. Although the physical care of
these patients can be burdensome, bedside nurses must
strive to ensure that time is allocated for family support.
When needed, nurses should be aware of the resources
available for patients families, including palliative care
teams, social workers, and chaplain services. These services can help by offering assistance to family members
during periods of critical illness and end of life.
The Future of ECPR

Use of ECMO as a final therapy during CPR in the
care of critically ill patients remains promising. As
providers continue to broaden the boundaries of use of
ECMO, it is imperative that judicious decision making
be maintained in the clinical setting. Further data and
research are needed to create guidelines and parameters
for withholding and withdrawing ECMO. It is essential
that clinicians providing this treatment be thoroughly
educated and knowledgeable about the literature, so that
decisions are based on evidence.
CriticalCareNurse
67
Finally, as with all end-of-life care, it is essential that

all members of the health care team be aware of parental
presence and concern. Support must be provided to
patients families on a constant basis to ensure that their
needs are met. It is very easy for physicians and nurses
to become overwhelmed by the technical aspects of
caring for these critically ill patients and focus solely on
maintaining life. However, a holistic approach to care
should remain a focus, with appropriate support of the
patient as well as the patients family. CCN
None reported.
To learn more about extracorporeal membrane oxygenation, read

Discharge Outcome in Adults Treated With Extracorporeal
Membrane Oxygenation by Guttendorf et al in the American
Journal of Critical Care, September 2014;23:365-377. Available at
www.ajcconline.org.
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treatment recommendations. Resuscitation. 2010;81(suppl 1):e213-e259.
37. Kelly RB, Porter PA, Meier AH, Myers JL, Thomas NJ. Duration of cardiopulmonary resuscitation before extracorporeal rescue: how long is
not long enough? ASAIO J. 2005;51(5):665-667.
38. Merril ED, Schoeneberg L, Sandesara P, et al. Outcomes after prolonged
extracorporeal membrane oxygenation support in children with cardiac
disease: Extracorporeal Life Support Organization registry study. J Thorac
www.ccnonline.org
Cardiovasc Surg. 2014;148(2):582-588.

39. Brogan TV, Zabrocki L, Thiagarajan RR, Rycus PT, Bratton SL. Prolonged
extracorporeal membrane oxygenation for children with respiratory
failure. Pediatr Crit Care Med. 2012;13(4):e294-e254.
40. Steinhorn DM. Termination of extracorporeal membrane oxygenation
for cardiac support. Artif Organs. 1999;23(11):1026-1030.
41. Lantos JD, Frader J. Extracorporeal membrane oxygenation and the ethics
of clinical research in pediatrics. N Engl J Med. 1990;326(6):409-413.
42. Lowry AW, Morales DL, Graves DE, et al. Characterization of extracorporeal membrane oxygenation for pediatric cardiac arrest in the United
States: analysis of the kids inpatient database. Pediatr Cardiol.
2013;34(6):1422-1430.
43. Truog RD, Brett AS, Frader J. The problem with futility. N Engl J Med.
1992;326(23):1560-1564.
44. Solomon MZ, Sellers DE, Heller KS, et al. New and lingering controversies in pediatric end-of-life care. Pediatrics. 2005;116(4):872-883.
www.ccnonline.org
45. Presidents Commission for the Study of Ethical Problems in Medicine

and Biomedical and Behavioral Research. Deciding to Forgo Life-Sustaining Treatment: A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions. Washington, DC: US Government Printing Office; 1983.
46. American Academy of Pediatrics, Committee on Bioethics. Guidelines
on forgoing life-sustaining medical treatment. Pediatrics. 1994;93(3):
532-536.
47. Gamulka BD. Ethical uncertainty: an approach to decisions involving extracorporeal membrane oxygenation. Can Med Assoc J. 1994;150:565-568.
48. Curley MA, Meyer EC. Parental experience of highly technical therapy:
Survivors and nonsurvivors of extracorporeal membrane oxygenation
support. Pediatr Crit Care Med. 2003;4(2):214-219.
CriticalCareNurse
69
CNE Test Test ID C151: Extracorporeal Membrane Oxygenation for Pediatric Cardiac Arrest
Learning objectives: 1. Determine the difference between venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) 2. Describe the
benefits of extracorporeal cardiopulmonary resuscitation 3. Discuss the ethical considerations related to management of patients undergoing ECMO
7. The use of ECPR in pediatric critical care is complicated by all except which of
the following?
a. High cost of care
b. Questionable effectiveness
c. Intensified emotions of families and providers
d. Absence of standardized clinical guidelines for withdrawal
1. Venoarterial extracorporeal membrane oxygenation (ECMO) is the preferred

extracorporeal support for extracorporeal cardiopulmonary resuscitation
(ECPR) patients over venovenous ECMO because of which of the following?
a. Risk of hemodilution in neonates
b. Absence of adequate cardiac function
c. Impaired renal function
d. None of the above
8. Which of the following is the term for the concept of initiating and removing
advanced life support?
a. Initiating
b. Withholding
c. Withdrawing
d. All of the above
2. Complications in the postresuscitation phase in pediatric patients include all

except which of the following?
a. Impaired autoregulation of blood pressure
b. Myocardial dysfunction
c. Increased contractility of the heart
d. Hyperglycemia
9. Nursing care of patients receiving ECMO include which of the following?

a. Neurologic assessment
b. Highly skilled nursing care
c. Early mobility
d. A and B
3. Benefits of mechanical circulation via ECMO include which of the following?

a. Decreased risk of hypotensive shock
b. Decreased risk of aggressive vasoactive resuscitation
c. Promotion of autoregulation of blood pressure in the initial resuscitation period
d. Promotion of hemodynamic stability
10. Which of the following can help nurses assist families with emotional
support during hospitalization?
a. Child life specialists
b. Palliative care, social workers, and chaplain services
c. Physician support
d. Leadership support
4. ECPR is recommended for use in which of the following types of patient settings?
a. Heart transplant surgery
b. Brief no-flow cardiac arrest in the hospital setting
c. Severe hyperthermia
d. Prolonged cardiopulmonary resuscitation with spontaneous return of circulation
11. Studies examining parents experiences with ECMO report which of the
following?
a. Parents felt they had no other choice as death was the only other option.
b. ECMO is one of several treatments available to improve their childs condition.
c. Parents preferred optimistic reports on their childs condition over reasonable prognosis.
d. Parents relied heavily on the physicians to guide them through the daily stressors
of having a child undergoing supportive measures.
5. Which of the following preexisting measurements can help determine survival

potential?
a. Preexisting diagnosis of cardiac illness has shown to improve survival outcomes
b. A pre-ECMO pH of less than 7.2 is associated with higher mortality
c. A pre-ECMO pH of less than 6.9% is associated with negative outcomes
d. All of the above
6. Which of the following is the only clear indicator for withdrawal of ECMO
support?
a. Neurological deterioration
b. Ongoing cardiac dysfunction
c. Ongoing pulmonary failure
d. Oxygenator-associated thrombi
12. Which of the following statements is true regarding treatment of neonates

with ECMO?
a. Large immediate infusion of crystalloids is a standard of care for neonates.
b. Immediate infusion with crystalloids is well tolerated by neonates.
c. Benefits of immediate end-organ perfusion often outweigh the risks of low hematocrit.
d. Hemodilution is not a significant risk with neonates.
1. a
b
c
d
2. a
b
c
d
3. a
b
c
d
4. a
b
c
d
5. a
b
c
d
6. a
b
c
d
7. a
b
c
d
8. a
b
c
d
9. a
b
c
d
10. a
b
c
d
11. a
b
c
d
12. a
b
c
d
Synergy CERP Category A Test writer: Tina Cronin
Name
Program evaluation
Yes


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Certification Test Prep

Celebrate and Be Proud!
hirty years ago this month (February 1985) I took the CCRN
exam. Achieving and maintaining my critical care certification
is one of the accomplishments, in my 34 years as a critical care
nurse, of which I am most proud. Many of the nurses who are reading this column were not yet born when I became certified. My
efforts to help others prepare for and achieve this coveted certification is exciting and humbling. The recent changes that have
occurred in the eligibility criteria have allowed more nurses to
obtain and maintain their CCRN certification. Now all nurses who
affect the care of critically ill patients and their families, whether
electronically (CCRN-e), in the classroom, at the bedside, or from an
administrative office (CCRN-K), can proudly wear the CCRN credential. I feel honored to be a member of this group. Please join me in
celebrating my anniversary and remember to celebrate your own!
Adult CCRN Practice

