The average resting heartbeat for all humans before reaching the age of approximately 45 is 72 beats per minute. 90 BPM as a resting pulse is high when compared to the average. However, there is no cause for alarm as long as you are healthy and not having any symptoms of a problem. A higher pulse simply means that your heart is emitting an insignificantly smaller amount of blood when compared to an average heart beat. Consequently, your heart will beat more to provide the blood needed for the body. There are many benign reasons to account for elevated resting pulse rates including stress, tension, anxiety and adrenaline. There are also malevolent reasons such as high blood pressure. If you are athletic, your resting heartbeat will decline. As you age, your resting heartbeat can increase (although will not necessarily do so) and should not do so significantly. Generally, there is no cause for concern as you are within the range of normal. Under the term heart disease we may include the underlying coronary
artery atherosclerosis as well as the metabolic and hemodynamic characteristics of the coronary disease process. We also include the various clinical manifestations of stable and unstable angina pectoris and acute myocardial infarction for being a smoker. As described in several books, the Framingham study reported angina pectoris to be more common as a first manifestation of coronary heart disease in women than in men. This unstable form of coronary disease can be seen as an early stage of the infarction process and is sometimes referred to as an impending infarction. Thus a major proportion of those people, who were admitted to a coronary care unit and hospitalized for acute coronary disease, have a serious and life threatening illness, which necessitates powerful clinical diagnostic resources and vigorous treatment.
Oxygen therapy is given to treat/prevent hypoxia and may be indicated in heart failure patients when pulmonary oedema causes impaired diffusion of oxygen into the blood. QMC Guidelines for the Administration of Oxygen state that oxygen should be treated as a drug and therefore administered by prescription only. It is the nurse’s responsibility to ensure the prescribed dose of oxygen is delivered to the patient and that this and the patient’s condition are regularly monitored. These facts and any changes MUST be documented in the patient’s nursing notes. Ensuring that appropriate oxygen therapy is prescribed is among the nursing actions advised on the heart failure care plan. This aspect of care readily lends itself to measurement as both medical and nursing notes could be checked for evidence of the oxygen administration and then cross-referenced with prescription charts.
• 24/52 patients had oxygen therapy administered during their hospital admission. None had this treatment prescribed regardless of whether or not a heart failure care plan had been implemented.
The care plan also recommends that physiotherapy referrals should be made where appropriate to promote optimum respiratory function. Although the audit did consider total numbers of physiotherapy referrals, we failed to ensure that our data collection tool distinguished between referrals made for breathing techniques or to aid expectoration and those made for the purposes of discharge planning. Consequently, the following findings relate to referrals made for either reason or cannot be accurately interpreted in terms of the individual aspects of patient care.
• A physiotherapy referral was indicated for 41/52 patients but referrals were only documented for 14. The referral rate to physiotherapy appeared to be slightly higher for the group in which care plans were used with 8 out of 12 potential referrals made compared to 6 out of 29 for the group without care plans.
Detection of actual and potential patient problems
One of the principle objectives in the medical management of heart failure is to relieve the patient of distressing congestive symptoms and fluid retention using a variety of pharmacological interventions. Response to drug therapy and prompt detection of the problems likely to be experienced by heart failure patients can be achieved through clinical assessment of the patient’s functional capacity, cardiac rhythm, nutritional and fluid status. The care plan thus identifies regular monitoring of blood pressure, heart and respiratory rate, peripheral oedema, fluid balance and daily weight as key nursing actions. Provision of education to both patients and their carers regarding the importance of a low sodium diet, implementation of a food chart for the purposes of nutritional assessment and referral to a dietician where appropriate are also recommended.
• 51/52 patients had documented evidence of satisfactory blood pressure monitoring.
• 50/52 patients had documented evidence of satisfactory pulse monitoring.
• Respiratory rate and oxygen saturations were poorly documented across the board.
Only 5/15 patients with a care plan and 15/37 without had regularly recorded monitoring of this nature.
