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During military aeromedical evacuation (AE) and prolonged field care (PFC), casualties are at increased pressure injury (PI) risk. Operational PI mitigation strategies research is limited.Using multiple factors, this study examined Mepilex/LiquiCell effects on PI risk under simulated AE/PFC.Healthy adults were stratified by body fat (%) and randomized to six groups on three surfaces. Set A: Warrior Evacuation Litter Pad (WELP) with/without Mepilex; Set B: Vacuum Spine Board (VSB) with/without Mepilex; Set C: Talon litter with/without LiquiCell. Two hours supine (loaded) was needed.Sacral skin transcutaneous tissue oxygen (TcPO2), temperature, moisture, interface pressure, interleukin-1α/Total Protein.54 participants. Sets A/B: No Mepilex effects; temperature increased 2.5°C. Set C: No LiquiCell effects. Significant ΔTcPO2 (unloaded-loaded), with 100% impaired perfusion; temperature increased 1.2°C.Multiple risk factors for PI mitigating strategies must consider. Talon with increased pressure/impaired perfusion but smaller temperature/moisture changes; WELP/VSB with increased temperature/moisture but lower pressure/adequate perfusion.

Introduction Combat casualties are at increased risk for pressure injuries (PIs) during prolonged casualty care. There is limited research on operational PI risk mitigation strategies. The purpose of this study was to (1) compare a prototype mattress (AirSupport) designed for operational conditions versus the foldable Talon litter and Warrior Evacuation Litter Pad (WELP) on PI risk factors and (2) determine whether the Talon + AirSupport pad was noninferior and superior to the Talon + WELP on skin interface pressure. Materials and Methods Healthy adults (N = 85; 20 men and 65 women), aged 18 to 55 years, were stratified based on body fat percentage and randomized into three groups: Talon (n = 15), Talon + AirSupport (n = 35), and Talon + WELP (n = 35). The participants were asked to lie in a supine position for 1 hour. The outcomes included skin interface pressure (body surface areas: Sacrum, buttocks, occiput, and heels), sacral and buttock skin temperature and moisture, and discomfort and pressure. The study was approved by the University of Washington Institutional Review Board. Results Aim 1: The Talon had significantly higher peak skin interface pressure versus the AirSupport and WELP on the sacrum, buttocks, occiput, and heels. Skin temperature increase over the 1-hour loaded period was significantly lower on Talon versus AirSupport or WELP, reflecting a lower temperature–induced ischemic load. There was no significant difference in skin moisture changes or discomfort between the surfaces. Aim 2: The upper confidence limits for the difference in skin interface pressure (all body surface areas) for AirSupport versus WELP were below 25 mm Hg, establishing noninferiority of the AirSupport to the WELP. AirSupport was also superior to WELP for the peak interface pressure on the sacrum, occiput, and heels but not on the buttocks. Skin temperature changes (sacrum or buttocks) were not significantly different between the AirSupport and WELP. Conclusions The Talon litter presents a PI risk because of increased skin interface pressure, and hence, immediate action is warranted. The decreased PI risk associated with the lower skin interface pressures on the AirSupport and WELP was offset by the higher skin temperature, which may add the equivalent of 20 to 30 mm Hg pressure to the ischemic burden. Thus, any pressure redistribution intervention must be evaluated with a consideration for skin interface pressure, temperature, and moisture. Data from this study were applied to a predictive model for skin damage. Under operational conditions where resources and the environment may limit patient repositioning, it would be expected that casualties would suffer skin damage within 2 to 5 hours, with the occiput as the highest risk area. The severity of predicted skin damage is lowest on the AirSupport, which is consistent with the noninferiority and superiority of the AirSupport mattress compared to the WELP and Talon. Operational utility: The AirSupport and WELP, which were both superior to the Talon, are operationally feasible solutions to mitigate PI risk. The smaller size of the Talon (2.7 kgs compressible) versus the WELP (5 kgs noncompressible) may make them appropriate for different levels of the operational setting.

Maintaining strict temperature control during the maintenance phase of targeted temperature management (TTM) after cardiac arrest may be an important component of clinical care. Temperature variability outside of the goal temperature range may lessen the benefit of TTM and worsen neurologic outcomes. The purpose of this retrospective study of 186 adult patients (70.4% males, mean age 53.8 ± 15.7 years) was to investigate the relationship between body temperature variability (at least one body temperature measurement outside of 36°C ± 0.5°C) during the maintenance phase of TTM at 36°C after cardiac arrest and neurologic outcome at hospital discharge. Patients with temperature variability (n = 124 [66.7%]) did not have significantly higher odds of poor neurologic outcome compared with those with no temperature variability (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 0.36–2.82). Use of neuromuscular blocking agents (NMBAs) and having an initial shockable rhythm were associated with both higher odds of good neurologic outcome (shockable rhythm: OR = 10.77, 95% CI = 4.30–26.98; NMBA use: OR = 4.54, 95% CI = 1.34–15.40) and survival to hospital discharge (shockable rhythm: OR = 5.90, 95% CI = 2.65–13.13; NMBA use: OR = 3.03, 95% CI = 1.16–7.90). In this cohort of postcardiac arrest comatose survivors undergoing TTM at 36°C, having temperature variability during maintenance phase did not significantly impact neurologic outcome or survival.