Questions
1. Following a craniotomy, a
patient has a decreased serum
sodium level. Which other laboratory findings would lead the
nurse to suspect syndrome of
inappropriate antidiuretic hormone (SIADH)?
A. High serum osmolality and low
urine sodium
B. Low serum osmolality and high
urine sodium
C. High urine specific gravity and
high urinary output
D. Low urine specific gravity and
low urinary output
Test plan topic: Endocrine, 6% of the
CCRN questions
RAUEN
CEBALLOS
RISCH
Contributors
Carol Rauen, RN, MS, CCNS, CCRN, PCCN, CEN, RN-BC, the department editor,
is an independent clinical nurse specialist in The Outer Banks of North Carolina.
Carol welcomes feedback from readers and practice questions from potential
contributors at rauen.carol104@gmail.com.
Kirtley Ceballos, MSN, RNC-NIC, PCNS-BC, clinical nurse specialist in the
neonatal intensive care unit at University of Colorado Hospital, University of
Colorado Health, Colorado Institute for Maternal Fetal Health, Aurora, Colorado,
contributed the pediatric CCRN questions.
Steve Risch, RN, MSN, CCRN, CCNS, a critical care clinical nurse specialist at
Holy Cross Hospital, Silver Spring, Maryland, contributed the adult CCRN
questions.
www.ccnonline.org
2. A multiple trauma patient has

received 4 L of normal saline and
2 units of packed red blood cells
but continues to be hypotensive.
Which recent assessment finding
of this patient would best reflect
improving tissue perfusion?
A. Increasing creatinine level
B. Increasing hematocrit
C. Decreasing heart rate
D. Decreasing lactic acid levels
Test plan topic: Multisystem, 8% of
the CCRN questions
3. A patient who continues to
experience full-body tonic-clonic
CriticalCareNurse
71
movements with no apparent response despite

administration of lorazepam (Ativan) and phenytoin (Dilantin) is most likely experiencing which
type of seizure?
A. Partial complex
B. Simple complex
C. Status epilepticus
D. Myoclonic seizure
Test plan topic: Neurological, 12% of the CCRN questions.
4. A patient who sustained a cervical (C5) spinal
cord injury 8 weeks ago and is quadriplegic has
sudden development of hypertension, blurred
vision, flushing, and diaphoresis of the face and
neck. The nurse should immediately:
A. Lower the head of the bed to flat position
B. Coach the patient to breathe deeply and cough
effectively
C. Check the patients temperature and administer an
antipyretic as needed
D. Irrigate the patients urinary catheter
Test plan topic: Neurological, 12% of the CCRN questions.
5. A patient has these hemodynamic findings after
mitral valve replacement:
Heart rate (HR), 65/min
Systolic blood pressure (SBP), 70 mm Hg
Mean arterial pressure (MAP), 55 mm Hg
Cardiac output (CO), 3.8 L/min
Cardiac index (CI, calculated as CO in liters per
minute divided by body surface area in square
meters), 1.8
Central venous pressure (CVP), 12 mm Hg
Pulmonary artery occlusion pressure (PAOP),
15 mm Hg
Which of the following interventions should the
nurse perform?
A. Increase epinephrine infusion from 4 g/min to
6 g/min.
B. Decrease the norepinephrine infusion from 8 g/min
to 4 g/min
C. Prepare to administer a 1-L bolus of normal saline
D. Attach the epicardial pacing wires to a pacemaker
and begin ventricular (VVI) pacing
72
CriticalCareNurse
Test plan topic: Cardiovascular, 20% of the CCRN questions
Correct Answers and Rationales for

Adult CCRN Practice Questions
1. Correct Answer: B
Rationale
SIADH or diabetes insipidus (DI) can develop after

craniotomy. The posterior lobe of the pituitary gland,
which is regulated by the hypothalamus, releases antidiuretic hormone (ADH). In SIADH, increased release of
ADH causes fluid retention. The fluid retention causes
the patient to have a low urinary output, low serum
osmolality, low serum level of sodium, high specific
gravity of urine, and high sodium level in the urine.
Source
Morton P, Fontaine D. Critical Care Nursing: A Holistic Approach. 10th ed.
Philadelphia, PA: Lippincott, Williams & Wilkins; 2013:391.
2. Correct Answer: D
Rationale
The best indicator of improved oxygen delivery to

the cells during resuscitation is a decreasing level of lactic
acid, which is a byproduct of anaerobic metabolism.
Creatinine and hematocrit are not good indicators of oxygenation at the cellular level, and a decrease in heart rate
can reflect adequate resuscitation, but is not as specific
an indicator of tissue perfusion as are lactic acid levels.
Source
Philadelphia, PA: Lippincott, Williams & Wilkins; 2013:1408-1418.
3. Correct Answer: C
Rationale
Status epilepticus is a seizure that is continuous for a

prolonged period of time and typically does not respond
to single/initial administration of antiepileptic medication and benzodiazepine. Simple and partial complex
seizures last only 5 to 7 minutes. Myoclonic seizures are
associated with hypoxic brain injury and have a single
jerklike presentation, not full-body involvement.
Sources
Bardwaj A, Mireski M. Handbook of Neurocritical Care. 2nd ed. New York, NY:
Springer; 2012:499.
Philadelphia PA: Lippincott, Williams & Wilkins; 2013:902.
www.ccnonline.org
Rationale
The most common cause of autonomic dysreflexia is

obstruction of the urinary catheter, so irrigation might
correct the problem. The head of the bed (A) should be
elevated, not lowered. Although C5-level quadriplegics
must be monitored carefully for airway and pulmonary
issues, assisting the patient with effectively coughing (B)
will not help to treat the current problem. Fever (C) is
not a symptom of autonomic dysreflexia.
Sources
Bardwaj A, Mireski M. Handbook of Neurocritical Care. 2nd ed. New York, NY:
Springer; 2012:499.
5. Correct Answer: A
Rationale
Increasing the epinephrine infusion would further

increase - and -receptor stimulation to increase heart
rate, contractility, and blood pressure. Decreasing the
norepinephrine (B) could further decrease the blood
pressure. The CVP and the PAOP are both high, indicating that more volume (C) is not needed at this time. No
need to pace for a heart rate of 65/min.
Source
2. A 3-week-old infant is newly admitted to the

pediatric intensive care unit (PICU) with a heart
rate of 246/min. The parents report the baby has
refused feeding for 8 hours and is difficult to
console. The infant is pale and sweating. What
intervention will be tried first?
A. Digoxin
B. Applying ice to the face
C. Synchronized cardioversion
D. Intravenous (IV) adenosine
Test plan topic: Cardiac, 14% of the pediatric CCRN
questions
3. An 11-year-old admitted for bacterial meningitis
has complained of headache and abdominal pain
for the past 4 hours and is now febrile, tachycardic, and vomiting. The nurse contacts the
physician immediately because the nurse suspects:
A. Acute adrenocortical insufficiency
B. Appendicitis
C. Hyponatremia
D. Cushing syndrome
Test plan topic: Neurological, 14% of the pediatric CCRN
questions

Pediatric CCRN Practice Questions

1. A 13-year-old is now permanently disabled after a
motor vehicle collision (MVC) in which the
mother was driving. What is an effective way for
the nurse to promote coping for this patient and
family?
A. Instruct the parents to recognize how different the
child will be from their peers.
B. Discourage expression of feelings of anger by the
patient toward the mother.
C. Provide information about other children in similar
situations who are doing well.
D. Do not include the child in discussions or decisions
about care.
Test plan topic: Professional Caring and Ethical Practices,
20% of the pediatric CCRN questions
www.ccnonline.org
4. A 6-kg infant is in the PICU after 6 days of having

bloody diarrhea, vomiting, and fever at home.
Urine output in the past 12 hours is 10 mL and is
amber in color. Blood pressure is 110/85 mm Hg.
What diagnostic test do you expect to evaluate
these new symptoms?
A. Liver function tests
B. Magnetic resonance imaging
C. Renal scan
D. Echocardiogram
Test plan topic: Renal, 6% of the pediatric CCRN questions
5. An 8-year-old recovering from an open femoral
fracture is moved from the medical-surgical unit
to the PICU because of signs of infection. What
symptom of osteomyelitis may be masked by
treatment of the primary injury?
CriticalCareNurse
73
A. Local signs infection

B. Fever
C. Dehydration
D. Pain
lower quadrant. Hyponatremia (C) should always be considered in patients with central nervous system infection
and can be a result of adrenal insufficiency. Cushing syndrome (D) is rare in children and most often caused by
steroid therapy.
Test plan topic: Multisystem, 11% of the pediatric CCRN

questions
Source
Correct Answers and Rationales for

Pediatric CCRN Practice Questions
Hockenberry MJ, Wilson D. Wong's Nursing Care of Infants and Children. St

Louis, MO: Elsevier Health Sciences; 2013:1586.
Rationale
Rationale
Oliguria, amber urine, and hypertension are clinical

manifestations of hemolytic-uremic syndrome (HUS),
the leading cause of acute renal failure in infants and young
children. HUS generally follows an episode of gastroenteritis.
A renal scan to assess renal perfusion is an expected diagnostic procedure.
Fostering hopefulness (C) may help improve the

patients sense of well-being. It is important to promote
normalization by emphasizing abilities, rather than
focusing on differences (A). If the child is not allowed to
express anger (B), this family will not be able to develop
a nurturing environment. Allowing the patient to participate in decisions (D) will encourage a positive self-image.
Source
Potts NL, Mandleco BL. Pediatric Nursing: Caring for Children and Their Families.
Independence, KY: Cengage Learning; 2011:723.
Source
Hockenberry MJ, Wilson D. Wong's Nursing Care of Infants and Children. St
Louis, MO: Elsevier Health Sciences; 2013:857-858.
Rationale
2. Correct Answer: B
Rationale
This patient has clinical signs of supraventricular

tachycardia (SVT). A vagal maneuver, like applying ice
to the face, can immediately reverse SVT. IV adenosine
(D) may be used in the emergency setting when vagal
maneuvers fail. Digoxin (A) is first-line medical management for chronic SVT. Synchronized cardioversion
(C) can be used to treat SVT in the ICU setting if cardiac
output is compromised.
Source
Hockenberry MJ, Wilson D. Wong's Nursing Care of Infants and Children. St Louis,
MO: Elsevier Health Sciences; 2013:1400.
3. Correct Answer: A
Rationale
Because the patient is most likely receiving pain medication for the fracture, increased pain and tenderness may
not be perceived. The nurse should monitor for signs of
acute infection and alterations in thermoregulation while
continuing to provide pain-relief measures.
Source
Potts NL, Mandleco BL. Pediatric Nursing: Caring for Children and Their Families.
Independence, KY: Cengage Learning; 2011:1312.
AACN Certcorp publishes a study bibliography that

identifies the sources from which items are validated. The
document may be found in the AACN Certification exam
handbook. The contributor of each question written for
this column has listed the source used in developing each
item. CCN
Although rare, acute adrenocortical insufficiency

can be caused by damage of the adrenal gland from
meningococcemia. Early symptoms include headache,
diffuse abdominal pain, nausea, and vomiting. Although
abdominal pain and vomiting can be symptoms of
appendicitis (B), classic signs include anorexia and periumbilical pain followed by nausea and pain in the right
74
CriticalCareNurse
www.ccnonline.org
Ask the Experts