• Review of the medical records suggested the majority of patients audited had some degree of peripheral oedema ranging from mild swelling of the ankles to ascites. However, nursing assessment for signs of oedema was very poorly documented with only
• 2/15 patients with care plans and 5/37 of those without having any reference made to this particular feature of heart failure.
• Fluid balance monitoring was indicated for 47/52 patients. 8/15 patients with a care plan had their fluid balance monitored compared to 10/32 patients without a care plan.
• Daily weight monitoring was indicated for 45/52 patients and was adequately evidenced across both groups. 10/12 patients with a care plan and 27/33 without had this particular regime implemented. While weight was clearly recorded on a daily basis for the 10 patients with a care plan, it was noted that weight monitoring was not consistently undertaken for 8 of the 27 patients who had the regime implemented but who did not have a care plan.
• If education was indeed given to patients regarding the importance of a low sodium diet, this practice was not documented at all in the nursing notes.
• Overall only a very small number of appropriate referrals were made to a dietician regardless of whether or not a care plan had been implemented (6/31).
Provision of information
Good communication between healthcare professionals and patients and carers is essential for the best management of heart failure. The care plan advises nursing staff to document the provision of information by medical staff to patients about their diagnosis and to ensure that such information is given promptly and in a way that the patient understands. The care plan also encourages sharing information with patients’ close relatives particularly when explaining the need for fluid restriction, low sodium diet or the potential side effects of prescribed drugs.
• 12/15 patients with a care plan and 22/37 without had documentation indicating that they been made aware of their heart failure diagnosis.
• Overall, only 22/34 patients informed of their condition had been made aware of the diagnosis within 24hrs of hospital admission.
• Documented evidence of provision of information to families about their relatives’ condition, prognosis and treatment was poorly represented in both groups. 8/15 of those with a care plan and 18/37 of those without had evidence that the family were in some way involved in the care of their relatives.
Referrals to the Heart Failure Nursing Service
It is important for the Heart Failure Nursing Team provides education, practical support and specialist follow-up for heart failure patients. Referral of appropriate patients into the service is actively encouraged by the care plan. There is substantial evidence that educational initiatives of this nature delivered by specialist nurses bring about improved quality of life for the patient group targeted and contribute toward a reduction in readmission rates.
• 12/52 patients did not fulfil the criteria necessary for referral into the Heart Failure Nursing Service.
• Only 11/40 eligible patients were actually referred into the service, 5/13 with care plans and 6/21 without.
Discharge arrangements and outcomes
The care plan recommends early initiation of discharge planning to identify any potential impediments to discharge. To further ensure smooth discharge, the care plan also emphasises an integrated multidisciplinary approach to planning incorporating close patient and carer liaison.
• 18/52 patients had no documented evidence of any form of discharge planning, 6 of these patients had care plans and the remaining 12 did not.
• A total of 34/52 patients had documented evidence of discharge planning. 3/9 patients with care plans and 6/25 of those without had this planning initiated within 24hrs of hospital admission.
• 8/9 patients with a care plan had evidence of a multi-disciplinary approach to their discharge planning compared to 11/25 of those without a care plan.
• 27/34 patients had evidence of family/carer involvement in discharge planning. 7 of these patients had care plans 20 and did not.
• Although the audit form failed to capture vital information relating to the actual number of occupational therapy referrals made, documented referrals to this service were taken as positive evidence of discharge planning.
Anthracyclines are important drugs for the treatment of Ben Long. Unfortunately these drugs induce serious side-effects, among others to the heart muscle. Patients treated with anthracyclines have an increased risk of developing myocardial dysfunction. It appears from literature that these children either suffer from a lowered systolic heart function (congestive heart failure), or from a loss of heart muscle mass, without dilation of the ventricles (restrictive cardiomyopathy).
The time course of the development of myocardial damage is not well known, since adequate diagnostic methods are not yet available.
Ultrasound Tissue Doppler Imaging (TDI) is a recent echocardiographic technique which allows for the assessment of tissue motion (i.e. velocity of movement of the heart walls), is non-invasive, easy to use and causes no radiation damage. This technique has been introduced in the Children's Heart Centre and will be applied in this study, together with conventional echo-Doppler techniques. TDI measurements yield a direct estimate of the local, active and passive contraction/relaxation of the heart muscle.