IntroductionWithin the Military Health System, the process of transporting patients from an initial point of injury and throughout the entire continuum of care is called “en route care.” A Committee on En Route Combat Casualty Care was established in 2016 as part of the DoD Joint Trauma System to create practice guidelines, recommend training standards, and identify research priorities within the military en route care system.Materials and MethodsFollowing an analysis of currently funded research, future capabilities, and findings from a comprehensive scoping study, members of a sub-working group for research identified the top research priorities that were needed to better guide evidence-based decisions for practice and policy, as well as the future state of en route care.ResultsBased on the input from the entire committee, 10 en route care research topics were rank-ordered in the following manner: (1) medical documentation, (2) clinical decision support, (3) patient monitoring, (4) transport physiology, (5) transfer of care, (6) maintaining normothermia, (7) transport timing following damage control resuscitation or surgery, (8) intelligent tasking, (9) commander’s risk assessment, and (10) unmanned transport. Specific research questions and technological development needs were further developed by committee members in an effort to guide future research and development initiatives that can directly support operational en route care needs. The research priorities reflect three common themes, which include efforts to enhance or increase care provider capability and capacity; understand the impact of transportation on patient physiology; and increase the ability to coordinate, communicate, and facilitate patient movement. Technology needs for en route care must support interoperability of medical information, equipment, and supplies across the global military health system in addition to adjusting to a dynamic transport environment with the smallest possible weight, space, and power requirements.ConclusionsTo ensure an evidence-based approach to future military conflicts and other medical challenges, focused research and technological development to address these 10 en route care research gaps are urgently needed.

To synthesize data on prevalence and risk factors for return to work (RTW) in ICU survivors.Systematic review and meta-analysis.PUBMED, CINAHL, EMBASE and PsycINFO databases were searched from 2000-Feb 2020.Peer-reviewed articles that included adult ICU survivors and employment outcomes. Two investigators independently reviewed articles following the PRISMA protocol. Pooled prevalence for RTW was calculated. Meta-regression analyses were performed to assess the association between disability policies, temporal factors and RTW following ICU.Twenty-eight studies (N = 8,168) met the inclusion criteria. All studies were scored as 'low risk of bias'. Using meta-analysis, the proportion (95% CI) of RTW following ICU was 29% (0.20,0.42), 59% (0.50,0.70), 56% (0.50,0.62), 63% (0.54,0.72), 58% (0.37,0.91), 58% (0.42,0.81), and 44% (0.25,0.76) at 3, 4-6, 7-12, 13-24, 25-36, 37-48, and 49-60 months, respectively. Time and disability policy support are factors associated with the proportion of ICU survivors who RTW. Through meta-regression, there is a 20% increase (95% CI: 0.06, 0.33) in the proportion of individuals who RTW per year. However, the average rate of increase slows by 4% (-0.07, -0.1) per year. In countries with high support policies, the proportion of RTW is 32% higher compared with countries with low support policies (0.08, 0.24). However, as subsequent years pass, the additional proportion of individuals RTW in high support countries declines (β = -0.06, CI: -0.1, -0.02).Unemployment is common in ICU survivors. Countries with policies that give higher support for disabled workers have a higher RTW proportion to 3 years following ICU admission. However, from 3-5 years, there is a shift to countries with lower support policies having better employment outcomes.Health care policies have an impact on RTW rate in survivors of ICU. Healthcare providers, including nurses, can function as public advocates to facilitate policy change.目的: 综合汇总ICU康复者复工(RTW)的患病率和风险因素 设计: 系统评估和荟萃分析。 数据来源: 检索PUBMED、CINAHL、EMBASE和PsycINFO数据库自2000年至2020年2月期间的数据。 评估方法: 同行评审文章包含成年人ICU康复者和就业结果。两位研究员各自按照PRISMA方案对文章进行了评估。计算了复工后的合并就业率。采用了荟萃回归分析,评估残疾政策、暂时性因素以及ICU后复工之间的关系。 结果: 28份研究(N = 8,168)符合纳入标准。其中,所有研究都被评为‘低偏见风险’。通过荟萃分析,ICU复工率(95%CI)在3个月时为29% (0.20和0.42),4-6个月时为59%(0.50和0.70),7-12个月时为56%(0.50和0.62),13-24个月时为63%(0.54和0.72)、25-36个月时为58%(0.37和0.91)、37-48个月时为58%(0.42和0.81)以及49-60 个月时为44%(0.25和0.76)。时间和残疾政策支持是与ICU复工幸存者的比例有关的因素。通过荟萃回归,复工患者的比率每年上升20%(95% CI: 0.06和0.33)。然而,平均增长率每年下降4%(−0.07和 −0.1)。政策支持力度大的国家,其复工比率比政策支持力度小的国家高32%(0.08和0.24)。然而,在之后的几年中,政策支持力度大的国家,其额外个人复工比率有所降低(β = −0.060和CI: −0.1和−0.02)。 结论: ICU康复者失业是非常常见的事情。在为残疾工人提供较高支持政策的国家中,ICU住院3年后的复工比率较高。然而就3到5年以及之后的复工率而言,反而是政策支持力度低的国家就业情况比较可观。 影响: 医保政策对ICU康复者的复工率有一定影响。包括护士在内的医保提供者可作为公共提倡者,从而促进政策变更。.