Comparing Blood Pressure Measures:
Does One Measurement Equal Another?
Is it prudent to correlate noninvasive blood

pressure (NIBP) measurements with arterial
blood pressure measurements? My understanding is that the
accuracy of arterial
blood pressure measurements is assessed
by doing the squarewave test and leveling, not by correlating
the arterial measurements with the NIBP
values. However, I
observe the practice
Author
Barbara McLean is a critical care clinical
nurse specialist at Grady Health Systems
in Atlanta, Georgia.
Corresponding author: Barbara McLean, RN, MN,
CCNS-BC, NP-BC, CCRN, Grady Health Systems, 80 Jesse
Hill Jr. Drive SE, Atlanta, GA 30303 (e-mail:
bmclean1@gmh.edu).
To purchase electronic and print reprints, contact the
American Association of Critical-Care Nurses, 101
Columbia, Aliso Viejo, CA 92656. Phone, (800) 8092273 or (949) 362-2050 (ext 532); fax, (949) 3622049; e-mail, reprints@aacn.org.
doi: http://dx.doi.org/10.4037/ccn2015557
www.ccnonline.org
of correlating with the NIBP

values so often, it makes me
wonder if I have misunderstood my previous training
on arterial catheters.
Barbara McLean, RN, MN,

CCNS-BC, NP-BC, CCRN,
replies:
Many critically ill patients are
monitored with continuous blood
pressure measurements, which
provide clinicians with the important measures of systolic blood
pressure (reflecting the change of
pressure in the artery related to
ventricular stroke volume) and
diastolic blood pressure (related
to vascular tone), as well as the
calculated mean arterial pressure
and pulse pressure. The physiology
of blood pressure monitoring is
quite complex, and the meanings
of the different values are often
misunderstood. Although most
providers use target end points for
pressure monitoring and intervention, little evidence supports the
use of a single blood pressure target. When measuring noninvasively,
the points of measure are static,
versus the invasive measures, which
are dynamic (beat to beat). The
complexity of variables requires a

physiological appreciation of a
constellation of signs and symptoms, not just the blood pressures
or the mean pressure.1
In 1896, the mercury sphygmomanometer was designed and
then adopted and disseminated in
part by Harvey Cushing. In 1905,
Korotkoff developed methods for
auscultating Korotkoff sounds,
which were related primarily to
diastolic pressures. The clinical
techniques of direct measurement
of blood pressure by intra-arterial
cannula were initially developed
in the 1930s but were not used
effectively until the 1950s. These
measurements were soon accepted
as representing true systolic and
diastolic pressures.2 Since that time,
a significant amount of research
and engineering has produced a
variety of invasive and alternative
indirect methods of measuring
blood pressure. Following a brief
summary of the current methods
of evaluating blood pressure, a
simple overview of validation of
invasive arterial blood pressure
will simplify the comparisons.
Providers can indirectly monitor blood pressure by using a number of techniques, most of which
describe the external pressure
CriticalCareNurse
75
applied to block flow to an artery

distal to the occlusion. These
methods actually detect the effects
of blood flow, not intra-arterial
pressure. These differences in what
is actually measured are the major
points of discrepancy between
direct and indirect measurements.
Five methods are currently used
for noninvasive monitoring of blood
pressure: Doppler flow, infrasound,
oscillometry, the volume clamp
technique, and arterial tonometry.
Doppler Flow
Systems that operate on the
Doppler principle take advantage
of the change in frequency of an
echo signal when there is movement between 2 objects. Doppler
devices emit brief pulses of sound
at a high frequency that are reflected
back to the transducer. In an uncompressed artery, the small amount
of motion of the artery wall does
not cause a change in frequency of
the reflected signal. The compressed
artery exhibits a large amount of
wall motion when flow first appears
in the vessel distal to the inflated
cuff, which changes the frequency
of the signal, causing what is known
as a Doppler shift. The first appearance of flow in the distal part of the
artery represents systolic pressure.
When the Doppler shift in the echo
signal disappears, that represents
diastolic pressure.
Infrasound
Infrasound devices use a
microphone to detect low-frequency
(20-30 Hz) sound waves associated
with the oscillation of the arterial
wall. These sounds are processed by
76
CriticalCareNurse
a minicomputer, and the processed

signals are usually displayed in
digital form.
Oscillometry
Most automated NIBP devices
are based on oscillometry. Oscillometric devices operate on the same
principle as manual oscillometric
measurements. The cuff senses
pressure fluctuations caused by
vessel wall oscillations in the presence of pulsatile blood flow. Maximum oscillation is seen at mean
pressure, whereas wall movement
greatly decreases below diastolic
pressure. As with the other automated methods described, the
signals produced by the system
are processed electronically and
displayed in numeric form.3 In
oscillometry, variations in cuff
pressure resulting from arterial
pulsations during cuff deflation
are sensed by the monitor and
used to determine arterial blood
pressure values. The pressure at
which the peak amplitude of arterial pulsations occurs corresponds
closely to directly measured mean
arterial pressure, and values of
systolic and diastolic pressure are
derived from proprietary formulas
that examine the rate of change of
the pressure pulsations. Consequently, systolic and diastolic values obtained with this technique
are less reliable than mean arterial
pressure values.
Indirectly measured pressures
vary depending on the size of the
cuff used. Cuffs of inadequate width
and length can provide falsely elevated measurements. Bladder width
should equal 40% and bladder
length at least 60% of the circumference of the extremity measured.

When a cuff is slowly deflated and
blood first begins to flow through
the occluded artery, the arterys
walls begin to vibrate. This vibration can be detected as an oscillation in pressure and has served as
the basis for the development of
several automated devices for monitoring blood pressure. The disadvantages include the inability to
measure diastolic pressure, poor
correlation with directly measured
pressures, and lack of utility in
situations in which Riva-Rocci
(auscultation) measurements are
also unobtainable.4
Volume Clamp Technique

The volume clamp method
avoids the use of an arm cuff. A
finger cuff is applied to the proximal or middle phalanx to keep
the artery at a constant size. The
pressure in the cuff is changed as
necessary by a servocontrol unit
strapped to the wrist. The feedback in this system is provided by
a photoplethysmograph that estimates arterial size. The pressure
needed to keep the artery at its
unloaded volume can be used to
estimate the intra-arterial pressure.5
Arterial Tonometry
Arterial tonometry provides
continuous noninvasive measurement of arterial pressure, including pressure waveforms. It slightly
compresses the superficial wall of
an artery (usually the radial artery).
Pressure tracings obtained in this
manner are similar to intra-arterial
tracings. A generalized transfer
www.ccnonline.org
function can convert these tracings

to an estimate of aortic pressure.
This method has not yet achieved
widespread clinical use.
In summary, automated noninvasive measurement of blood
pressure is a major component of
modern critical care monitoring.
Oscillometric and Doppler-based
devices are adequate for frequent
blood pressure checks in patients
without hemodynamic instability,
in patient transport situations
where arterial catheters cannot be
easily used, and in patients with
severe burns, in whom direct arterial pressure measurement would
be associated with an unacceptably
high risk of infection. Automated
NIBP monitors have a role in following trends of pressure change;
however, the averaging over time is
the value-laden data, not the single
measure, or its comparison to
invasive arterial pressure. In general, such automated devices have
significant limitations in patients
with rapidly fluctuating blood
pressures, and blood pressure values obtained with such devices
may differ substantially from
directly measured intra-arterial
pressures.
Given these limitations, critical
care practitioners should be wary
of relying solely on NIBP measurements in patients with rapidly
changing hemodynamics or in
whom very exact measurements
of blood pressure are important.6
It is vital to remember that regardless of the method by which blood
pressure is measured, it is a poor
surrogate for the true value of concern, that is, the stroke volume
www.ccnonline.org
that forces itself (via cardiac ejection) into the resistant arteries. For
most trials conducted in humans
or animals, blood pressure measures obtained by using a wide variety of methods correlate poorly with
invasive arterial pressure measurements, particularly in patients
with edema, who are receiving
vasoactive medications, or who
have significant hypoperfusion.7-9
In the clinical environment,
monitoring of direct arterial
pressure uses an underdamped
catheter-transducer system. The
arterial response to ventricular
ejection is a frequency response,
that is, the stroke volume bolus of
blood goes into the artery, generating a vibration column that emits
many responses (arterial wall
oscillations) that are averaged into
the systolic pressure. These frequencies transmit into the system,
which transmits the frequencies
through the fluid-filled tubing and
transducer.10 Nowadays, monitors
offer internal calibration, filtering
of artifacts, and printouts of the
display. The digital display shows
an average of values over time and
thus does not show beat-to-beat
variability accurately. Beat-to-beat
differences in amplitude can be
measured precisely by freezing the
monitor display with on-screen
calibration, allowing assessment
of the effect of ectopic beats on
blood pressure, variations in pulse
pressure or systolic pressure, and
the severity of pulsus paradoxus.
Direct measurement of arterial
blood pressure requires that the
pressure waveform from the cannulated artery be reproduced
accurately on the bedside monitor.