Recently, the applicants performed a study with healthy children (n=160, 4-18 yr) to establish the range of normal TDI parameters. Finally, a retrospective study (>5 years after ending of chemotherapy) was performed (n=148) to detect risk factors for induced cardiomyopathy, as revealed by conventional echo-Doppler parameters.
• To prevent serious, irreversible myocardial damage due to treatment with anthracyclines. For this purpose it is necessary to establish the moment, degree and time course of cardiomyopathy with non-invasive and reliable methods. By this means it would ultimately become feasible to individually modulate the treatment protocol, and to investigate the applicability and efficacy of potentially cardio protective drugs.
Plan of investigation:
The results of preliminary investigations (healthy children, retrospective assessment of risk factors from own patients) have been used to develop a set of conventional echo-Doppler (M-mode and blood flow velocity) and of TDI parameters to be used in the following studies (summarized as: 'echocardiographic parameters' below):
1. Retrospective studies of:
a) Chronic effects: comprises patients within one year after treatment (n=20, 1999-2001).
b) Intermediate cardio toxic effects: patients whose treatment ended between 1 and 5 years (n=50, 1999-2001).
c) Late cardio toxic effects: comprises patients whose treatment ended more than 5 years before the current study (n=60; 1999-2000).
2. Prospective study of acute and subacute effects (n=15-20, 1999-2001). This group requires an extensive echocardiographic protocol, since the total duration of treatment varies between 7 and 34 weeks, with several non-treatment intervals in which the echocardiography will be performed.
Relevance of research:
The early detection of drug induced myocardial damage is relevant to cancer treatment not only in children, but also in adults. Cardio toxicity is due to irreversible damage of myocytes, which may ultimately become manifest clinically as 'chronic heart failure' and even sudden death. Individual modulation of therapy, the feasibility of investigating the efficacy of cardio protective drugs and the adequate documentation of the course and stage of cardiac dysfunction may be considered highly relevant. The long term prognosis of the cardiac function of children successfully treated for a primary cancer with anthracyclines is still not fully known, but this group increases with 100 individuals per year in The Netherlands and it may be expected that by the year 2010 one in every 250 children is survivor of a malignancy (USA study). Therefore, the socio-medical impact is rapidly increasing.
Appropriate Assessment of Ben Long
CPAP or Continuous Positive Airway Pressure is a method of applying a positive pressure to the inside of the throat to prevent it from collapsing during sleep. The individual wears a special mask over the nose that is connected to a pump. The pump applies pressure through the mask to keep the throat from collapsing. CPAP is used in the treatment of Obstructive Sleep Apnea (OSA). It is the best way of treating patients with severe OSA, and is one of the several options for treating patients with mild to moderate OSA.CPAP is very beneficial in the majority of people who continue using their machines. The pressure can be adjusted to restore normal breathing during sleep. However, statistics have shown that 1 in 3 patients stop using their CPAP within the first year. The main reasons that patients give for not using their CPAP are inconvenience and discomfort. Most of these problems are solvable by finding a mask that fits properly.
Advantages of CPAP
• Can provide immediate relief of OSA.
• Can be used on a trial basis and stopped if not tolerated by the patient.
• Can be used in conjunction with other treatments such as dental appliances.
The CPAP versus BIPAP issue can cause pressure on patients who are unfamiliar with the differences. However, they will both help alleviate the symptoms of sleep apnea and cause the patients to have a more pleasant sleeping experience. Because excessive snoring is also associated with apnea, the machines will also help alleviate any sleepless nights loved ones might experience due to the excessive snoring that occurs. The issue of one machine versus another is not nearly as important as the issue of proper treatment of sleep apnea. They will be prescribed based on your need and properly explained on their use. Patients will generally get an immediate feeling of relief. Some patients may need to get used to the mask and the machine but they are typically comfortable and easy to wear. They are also covered under most insurance plans so people who are suffering from sleep apnea will not need to worry about a very large out of pocket expense.