Energy expenditure (EE) is the sum of metabolic activity within the body at a given time and comprises basal EE, diet-induced thermogenesis, and physical activity. In the intensive care unit, EE is most often assessed to determine a patient’s caloric requirements. Energy expenditure also may be useful to understand disease states and the metabolic impact of interventions. Several methods for estimating EE are relevant for clinical use, including indirect calorimetry, predictive equations, exhaled carbon dioxide volume, and the Fick method. Indirect calorimetry is the preferred method for evaluating EE and is considered the gold standard for estimating EE in hospitalized patients. However, use of indirect calorimetry is not always practical or possible. Therefore, other methods of estimating EE must be considered. In this review, methods of evaluating EE in critically ill adults are examined and the benefits and limitations of each method are discussed, with practical considerations for use.

Patients undergoing targeted temperature management (TTM) after cardiac arrest are at risk for shivering, which increases energy expenditure (EE) and may attenuate TTM benefits. This article reports patterns of EE for patients with and without shivering who received TTM at 36°C after cardiac arrest. Based on 96 case assessments, there were 14 occasions when more than one 15-minute interval period was required to appropriately modify the Bedside Shivering Assessment Scale (BSAS) score. Investigators noted that although higher EE was related to higher BSAS scores, there may be opportunities for earlier detection of shivering.

Care under operational conditions is complex and unique. Although there is a growing body of evidence to inform this care, very few resources address operational nursing care. To address this issue and the lack of a compilation of relevant studies and evidence-based guidelines, the TriService Nursing Research Program Battlefield and Disaster Nursing Pocket Guide was created. The pocket guide has been updated and incorporates new and emerging evidence and also showcases the focused operational research of military nurse scientists. Eight thousand copies of the second edition of the guide, which curates a comprehensive body of literature related to operational nursing care, are being distributed to the three services. Military nurse scientists and multidisciplinary clinical experts contributed to the guide, with the content undergoing critical review by experts in operational care. This article summarizes the development of the pocket guide, summarizes some of the updates from the first edition, and demonstrates the integration of the guide into the major phases of evidence translation: knowledge, creation, and distillation; diffusion and dissemination; and adoption, implementation, and institutionalization. The incorporation of the pocket guide into readiness training reflects a goal of TriService Nursing Research Program to “develop and strengthen the Triservice community of nurse scholars to generate new knowledge in military nursing and translate it into practice” and an unending commitment to bring world class care to those in harm’s way.

Inability to return to work (RTW) is common after acute respiratory distress syndrome (ARDS).The aim of this study is to examine interrelationships among pre-ARDS workload, illness severity, and post-ARDS cognitive, psychological, interpersonal, and physical function with RTW at 6 and 12 months after ARDS.We conducted a secondary analysis using the US multicentre ARDS Network Long-Term Outcomes Study. The US Occupational Information Network was used to determine pre-ARDS workload. The Mini-Mental State Examination and SF-36 were used to measure four domains of post-ARDS function. Analyses used structural equation modeling and mediation analyses.Among 329 previously employed ARDS survivors, 6- and 12-month RTW rates were 52% and 56%, respectively. Illness severity (standardised coefficients range: -0.51 to -0.54, p 0.001) had a negative effect on RTW at 6 months, whereas function at 6 months (psychological [0.42, p 0.001], interpersonal [0.40, p 0.001], and physical [0.43, p 0.001]) had a positive effect. Working at 6 months (0.79 to 0.72, P 0.001) had a positive effect on RTW at 12 months, whereas illness severity (-0.32 to -0.33, p = 0.001) and post-ARDS function (psychological [6 months: 0.44, p 0.001; 12 months: 0.33, p = 0.002], interpersonal [0.44, p 0.001; 0.22, p = 0.03], and physical abilities [0.47, p 0.001; 0.33, p = 0.007]) only had an indirect effect on RTW at 12 months mediated through work at 6 months.RTW at 12 months was associated with patients' illness severity; post-ARDS cognitive, psychological, interpersonal, and physical function; and working at 6 months. Among these factors, working at 6 months and function may be modifiable mediators of 12-month post-ARDS RTW. Improving ARDS survivors' RTW may include optimisation of workload after RTW, along with interventions across the healthcare spectrum to improve patients' physical, psychological, and interpersonal function.