The displayed pressure signal is
markedly influenced by the measuring system, including the arterial
catheter, extension tubing, stopcocks, flush devices, transducer,
amplifier, and recorder.
Zeroing and leveling are common procedures for most providers,
but the importance of the dynamic
response to fluid flush is not generally well understood or used to
test the accuracy of the system.
The length, width, and compliance
of the tubing all affect the systems
response to change. Small-bore
catheters are preferable because
they minimize the mass of fluid
that can oscillate and amplify the
pressure. The compliance of the
system (the change in volume of
the tubing and the transducer for
a given change in pressure) should
be low. In addition, bubbles in the
tubing can affect measurements
in 2 ways. Large amounts of air in
the measurement system damp
the system response and cause
the system to underestimate the
pressure. Large amounts of air
are usually easily detectable.
Small air bubbles cause an increase
in the compliance of the system
and can markedly amplify the
reported pressure.
Testing the Accuracy of

the Monitoring System
Zero Reference
When pressure measurements
seem inaccurate or differ markedly
from indirect measurements, the
systems accuracy can be checked
quickly. The most likely source of
error is improper zeroing of the
CriticalCareNurse
77
300 mm Hg
Systole
Dicrotic
notch
Square wave or flush test,

natural resolution to normal oscillation,
only 2 oscillations before return to baseline
Systolic
Mean
Diastolic
Pressure
Diastole
Time
Figure 1 Crisp systole, dicrotic notch, and diastole. When flush test is applied, 2 oscillations follow before return to baseline.
system, which can be caused either

by a change in the patients position
or by zero drift. Opening the transducer stopcock to air and aligning
the transducer with the midaxillary
line should confirm that the monitor displays zero (a transducer that
is below the zero reference line will
result in falsely high measurements
and vice versa). The monitor should
be zeroed whenever the patients
position changes, when blood pressure changes significantly, and routinely every 6 to 8 hours because
of zero drift. Disposable pressure
transducers are standardized and
do not require calibration. If zero
referencing is correct, a fast-flush
test can be done to assess the systems dynamic response.10,11
Square-Wave Test
Two major factors affect the
validity of pressures measured:
resonant frequency response, the
78
CriticalCareNurse
vibration of the fluid column in

response to a change in the system
(eg, flush), and the damping coefficient, evaluating the end of the
vibrations.
Overdamped tracings are usually caused by problems that are
correctable, such as air bubbles,
kinks in tubing, clots, overly
compliant tubing, loose connections, a deflated pressure bag, or
anatomical factors that affect the
catheter. An underdamped tracing results in systolic overshoot
and can be due to excessive tubing length or patient-related factors such as increased inotropic
or chronotropic state, as the vessel
wall is more rigid and oscillates
at a higher level. Many monitors
can be adjusted to filter out frequencies above a certain limit,
which can eliminate frequencies
in the input signal that are causing ringing, although elimination
of important frequencies will result

in inaccurate measurements.10
Although other techniques can
be used, the easiest way to test the
damping coefficient and resonant
frequency of a monitoring system
is by doing a fast-flush test (also
known as a square-wave test). This
test is performed at the bedside
by briefly opening and closing the
continuous flush device, producing
a square-wave displacement on
the monitor followed by a return
to baseline, usually after a few
smaller oscillations. Visual inspection is usually sufficient to ensure
a proper frequency response. An
optimal fast-flush test causes an
undershoot followed by a small
overshoot, then settles back into
the patients waveform (Figure 1).
When air is present in the tubing,
a clot is on the tip of the catheter,
or the catheter is not properly
positioned, the waveform will
www.ccnonline.org
300 mm Hg
Square wave or flush test
Normal
systole
Constant
mean
Underestimated
systole
Oscillations absent,
indicates overdamping
Systolic
Mean
Pressure
Diastolic
Normal diastole
Overestimated
diastole
Comparing normal
with overdamped
Time
Figure 2 When the arterial pressure loses its sharp visualization or the digital measure is lower than oscillated or anticipated,
check the patient first. Then check all connections on the monitoring system, starting at the patient all the way to the transducer
and then the pressure bag. An overdamped picture can occur when connections are loose, the pressure bag is inflated at less
than 300 mm Hg, there is air in the tubing, or a clot forms on the tip. Validate the mean pressure of both the arterial catheter
and the oscillated pressure.
appear more rounded and less

defined. When the square-wave
flush is applied, no resonance is
seen (Figure 2). Finally, when the
system is underdamped, the tubing is too long, or the catheter is
the wrong size, multiple oscillations are apparent after the squarewave test is applied (Figure 3).
Dynamic response validation by
fast-flush test should be performed
frequently: at least every 8 hours,
with every significant change in
the patients hemodynamic status,
after each opening of the system
(zeroing, blood sampling, tubing
change), and whenever the waveform appears damped.
Components of the monitoring
system are designed to optimize
the frequency response of the entire
system. The 18- and 20-gauge
catheters used to gain vascular
access are not a major source of
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distortion but can become kinked

or occluded by thrombus, resulting
in overdamping of the system.
Standard, noncompliant tubing
is provided with most disposable
transducer kits and should be as
short as possible to minimize signal amplification (overdamping).
Air bubbles in the tubing and connecting stopcocks are a notorious
source of overdamping of the tracing and can be cleared by flushing
through a stopcock.
Despite technical problems,
direct arterial pressure measurement offers several advantages.
Arterial catheters actually measure
the end-on pressure propagated by
the arterial pulse. In contrast, indirect methods report the external
pressure necessary either to obstruct
flow or to maintain a constant
transmural vessel pressure. Arterial
catheters can also detect pressures
at which Korotkoff sounds are

either absent or inaccurate. Arterial catheters provide a continuous
measurement, with heartbeat-toheartbeat blood pressures.
Problems With Comparing

Noninvasive and Invasive
Pressure Monitoring
Indirect methods of measuring blood pressure estimate the
arterial pressure by reporting
the external pressure necessary to
either obstruct flow or maintain a
constant transmural vessel size. A
recently published meta-analysis12
of 28 studies involving 919
patients concluded that
inaccuracy and imprecision
of continuous noninvasive
arterial pressure monitoring
devices are larger than what
was defined as acceptable.
This may have implications
CriticalCareNurse
79
300 mm Hg
Systolic
Overestimated
systole
Normal
systole
Square wave or flush test
Constant
mean
Mean
Ringing oscillations
indicate underdamping
Pressure
Diastolic
Normal
diastole
Comparing normal
with underdamped
Underestimated
diastole
Time
Figure 3 Spiked systole with a lower diastole should alert the provider to a possible underdamping issue. Underdamping usually
occurs when the tubing is too long or the catheter is the wrong size. The problem is usually not physiologic. Reduce the tubing
length and stabilize or replace the catheter. Observe that the mean pressure remains constant between oscillated and invasive.
for clinical situations where

continuous noninvasive arterial pressure is being used for
patient care decisions.
Direct arterial catheters measure

the end-on pressure propagated by
the arterial pulse with every beat.
They are not measuring the same
end points as indirect methods
measure. Rigorous validation of
the accuracy of the monitoring
system can be done with the squarewave flush test, but that does not
ensure the value of the blood
pressure measurements, just the
accuracy of the system.11
Direct arterial pressure measurement offers several advantages in many but not all patients.
Although an invasive catheter is
required, the reported risk of complications is low. Arterial catheters
provide a heartbeat-to-heartbeat
measurement, can detect pressures
at which Korotkoff sounds are
80
CriticalCareNurse
either absent or inaccurate, and

do not require repeated inflation
and deflation of a cuff. Regardless
of the method used, the mean
arterial pressure should generally
be the value used for decision
making in most critically ill
patients, because it is the most stable (least affected) measurement
(calculation) across all methods of
blood pressure monitoring.
So to answer the first question,
Is it prudent to correlate NIBP
measurements with arterial blood
pressure measurements? No.
Most noninvasive methods provide
an average calculation for systolic
and diastolic blood pressures,
based on a measured mean pressure. Compare the mean pressures
and consider the tested and zeroed
invasive arterial pressure to be the
true measure whether you like the
numbers or not. These 2 types of
measurements evaluate something
quite different: direct pressure
monitors beat-to-beat pressure

pulse, whereas the commonly used
noninvasive methods measure
peak oscillations related to blood
flow. Especially in patients treated
with vasopressors, inotropic agents,
and vasodilators, these measurements may differ significantly.
The second question was, My
understanding is that the accuracy
of arterial blood pressure measurements is assessed by doing the
square-wave test and leveling, not
by correlating the arterial measurements with the NIBP values.
However, I observe the practice of
correlating with the NIBP values
so often, it makes me wonder if I
have misunderstood my previous
training on arterial catheters.
Leveling and square-wave testing provide an evaluation of the
system and validation of system
acceptability. Neither test validates
the patients arterial pressure, but
the tests validate the integrity of
www.ccnonline.org
the monitoring system that measures the pressure. If zeroing is