BiPAP or Bi-level Positive airway pressure is used to restore functional residual capacity (FRC) the volume left in the lungs at the end of a resting exhalation. This residue allows more efficient gas exchange at the alveoli and hence improves oxygenation. It is also known as non-invasive positive pressure ventilation (NPPV). It differs from Continuous Positive Airway Pressure (CPAP) in that it provides assistance with ventilation. CPAP only provides a constant positive pressure. BiPAP is used to treat hypercapnoeic respiratory failure. Examples of this might include: Sleep apnea, chronic airway limitation (CAL) and some neuromuscular disorders. Recent studies have found it effective in the treatment of hydrostatic pulmonary oedema and pneumonia. To achieve BiPAP a patient ventilator interface (known in the business as the face mask) is secured snugly to the patients face (usually with the aid of elastic straps).
Fractional concentration of inspired oxygen (FiO2) is titrated via a flow valve to meet patient requirements. When the patient begins to breathe in a transducer in the unit senses the decrease in airflow within the circuit and delivers IPAP supporting the patient’s aspiratory effort and producing a larger tidal breath. As the patient finishes her inspiration the transducer senses the drop in aspiratory flow and allows the patient to exhale with pressure support (PS) to the EPAP level. (IPAP-EPAP=PS)
BiPAP is a mode of non-invasive ventilatory support, which achieves the combination of pressure-controlled ventilation and spontaneous breathing. BiPAP creates two different positive airway pressure levels (IPAP and EPAP), responding to the patient's respiratory cycle. Theoretically, the EPAP provides the physiological advantages similar to those of PEEP in mechanical ventilation. The IPAP creates further PS effects to permit passive ventilation. These two pressure levels alternating at preset time intervals improve lung mechanics by recruiting atelectatic alveoli, increasing pulmonary compliance, and reducing the work of breathing. The BiPAP ventilation has been demonstrated to be an effective means of improving gas exchange in patients with many types of acute respiratory failure and cardiogenic pulmonary edema, and in postoperative high-risk patients. In our study, oxygenation also improves by BiPAP in adult patients after surgery under CPB. The BiPAP administration increased PaO2/FiO2 in the patients with poor oxygenation on arrival in ICU immediately after surgery and before extubation. The BiPAP therapy allowed those patients after extubation to maintain PaO2/FiO2 levels similar to the levels in the patients without BiPAP.
There are several potential advantages of BiPAP for these patients. First, BiPAP allows a better alveolar recruitment during both inhalation and exhalation. Second, continuous positive airway pressure increases oxygen uptake in the setting of impaired oxygen diffusion, which results from acute lung injury by CPB. Third, improved oxygenation may result in increased tissue partial pressure of oxygen and may promote wound healing and avoid surgical wound infection. Fourth, BiPAP, especially IPAP, unloads the work of breathing, which may increase myocardial oxygen demand. Fifth, BiPAP may avoid the morbidities of endotracheal intubation for mechanical ventilation, including ventilator-associated pneumonia, patient discomfort, absence of oral intake and speech, and requirement of deep sedation. Sixth, BiPAP may also improve hemodynamics by reducing afterload transmural pressure, sympathetic nerve activity, and afterload, resulting in enhanced ventricular performance. In our study, the BiPAP bestowed benefits especially on female patients with lower total protein and small body mass index, who underwent more invasive emergency operation with prolonged CPB with lower temperature and hemoglobin levels. These advantages of BiPAP may give more beneficial effects to high-risk patients with poor nutrition undergoing more invasive surgery.
Of course, the BiPAP therapy is not appropriate for all patients after surgery with CPB. The major premise for applying BiPAP is stable hemodynamic condition. In our study, reintubation for full ventilatory support was necessary in one patient who received BiPAP because of hemodynamic instability.