performed and the square-wave
test is passed, you can rest assured
that the direct pressure is being
monitored correctly. When invasive arterial pressure monitor is
zero referenced, leveled, and passes
the frequency response test, then
the invasive pressure is what should
be monitored. At the very best,
correlation can be made between
noninvasive and invasive measurements at the mean pressure
measure only.
Remember that the primary
role of the circulation is to provide
tissues with dissolved and bound
oxygen as well as other energy
substrates, so it is always best to
correlate pressure readings with
indicators of tissue perfusion, no
matter what method(s) you choose
for monitoring. Recommendations
for pressure targets must take into
consideration the site and method
of measurement as well as the true
value of blood pressure versus
oxygen adequacy. Trends in blood
pressure and the relationship to
metabolic measures are the most
important measures in todays
critical care environment. CCN
4. Bruner JM, Krenis LJ, Kunsman JM, Sherman AP. Comparison of direct and indirect
methods of measuring arterial blood pressure: Pt III. Med Instrum. 1981;15(3):182-188.
5. Bogert LW, van Lieshout JJ. Non-invasive
pulsatile arterial pressure and stroke volume
changes from the human finger. Exp Physiol.
2005;90:437-446.
6. Van Egmond J, Hasenbros M, Crul JF. Invasive v. non-invasive measurement of arterial
pressure. Br J Anaesth. 1985;57(4):434-444.
7. Aarnes TK, Hubbell JAE, Lerche P, Bednarski RM. Comparison of invasive and
oscillometric blood pressure measurement
techniques in anesthetized sheep, goats, and
cattle. Vet Anaesth Analg. 2014;41:174-185.
8. Hohn A, Defosse JM, Becker S, et al. Noninvasive continuous arterial pressure monitoring with Nexfin does not sufficiently
replace invasive measurements in critically
ill patients. Br J Anaesth. 2013;111(2):178-184.
9. Stover JF, Stocker R, Lenherr R, et al. Noninvasive cardiac output and blood pressure
monitoring cannot replace an invasive
monitoring system in critically ill patients.
BMC Anesthesiol. 2009;9:6.
10. Troy P, Smyrnios NA, Howell MD. Routine
monitoring of critically ill patients. In:
Irwin RS, Rippe JM, eds. Irwin and Rippes
Intensive Care Medicine. Philadelphia, PA:
Lippincott Williams & Wilkins; 2011:258-276.
11. McGhee BH, Bridges EJ. Monitoring arterial blood pressure: what you may not
know. Crit Care Nurse. 2002;22(2):60-79.
12. Kim SH, Lilot M, Sidhu KS, Rinehart J, Yu
Z, Canales C, Cannesson M. Accuracy and
precision of continuous noninvasive arterial
pressure monitoring compared with invasive
arterial pressure: a systematic review and
meta-analysis. Anesthesiology. 2014;120(5):
1080-1097.
Hold it in your
hand, like the
print copy
Easy navigation
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pages
None reported.
References
1. Magder SA. The highs and lows of blood
pressure: toward meaningful clinical targets
in patients with shock. Crit Care Med. 2014;
42(5):1241-1251.
2. Pierce EC. Percutaneous arterial catheterization in man with special reference to aortography. Surg Gynecol Obstet. 1951;93:56.
3. Borow KM, Newberger JW. Non-invasive
estimation of central aortic pressure using
the oscillometric method for analyzing
systemic artery pulsatile blood flow: comparative study of indirect systolic, diastolic, and mean brachial artery pressure
with simultaneous direct ascending aortic
pressure measurements. Am Heart J.
1982;103:879.
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In Our Unit
Implementation of Early Exercise and
Progressive Mobility: Steps to Success
Melody R. Campbell, RN, DNP, CEN, CCRN, CCNS
Julie Fisher, PT, MPT
Lyndsey Anderson, MOT, OTR/L
Erin Kreppel, PT, MPT
new bundle of interventions to improve the care of critically ill

patients receiving mechanical ventilation has been identified.1,2
This bundle incorporates performance and coordination of
spontaneous awakening trials and spontaneous breathing trials; careful
selection of sedatives; assessment, prevention, and management of delirium; and early exercise with progressive mobility.1,2 In collaboration with
the Institute for Healthcare Improvement, and as a part of a critical care
collaborative, our hospital had implemented many parts of the bundle,
but early exercise and progressive mobility had not yet been incorporated into care. In this article, we share our process for literature review,
appraisal, and synthesis along with protocol development. An evidencebased performance improvement (EBPI) model was used to plan, implement, and disseminate the change.3 High-fidelity human simulation
boosted confidence and teamwork and also underscored important
safety aspects before implementation. Unit champions and daily multidisciplinary rounding assisted with culture change.
Authors
Melody R. Campbell is a critical care clinical nurse specialist and trauma program
manager at Kettering Medical Center, Kettering, Ohio.
Julie Fisher is a physical therapist and the lead therapist in the physical medicine
and rehabilitation department at Good Samaritan Hospital, Dayton, Ohio.
Lyndsey Anderson is an occupational therapist in the physical medicine and
rehabilitation department at Good Samaritan Hospital, Dayton, Ohio.
Erin Kreppel is a physical therapist in the physical medicine and rehabilitation
department at Little Company of Mary Hospital, Evergreen Park, Illinois.
Corresponding author: Melody R. Campbell, RN, DNP, CEN, CCRN, CCNS, Trauma Program, Kettering Medical
Center, 3535 Southern Blvd, Kettering, Ohio 45429 (e-mail: melody.campbell@khnetwork.org).
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses,
101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax,
(949) 362-2049; e-mail, reprints@aacn.org.
82
CriticalCareNurse
Literature Review,
Appraisal, and Synthesis
Electronic databases searched for
evidence included Cochrane, PubMed,
and CINAHL. Key words included
mechanical ventilation, critically ill,
critical illness, early mobilization protocol, delirium, intensive care unit, early
mobility, sedation, physical rehabilitation, and physical therapy. In CINAHL,
limits included research, English,
human, and all adults. Related citations were reviewed in PubMed with
limitations of clinical trials, human,
English, and publication between 2007
and 2012. References from key articles
were reviewed to search for additional
evidence. Articles were included in
the appraisal if content focused on
early mobility in critically ill patients
receiving mechanical ventilation.
Articles were rated by strength of
evidence.4 Level 1 evidence, that established by meta-analysis or systemic
review (and also the highest level of
evidence) was not found. No Cochrane
reviews or national practice guidelines
that were related to the subject had
been published between 2007 and
2012. Since that time, a clinical practice
guideline2 related to pain, agitation,
and delirium in the critically ill has
www.ccnonline.org
been published. Seven keeper articles

were identified.5-11
The articles were shared and
discussed with our multidisciplinary team. From these articles, the
team determined that early activity
had been demonstrated to be safe
and feasible7,8 and that early mobility was associated with an increase
in both delirium-free days and
ventilator-free days.5,6,10 Some studies noted that the implementation
of early mobility contributed to
decreases in length of stay in both
intensive care units (ICUs) and
hospitals.9,10 An additional article11
discussed barriers and facilitators
to implementation of early mobility.
Barriers included sedation, decreased
level of consciousness, and agitation.
Factors that facilitated change were
the presence of a protocol and the
presence of unit champions.11 The
multidisciplinary team decided that
the evidence was sufficient for us to
implement the practice of early
mobility for our patients.
Planning for Change

While our team was planning
implementation of early mobility,
we elected to be a part of an expedition on early mobility sponsored by
the Institute for Healthcare Improvement. The expedition was a series of
webinars that included presentations of the science surrounding early
mobility and assisted with protocol
development and implementation
planning. We invited various departments (respiratory therapy, physical
and occupational therapy, pharmacy)
and our medical director to attend
the webinars. We ensured that ICU
nursing staff, who would act as unit
champions, could attend. The webinar communicated the importance
www.ccnonline.org
of early mobility and the evidence

supporting the change.
Our early mobility protocol
(Figure 1) was developed after careful
reading of 2 key articles: a randomized controlled trial and a descriptive
study that detailed the intervention
arm of that same trial.5,6 The protocol
was reviewed by the multidisciplinary
team and by several critical care
intensivists. The protocol included
contraindications to initiating early
mobility designated by a yellow text
box indicating caution. Once the
patient had no contraindications,
preparation of early mobility would
begin, designated by a green text box
indicating that the patient was ready
to go. Preparing for early mobility
would include assessing and securing
all devices, stopping tube feeding, and
moving all catheters, intravenous
pumps, and the urinary catheter
drainage bag to the side of the bed
with the ventilator. Activity would
progress from active range-of-motion
exercises to bed mobility exercises
(lateral rolling, move from semirecumbent to upright), sitting on the
edge of the bed, sitting to/from standing and bed to/from chair transfers,
and finally ambulation. An additional red box was included in the
protocol that delineated contraindications to continuing early mobility.
If the patient experienced physiological changes such as hemodynamic
instability, or oxygen desaturation,
activity would be stopped.
An additional flowchart (Figure
2) was created to visualize and teach
others how early mobility would fit
into our process of coordination of
spontaneous awakening trials and
spontaneous breathing trials.
Our plan for implementation was
written and reviewed by our hospitals
Human Institutional Review Committee and the universitys institutional review board. We wanted to
collect patient data during the implementation of our project to monitor
process and outcomes and wanted
to ensure the safety of that data collection and dissemination of results.
The final aspects of planning for
practice change included creating
an aim statement. Using our EBPI
model, an aim statement would
help us to know whether we had
reached a short-term goal in our
implementation. Working with our
medical director, we determined
that our aim statement would be:
By month 3 of the project, early
mobility would be incorporated
into the care of 25% of patients
receiving mechanical ventilation
(as appropriate). The implementation steps in accordance with our
EBPI model are listed in Table 1.
Practicing With HighFidelity Human Simulation

One of our physical therapists
had read an article about the use of
high-fidelity human simulation to
teach physical therapy students.
Training with simulation helped
improve the students confidence
before they started getting clinical
experience in an actual ICU.13 The
physical therapist expressed a
desire to try our protocol by using
simulation first so that the team
could practice together to ensure
that the protocol was easy to understand and that safety concerns were
addressed. Her main concern was
related to accidental extubation of
a patient, and she wanted us to plan
the steps of how we would care for
a patient who experienced that serious adverse event. We developed 3
CriticalCareNurse
83
Contraindications to initiating early mobility5,6

1. Mean arterial pressure, < 65 mm Hg
2. Heart rate, < 60/min or > 120/min
3. Respiratory rate, < 10/min or > 32/min
4. Oxygen saturation (pulse oximetry), < 90%
5. Actively undergoing a procedure
6. Patients agitation requiring increased sedation in past 30 minutes
7. Insecure airway device or difficult airway
Prepare for early mobility
Active or active assisted

range-of-motion exercises
Contraindications to continuing early

mobility5,6
1. Mean arterial pressure, < 65 mm Hg
2. Heart rate, < 60/min or > 120/min
3. Respiratory rate, < 10/min or > 32/min
4. Oxygen saturation (pulse oximetry),
< 90%
5. Marked patient-ventilator dyssynchrony
6. Patient distress
a. Evidenced by nonverbal cues
and gestures
b. Physically combative
7. New arrhythmia
8. Concern for myocardial ischemia
9. Concern for airway integrity
10. Fall to knees
11. Inadvertent removal of endotracheal
tube
12. Judgment of nurse, physical therapist, or occupational therapist
Bed mobility exercises: lateral rolling,

move semirecumbent to upright
Sitting balance activities, apply gait

belt, assist to sit at side of bed,
incorporate activities of daily living
Prepare for early mobility5,6

1. Assess all devices before beginning
2. Secure all devices
3. Stop tube feeding
4. Remove or detach unnecessary
devices (eg, sequential compression systems)
5. Move urinary catheter drainage
bag, intravenous poles, and fecal
collection bag to side of bed next to
ventilator
6. Always mobilize to side of bed next
to ventilator
7. For ambulation, use transport ventilator. Always have wheelchair
behind patient to use in event of
weakness, intolerance of activity.
Work on transfers: sit to stand, bed

to chair, bed to commode, repetition
Improve standing balance and tolerance:

reach, march in place, weight shift
Ambulation with assistance
Figure 1 Early mobility protocol.
simulation scenarios (see Table 2 for

examples):
Assessment of the patient to
determine whether any contraindications for beginning early mobility
were present.
Preparation of the patient and
beginning activity with recognition
of changes in condition that would
require stopping activity.
Inadvertent extubation during
activity.
84
CriticalCareNurse
The project leader/clinical nurse

specialist worked with the personnel
in the simulation laboratory to prepare for practice. Intravenous pumps,
a tube feeding pump, a sequential
compression device, a ventilator, a
manual resuscitation bag, a cardiac
monitor, a walker, and a transport
ventilator were transported to the
laboratory. The simulation laboratory was set up with the appropriate
equipment to look like one of our
ICU rooms. Nursing unit champions,

physical therapists, occupational
therapists, and respiratory therapists participated. The clinical
nurse specialist reviewed the draft
protocol, including the sections on
contraindications for early mobility, preparation of the patient,
progression of activity, and when
to stop activity if the patients
condition changed. Additionally,
the flowchart of how early mobility
www.ccnonline.org
Patient meets criteria for

spontaneous awakening trial12
Perform spontaneous awakening trial
Assess wakefulness
Patient is awake and calm:

(1) opens eyes to voice,
(2) squeezes hand of nurse,
(3) sticks out tongue6
Proceed with early mobility with

physical/occupational therapist6
Patient with decreased responsiveness5:

(1) perform passive range-of-motion
exercises, (2) continue sedation vacation, (3) continue to monitor and assess
Agitation: restart sedation at half dose6,12
Considerations for spontaneous breathing trial6,12:

(1) spontaneous breathing trial should be done daily when indicated, (2) coordinate timing of early mobility with spontaneous breathing trial: (a) perform spontaneous breathing trial earlier in day, (b) perform early mobility session later in day after spontaneous
breathing trial if trial is unsuccessful, (c) patient to be extubated? Extubate, and do
physical/occupational therapy later in day
Figure 2 Incorporation of early mobility into our current process.
would be incorporated into our

current process was reviewed and
discussed.
The simulation began and the
group focused on how to begin to
move the patient. Discussion was
intense, with brainstorming about
the roles and responsibilities of
each of the team members. When
the patient needed to move from
sitting at the edge of the bed to
standing or transfering to a chair, a
team member was substituted for
the patient simulator so that the
www.ccnonline.org
team could practice standing the

patient at the bedside and ambulation in the hallway. Proper body
mechanics and safe handling of
patient were emphasized. The group
thoroughly enjoyed the simulation
and found that the hands-on
approach boosted confidence. Four
priorities were identified for implementation of the protocol with a
real patient:
The nurse caring for the patient
could begin to prepare all tubes
and catheters anticipating the
other team members arrival.

Doing so decreased the preparation time for the other disciplines, thereby increasing the
number of other patients that
they were able to see in their
work day.
One person should be designated to communicate with
the patient and provide direction to the team during early
mobility. The physical therapist or occupational therapist
was positioned immediately
CriticalCareNurse
85
Table 1
Plan for implementing the evidence-based

performance improvement modela
1. Describe the problem: Need for implementation of early mobility into practice.
2. Formulate focused clinical question: What is the effect of an early mobility protocol
on delirium and length of stay in the intensive care unit over the course of 3 months?
3. Search for evidence.
4. Appraise and synthesize evidence.
5. Develop aim statement: By month 3 of project, early mobility will be incorporated
into care of 25% of patients receiving mechanical ventilation (as appropriate).
6. Engage in small tests of change.
Ensure safety: high-fidelity human simulation
Ensure safety and reproducibility: protocol refinement
7. Disseminate practice to all staff and patients.
8. Utilize plan-do-study-act process to monitor/evaluate implementation of new practice.
a Based
on information from Levin et al.3
in front of the patient while

the patient was moving and
the group determined that
this team member would
direct the patient and lead
communications for the team.
The goal was to help the
patient understand what to
do next and to decrease confusion for team members.
Additional roles were delineated.
The respiratory therapist would
be responsible at all times for
monitoring endotracheal tube
security and oxygenation status.
The nurse would monitor other
tubes and catheters as well as
vital signs. The physical and
occupational therapists would
assess and monitor motor
strength, balance, and tolerance of activity. The decision
to stop the intervention and
return the patient to a supine
position would be a team
decision led by the nurse. The
patient also could stop the
activity.
Specific equipment would
be helpful for mobilization.
A reclining-back manual
86
CriticalCareNurse
wheelchair would be positioned behind the patient

when walking in the hall in the
event of change of condition.
This specific type of wheelchair would allow supine positioning for ease in transferring
the patient back into the bed.
The transport ventilator would
be used when the patient was
ambulating in the hall.
Implementation
Small tests of change were used
to begin the implementation. After
each test, the multidisciplinary
team reviewed how things went.
The protocol flowed well and was
easily understood. The team, having
gained confidence through the use
of simulation, worked well together
and the patients were safe. Next steps
involved teaching others about early
mobility and disseminating the
practice. The physical medicine and
rehabilitation department conducted
several in-service training sessions
with their staff and added written
and oral competencies to ensure staff
knowledge and patient safety. Nurses
and respiratory therapists conducted
training during staff meetings as

well as special educational conferences focused on the bundle. We
used a slogan of Mobility Is Medicine and provided slogan buttons
to those staff members who had
cared for a patient during early
mobility. We also purchased cookies shaped like feet and emphasized
Feet to the Floor. This added fun
and helped create some excitement
regarding the change. Daily multidisciplinary rounding helped to
determine which patients were ready
for early mobility and supported
staff during implementation. The
team met every 2 weeks in conjunction with the medical director. Problems encountered with the practice
change were discussed and methods
to improve implementation were
developed. Constant communication with all the specialties involved
was done through staff meetings,
electronic mail, bulletin boards,
and departmental publications.
The patients experience was
also explored. One patient whom
we interviewed after he had been
extubated indicated that he enjoyed
being up while connected to the
ventilator. He had severe chronic
obstructive disease and had received
mechanical ventilation before. He
felt that he was ready to move
before the team was ready, and
when he began to ambulate out of
his room, he felt that he could
have walked much further but the
team was nervous. He walked
the next day around the whole
perimeter of the ICU. He stated
that it felt good to get out and walk
because there is nothing else to do
in the ICU and it made it more
interesting. The exercise made
him feel like he was improving.
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Table 2
Cardiac monitor
Simulation scenario 3 for early mobility: inadvertent removal of endotracheal tube
Ventilator
Simulation
Instructor
content
Expectations of
student group
Important learning
considerations
Normal sinus
Assist control Oral endotracheal Patient is improv- Verbalize the contraindirhythm
Fraction of
tube to subglottic
ing. Yesterday
cations to initiating
Heart rate = 80/min
inspired
suction
patient was able
early mobility. Examine
Noninvasive blood
oxygen=40%
to sit and dangle
patient and infusions.
Sequential compressure = 130/80 Positive endlegs at bedside,
Review ventilator settings
pression device
mm Hg
expiratory
sit to stand with
and vital signs.
(both legs)
Oxygen saturation
pressure =
2-person assist.
Verbalize preparing patient
(pulse oximetry) =
5 cm H2O
Gait was steady.
Nasogastric
for early mobility.
98%
Plan for today is
tubetube
Respiratory rate =
to march in place, Prepare patient for sit to
feeding/pump
16/min
weight shift,
stand, march in place,
Urinary catheter
and determine
weight shift, possible
if patient can
ambulation in room.
Peripherally
ambulate in room. Verbalize:
inserted central
Secure all devices
catheter
Turn off tube feeding
Infusions:
Move urinary catheter,
Dexmedetomidine
and intravenous poles
(Precedex)
to side of bed next to
0.7 g/kg per hour
ventilator.
Remove unnecessary
devices (eg, sequential
compression system)
Obtain portable ventilator
Walker with support
for portable cardiac
monitor
Recumbent wheelchair
Change in condition Low pressure