For patients who are extremely agitated or uncooperative, BiPAP is not likely to be well tolerated. In our patients, all patients adapted themselves well to BiPAP with careful coaching of the nurses and gradual titration of positive pressure. Patients with excessive airway secretion are also poor candidates for BiPAP because there is no direct access to remove secretions. In general, complications associated with BiPAP are uncommon. Gastric insufflation is rare at pressures of less than 30cm H2O. Aspiration of gastric contents has a very low incidence of 5% or less when the airway reflex is intact. Local complications such as skin abrasion, sinus complaints, and conjunctivitis are rather more common. In our patients, there were no complications associated with BiPAP. Since the BiPAP therapy produces less demerits and more merits, earlier institution of BiPAP may be better in postoperative managements of patients undergoing CPB.
Explanation of Findings
Cardiogenic shock is a state in which a weakened heart isn't able to pump enough blood to meet the body's needs. It is a medical emergency and is fatal if not treated right away. The most common cause of cardiogenic shock is damage to the heart muscle from a severe heart attack. Not everyone who has a heart attack develops cardiogenic shock. In fact, less than 10 percent of people who have a heart attack develop it. But when cardiogenic shock does occur, it's very dangerous. For people who die from a heart attack in a hospital, cardiogenic shock is the most common cause. The medical term "shock" refers to a state in which not enough blood and oxygen reach important organs in the body, such as the brain and kidneys. In a state of shock, a person's blood pressure is very low. Shock can have a number of different causes. Cardiogenic shock is only one cause of shock. Other causes of shock include:
• Hypovolemic (hy-poe-voe-LEE-mik) shock. This is shock due to not enough blood in the body. The most common cause is severe bleeding.
• Vasodilatory (VAZ-oh-DILE-ah-tor-ee) shock. In this type of shock, the blood vessels relax too much and cause very low blood pressure. When the blood vessels are too relaxed, there isn't enough pressure to push the blood through them. Without enough pressure, blood doesn't reach the organs. A bacterial infection in the bloodstream, a severe allergic reaction, or damage to the nervous system (brain and nerves) may cause vasodilatory shock.
When a person is in shock (from any cause), not enough blood or oxygen is reaching the body's organs. If shock lasts more than several minutes, the lack of oxygen to the organs starts to damage them. If shock isn't treated quickly, the organ damage can become permanent, and the person can die.
Some of the signs and symptoms of shock include:
• Confusion or lack of alertness
• Loss of consciousness
• A sudden, rapid heartbeat
• Pale skin
• Weak pulse
• Rapid breathing
• Decreased or no urine output
• Cool hands and feet
In the past, almost no one survived cardiogenic shock. Now, thanks to improved treatments, around 50 percent of people who go into cardiogenic shock survive. The reason more people are able to survive cardiogenic shock is because of treatments (medicines and devices) that restore blood flow to the heart and help the heart pump better. In some cases, devices that take over the pumping function of the heart are used. Implanting these devices requires major surgery. Cardiogenic shock occurs when there is failure of the pump action of the heart resulting in reduced cardiac output. This leads to acute hypoperfusion and hypoxia of the tissues and organs, despite the presence of an adequate intravascular volume. Cardiogenic shock can be defined as the presence of the following (despite adequate left ventricular filling pressure):
• Sustained hypotension (systolic blood pressure < 90 mmHg for more than 30 minutes)
• Tissue hypo perfusion (cold peripheries, or oliguria < 30 ml/hour, or both)
Cardiogenic shock most commonly occurs as a complication of acute myocardial infarction. It occurs in 7% of patients with ST segment elevation myocardial infarction and 3% with non-ST segment elevation myocardial infarction.2 It is a medical emergency requiring immediate resuscitation.
• Cardiogenic shock is the leading cause of death in acute myocardial infarction.
• Mortality rates may be 70-90%, reduced to 40-60% if patients are treated aggressively.
• A recent study showed that among patients with cardiogenic shock who survive for 30 days after an ST-segment elevation myocardial infarction, annual mortality rates of 2% to 4% are approximately the same as those of patients without shock. Percutaneous revascularisation was associated with a reduced risk of death.
• Early coronary revascularization in patient’s post-MI and adequate treatment of patients with structural heart disease may help to prevent cardiogenic shock.