Sinus tachycardia
alarm from
Heart rate = 116/min ventilator
Noninvasive blood
pressure =
150/84 mm Hg
Oxygen saturation
(pulse oximetry) =
90%
Respiratory rate =
30/min
Inadvertent
endotracheal
tube removal,
patient is
anxious,
tachypneic.
Sustaining Practice
Creating organizational memory
and knowledge reservoirs were
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Patients condition Nurse: talks to patient and

assures them of their
has changed.
safety, tells them what
Please work as
will happen.
a team to remedy
Team assists patient back
the situation.
to bed.
Respiratory therapist
applies face mask 100%
oxygen. Team assesses
patients tolerance of
extubation. Nurse notifies
physician/provider of
extubation.
important mechanisms in our

hospital to help with sustaining
practice.14 In our electronic medical
Have chart of contraindications for early mobility

available for team to
review.
Note that patient has no
contraindications.
Have chart of items for
consideration for planning for early mobility.
Discuss roles and
responsibilities of
different personnel.
Respiratory therapist:
responsible for endotracheal tube and tubing to
ventilator. Setup of
portable ventilator.
Nurse: responsible for
intravenous poles and
intravenous catheters.
Cardiac monitor onto
walker.
Patient care technician:
remove sequential compression device, and
move urinary drainage
bag to side of bed by
ventilator. Attach to
walker. Emphasize maintaining drainage bag
below level of bladder.
Physical/occupational
therapist: apply gait belt,
instruct patient. Assess
trunk stability, balance.
Assist to sit at side of
bed. Determine whether
may sit to stand, march
in place, begin ambulation in room.
Calm approach to patient
very important.
Indications that patient
may need reintubation:
Tachypnea, decreased
oxygen saturation,
circumoral cyanosis,
tachycardia, hypotension.
Resources for reintubation:
nurse practitioner, physician, or anesthesiologist.
record, we were able to create files

to hold resource documents. Our
early mobility protocol was placed
CriticalCareNurse
87
in these files for ease of reference at

each computer terminal. We revised
our mechanical ventilator order set
(computer physician order entry) to
include prechecked orders for early
mobility as well as consultation with
physical and/or occupational therapists for evaluation and treatment.
Then when the patient met criteria
for initiation of early mobility, the
appropriate orders were there. We
also used documents called standards
of nursing practice. These documents were a blend of nursing art
and science that helped to delineate
the important aspects of nursing
care for a specific type of patient.
They were used to help with orientation of new staff. Our standard of
nursing practice for patients receiving mechanical ventilation was
updated to include concepts related
to early mobility. Lectures for critical care class also were updated to
include early mobility.
Lessons Learned
After 3 months, we were excited
that we had met our aim. More
than 25% of critically ill patients
receiving mechanical ventilation in
that third month had received early
mobility. No serious adverse events
had occurred. Staff were not only
readily identifying patients who were
appropriate for early mobility but
also were obtaining orders for
physical and occupational therapy
for patients who were not receiving
mechanical ventilation. A physical
therapist and an occupational therapist were assigned to the ICU daily.
We had collected data related to
incidence and duration of delirium
and found a problem with the flowsheet design in our electronic medical
record. Additional changes were
88
CriticalCareNurse
made to add detail to the 4 features of

the Confusion Assessment MethodICU (CAM-ICU) to support critical
thinking and accuracy of documentation. We also noted problems with
sedation and analgesia practices and
are in the process of implementing a
nonverbal pain assessment tool and
an analgesia-first approach. As always,
change continues.
Summary
Our purposeful approach to the
implementation of early mobility by
using an EBPI model resulted in sustainment of the practice a year later.
Critical appraisal and synthesis of
the literature resulted in a good protocol for early mobility. High-fidelity
human simulation built confidence
with working together, and this
translated to experiences with early
mobility in actual patients. Lessons
learned from others related to the
use of unit champions and multidisciplinary rounding to help support
the practice change. We continue to
find opportunities to improve our
practice related to the care of patients
receiving mechanical ventilation. CCN
Acknowledgments
The authors acknowledge the leadership and support of Mary Jo Trout, PharmD, RPh, BCPS, Robyn R.
Razor, RN, MSN, and Thomas M. Yunger, Jr, MD,
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
the intensive care unit. Crit Care Med. 2013;

32(4):15-26.
Levin RF, Keefer JM, Marren J, et al. Evidencebased practice improvement: merging 2
paradigms. J Nurs Qual. 2010;25(2):117-126.
Melynk BM, Fineout-Overholt E. Evidence-Based
Practice in Nursing and Healthcare: A Guide to
Best Practice. 2nd ed. Philadelphia, PA: Wolters
/Kluwer/Lippincott Williams & Wilkins.
Schweikert WD, Pohlman MC, Pohlman AS,
et al. Early physical and occupational therapy
in mechanically ventilated, critically ill patients:
a randomized controlled trial. Lancet. 2009;
373(9678):1874-1882.
Pohlman MC, Schweickert WD, Pohlman
AS, et al. Feasibility of physical and occupational therapy beginning from initiation of
mechanical ventilation. Crit Care Med. 2010;
38(11):2089-2094.
Bailey P, Thomsen GE, Spuhler V, et al. Early
activity is feasible and safe in respiratory
therapy. Crit Care Med. 2007;35(1):139-145.
Thomsen GE, Snow GL, Rodriguez L, et al.
Patients with respiratory failure increase ambulation after transfer to an intensive care unit
where early activity is a priority. Crit Care Med.
2008;138(5):1224-1233.
Morris PE, Goad A, Thompson C, et al. Early
intensive care unit mobility therapy in the
treatment of acute respiratory failure. Crit
Care Med. 2008;36(8):2238-2243.
Needham DM, Korupolu R, Zanni JM, et al.
Early physical medicine and rehabilitation
for patients with acute respiratory failure: a
quality improvement project. Arch Phys Med
Rehabil. 2010;91(4):536-542.
Winkelman C, Peereboom K. Staff-perceived
barriers and facilitators. Crit Care Nurse. 2010;
30(2):S13-S16.
Girard TD, Kress JP, Fuchs BD, et al. Efficacy
and safety of a paired sedation and ventilator
weaning protocol for mechanically ventilated
patients in intensive care units (awakening
and breathing trial): a randomized controlled
trial. Lancet. 2008;371(9607):126-134.
Shoemaker MJ, Riermersma L, Perkins R.
Use of high fidelity simulation to teach physical therapist decision-making skills for the
intensive care setting. Cardiopulm Phys Ther J.
2009;20(1):13-18.
Virani T, Lemieux-Charles L, Davis DA, et al.
Sustaining change: once evidence-based practices are transferred, what then? Healthcare Q.
2009;12(1):89-96.
FCCP, DABSM.
None reported.
Now that youve read the article, create or contribute to

an online discussion about this topic using eLetters. Just
visit www.ccnonline.org and click Submit a response
in either the full-text or PDF view of the article.
References
1. Vasilevskis EE, Ely EW, Speroff T, et al.
Reducing iatrogenic risks: ICU-acquired
delirium and weaknesscrossing the quality chasm. Chest. 2012;138(5):1224-1233.
2. Barr J, Fraser GL, Puntillo K, et al. Clinical
practice guidelines for management of pain,
agitation and delirium in adult patients in
In Our Unit
In Our Unit highlights unique

practices, innovations, research, or
resourceful solutions to commonly
encountered problems in critical
care areas and settings where critically ill patients are cared for. If
you have an idea for an In Our
Unit article, send it to Critical Care
Nurse, 101 Columbia, Aliso Viejo,
CA 92656; e-mail, ccn@aacn.org.
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Book Reviews
Becoming Nursey
Kleber K. Portland, OR: Book Baby
Publishing; 2014. Paperback; 186 pages;
$12.99 (print), $7.99 (eBook). ISBN-13:
978-1483542460
Reviewed by Mary Pat Aust, RN, MS
he decision to become a nurse

is a long-term commitment
that sends nursing students on
a potentially confusing and frightening journey. The transition between
the safety and structure of nursing
school and becoming a licensed
health care provider in a hospital
never seems long or structured
enough to avoid the inevitable fear
and anxiety associated with it. In
her book, Becoming Nursey, Kleber
covers topics such as getting
www.ccnonline.org
through school, transitioning to working as a

nurse in a hospital,
and transitioning from
the acute care medicalsurgical unit to a
neuro/trauma intensive
care unit.
Klebers confident,
compassionate, and
witty demeanor is
evident throughout
the book, as she discusses combining the
technical and emotional work of nursing
and how to find your
place along the continuum. She offers tips
for conquering studying for the NCLEX
exam and strategies
for landing a job. She
calls out some of the most frightening things about being a new
nurse (eg, calling physicians,
rounding with physicians, giving
and receiving report from colleagues, and assessing patients)
and provides very practical, actionable tips.
Kleber offers advice on some
common areas where new nurses
stumble, such as time management,
shift work, and, the ultimate in stress,
the code blue. With wit and wisdom,
she shares stories from her own
experiences. She also shares her
perspective on the work-life balance, which is essential to becoming a resilient nurse.
As a nurse with more than 30
years of experience, I had 3 wishes
after reading this book. First, I wish
I had this book all those years ago

when I was becoming nursey so I
would not have been so surprised by
how different working as a nurse,
responsible and accountable for the
care of really sick patients, was from
what I learned in school. Second, I
have had some great preceptors
through the years and I wish Kati
Kleber had been one of them. Third, I
wish this book was available to give to
all new nurses who crossed my path.
It will make them feel as though they
are not alone, prepare them for what
is to come, and allow them to make
informed choices as they move from
school to becoming nursey.
Mary Pat Aust is a clinical practice
specialist at the American Association
of Critical-Care Nurses in Aliso Viejo,
California.
2015 American Association of Critical-Care
Nurses doi: http://dx.doi.org/10.4037/ccn2015997
Anatomy of
Research for
Nurses
Hedges C, Williams B.
Indianapolis, IN: Sigma
Theta Tau International;
2014. Paperback; 352
pages. ISBN-13: 978-1938835117
This book is part of the Anatomy

series, published by Sigma Theta Tau
International, that uses the concept of
anatomical structure and function to
develop the content. The foundation
of the book rests on distinguishing
research from quality improvement and
evidence-based practice, with additional
discussion about where these 3 components intersect.
CriticalCareNurse
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updates about
new issues,
CNE articles
and other topics
relevant to
critical care nurses.
Many well-known names in the

world of nursing research have
authored chapters in this book.
Their contributions are significantly
supported by the inclusion of a
medical librarian who coauthored
the chapter on conducting the literature search and review. In addition to
the process of conducting research,
the book includes legal and ethical
aspects, research involving special
and vulnerable populations, where to
find funding, and the impact of the
Internet and social media on the
conduct of research.
Foundations of
Clinical Nurse
Specialist
Practice
2nd edition
Fulton JS, Lyon BL,
Goudreau KA, eds.
New York, NY: Springer Publishing; 2014.
Paperback; 512 pages. ISBN-13: 9780826129666
This book is both a text for educating new clinical nurse specialists
(CNSs) and for the benefit of CNSs
in practice to continue their professional development journey. While
giving the history and context of the
role, this edition reaches into the
present and future opportunities
within the health care system for the
unique contributions of the CNS. As
health care continues to change, so
do the ways in which a CNS affects
patients and families, nurses, and
systems in the 3 spheres of influence.
The authors also discuss entrepreneurship, billing and reimbursement, and regulation of practice.
Finally, short exemplar chapters
demonstrate how the CNS role can
be implemented to achieve positive
outcomes in multiple settings.
Palliative Care
Nursing: Quality
Care to the
End of Life
4th edition
Matzo M, Sherman DW,
eds. New York, NY:
Springer Publishing; 2015. Hardcover;
704 pages. ISBN-13: 978-9826196354
This statement in the preface of

the 4th edition truly describes the
role and function of palliative care:
Unlike hospice care, palliative care is not dependent
on prognosis and can be
provided in the context of
curative treatments, curing
what can be cured, but with
the concurrent attempt of
alleviating symptoms
caused by disease or its
treatment.
Palliative Care Nursing
describes the ethical and legal
aspects of palliative and end-of-life
care, and presents the process of
providing that care within the framework of the whole person (including
family and caregivers). Provision of
nursing care is divided into 2 sections: (1) addressing the physical
aspects of dying for particular diagnoses and (2) addressing symptom
management for all patients. Palliative care nursing is a crucial aspect
of providing care across patients
life span, whether faced with congenital issues, chronic disease, or
aging. CCN
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Education Directory
FLORIDA
Miami
CCRN/PCCN Review Course
Date: February 20-21, 2015. Place: Nova Southeastern University.
Address: 8585 SW 124th Ave, FL 33183. Keynote Speaker: Mary Ann
Cammy Fancher. Sponsor: Greater Miami Area Chapter of AACN.
Contact: Joe Falise. Phone: (954) 594-1427. E-mail: jfalise@med.miami
.edu. Fee: Members, $140; nonmembers, $170; groups of 3 or more,
$130/person; 1-day course (all attendees), $100. Credits: 14 CEUs
Miami
SCRN (Stroke Certified Registered Nurse) Review Course
Date: February 20-21, 2015. Place: Nova Southeastern University.
Address: 8585 SW 124th Ave, FL 33183. Keynote Speaker: Kendra
Kent. Sponsor: Greater Miami Area Chapter of AACN. Contact:
Ruth Salathe. Phone: (305) 586-4203. E-mail: ruthsalathe@gmail.com.
Fee: Members, $150; nonmembers, $175; groups of 3 or more,
$140/person (applies only if registration received together); 1-day
course (all attendees), $100. Credits: 14 CEUs
Orlando
Certification in Legal Nurse Consulting (5-day Seminar and Online)
Date: April 13-17, 2015. Place: Marriott Orlando Airport. Address:
7499 Augusta National Dr, Orlando, FL 32822. Keynote Speaker:
Vickie L. Milazzo. Sponsor: Vickie Milazzo Institute. Phone: (800)
880-0944. Fax: (713) 942-8075. E-mail: mail@LegalNurse.com.
Website: www.LegalNurse.com. Fee: Varies. Credits: 25.3 CEUs
(5-day seminar); 40 CEUs (online)
Plantation
40th Annual Spring Seminar
Date: April 18, 2015. Place: Renaissance Hotel. Address: 1230 South
Pine Island, Plantation, FL 33324. Keynote Speakers: Teri Lynn Kiss,
Kendra Menzies-Kent, Douglas Houghton, Mary Ann Cammy
Fancher. Sponsor: Broward County Chapter of AACN. Contact:
Patty Kelly. Phone: (954) 722-8020. E-mail: pattykelly7 @att.net.
Fee: Members, $75; nonmembers, $100 before April 1, 2015.
Credits: 6.5 CEUs
OREGON
Eugene
PCCN/CCRN Review
Date: February 11-12, 2015. Place: Valley River Inn. Address:
1000 Valley River Way, Eugene, OR 97401. Keynote Speaker:
Nicole Kupchik. Sponsor: Willamette Valley Chapter of AACN.
Contact: Denise Hendrickson. Phone: (541) 868-6620. E-mail:
willamettevalleychapter@gmail.com. Credits: Applied
TEXAS
Tyler
CCRN/PCCN Review
Date: February 26-27, 2015. Place: Wisenbaker Conference
Center, Trinity Mother Frances Hospital, Tyler, TX. Keynote
Speaker: Julie Miller. Sponsor: Greater East Texas Chapter of
AACN. Contact: Kim Thompson. E-mail: getaacn@gmail.com.
Classified Advertising
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Itasca
Midwest Conference
Date: March 23-24, 2015. Place: Eaglewood Resort and SPA.
Address: 1401 Nordic Rd, Itasca, IL 60143. Keynote Speakers: TBA.
Sponsor: Midwest Chicago Area Chapter of AACN. Contact: Jenny
A. Zaker. Phone: (847) 309-0662. E-mail: zakerj46@gmail.com.
Fee: TBA. Credits: TBD
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CriticalCareNurse
91
I Am a Critical Care Nurse

Jacqueline Kramer, RN, is
a staff nurse in the ICU/Burn Unit
at Detroit Receiving Hospital in
Detroit, Michigan.
Why did you become a nurse?

I was made to be a nurse. It is in my nature to
care for, assess, troubleshoot, reassure, and encourage patients. Being a nurse is all I have ever wanted
to do.
What about your job as a nurse makes
you happy?
Seeing my patients make progress and recover
makes me happy. The patients I care for are burn
victims and they are very close to death. When these
patients take a turn for the better by just opening
their eyes for the first time in the unit, it is nothing
short of a miracle. As a nurse, I can be a change
agent and I can bring hope to the hopeless, deliver
healing to the resistant, encourage and teach the
noncompliant, and see miracles happen at the bedside. This is why I am so excited about my job.
Tell us about an extraordinary experience
youve had as a critical care nurse.
I cared for a very ill, severely burned, and heavily sedated patient for months. While caring for her,
I used to get close to her ear and whisper, You can
do it. Im here for you. Im praying for you. She
slowly improved and one day, when she was able to
sit up in bed, she said, Thank you for encouraging
me. I heard everything you said. It felt incredible
to find out that she heard me all those times when I
whispered reassuring words to her. To be able to
make a positive difference in the life of someone who is

suffering is truly a blessing.
What are the challenges you encounter and
how do you overcome them?
Fear of failing to do my very best as a nurse is the
greatest challenge I face every day. I turn to God for
strength and I pray diligently that He continues to use
me to help improve patients lives.
What has your journey as a nurse been like?
My journey as a nurse has been a beautiful educational experience and a true blessing. There have been
(and will continue to be) challenging days when I have
done all I can do and nothing helps, but knowing I did
my best gives me some satisfaction.
At the end of a busy day, how do you find
balance in your life?
I find balance in my faith and belief in God. I try
to live my life and treat others as I want to be treated.
What would we be surprised to know
about you?
I am a vegetarian!
How has AACN played a role in your career?
AACN has played a major role in my career. I look to
AACN for standards and resources, and I use the continuing nursing education to evolve and learn as a nurse.
AACN mandates excellence and I accept the challenge
to uphold, meet, and exceed this mandate. CCN
I Am a Critical Care Nurse features the extraordinary

in a critical care nurses ordinary experiences. To be
featured in this department, contact Critical Care Nurse
via e-mail at ccn@aacn.org.
2015 American Association of Critical-Care Nurses doi:

92
CriticalCareNurse
www.ccnonline.org
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Comparing Blood Pressure Measures:

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