BACKGROUND: The coronavirus disease 2019 pandemic continues to affect millions worldwide. Given the rapidly growing evidence base, we implemented a living guideline model to provide guidance on the management of patients with severe or critical coronavirus disease 2019 in the ICU. METHODS: The Surviving Sepsis Campaign Coronavirus Disease 2019 panel has expanded to include 43 experts from 14 countries; all panel members completed an electronic conflict-of-interest disclosure form. In this update, the panel addressed nine questions relevant to managing severe or critical coronavirus disease 2019 in the ICU. We used the World Health Organization's definition of severe and critical coronavirus disease 2019. The systematic reviews team searched the literature for relevant evidence, aiming to identify systematic reviews and clinical trials. When appropriate, we performed a random-effects meta-analysis to summarize treatment effects. We assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach, then used the evidence-to-decision framework to generate recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. RESULTS: The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued nine statements (three new and six updated) related to ICU patients with severe or critical coronavirus disease 2019. For severe or critical coronavirus disease 2019, the panel strongly recommends using systemic corticosteroids and venous thromboprophylaxis but strongly recommends against using hydroxychloroquine. In addition, the panel suggests using dexamethasone (compared with other corticosteroids) and suggests against using convalescent plasma and therapeutic anticoagulation outside clinical trials. The Surviving Sepsis Campaign Coronavirus Diease 2019 panel suggests using remdesivir in nonventilated patients with severe coronavirus disease 2019 and suggests against starting remdesivir in patients with critical coronavirus disease 2019 outside clinical trials. Because of insufficient evidence, the panel did not issue a recommendation on the use of awake prone positioning. CONCLUSION: The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued several recommendations to guide healthcare professionals caring for adults with critical or severe coronavirus disease 2019 in the ICU. Based on a living guideline model the recommendations will be updated as new evidence becomes available.

Background In-hospital stroke events account for 2% to 17% of all ischemic strokes in the United States. Current stroke guidelines do not provide guidance on how to care for in-hospital stroke. Use of checklists during high-acuity events reduces error and provides clarity for responding staff. We sought to determine whether the use of an evidence-based checklist to guide in-hospital stroke response improved intervention times and patient outcomes. Methods This study used a retrospective chart review of patients hospitalized between January 1, 2016, and December 31, 2018, at a community hospital certified as a primary stroke center with the Joint Commission. Encounters were sorted into preintervention and postintervention groups to evaluate for change in treatment rates, new or worsened disability, and mortality. Nursing staff who respond to in-hospital stroke calls ("response staff") were also surveyed regarding their perception of benefit and firsthand experience when using the checklist. Results A total of 168 patient charts were reviewed (18 prechecklist, 150 postchecklist). After checklist implementation, treatment with intravenous thrombolytics for in-hospital stroke events increased from 0% to 11%. All-cause mortality decreased from 23.1% to 15.0%, whereas ambulatory disability at discharge increased from 38.0% to 62.1%. The increase in disability likely reflects the reduction in mortality, improved data collection, and the increase in postimplementation reporting. Conclusions Use of a checklist during inpatient stroke events can potentially increase adherence to guidelines for appropriate treatment and reduce mortality. Hospital response teams should consider use of a structured response system with an evidence-based checklist for high-acuity, low-frequency events such as in-hospital stroke.

A keynote of reader-response theory is the individuality of the response, that is, the affective influence of personal experiences, attitudes, and backgrounds. Among these are culture and language. The focus of this chapter is a cultural marker, particular body language used by many African American students as part of their response process. Research in the area of culture and reader-response tends to focus on outcomes. The emphasis has been on what a student says, writes, or draws during or after the reading of certain texts. Most commonly seen in animated conversation, body punctuation is a culturally specific part of Black English. Regardless of who used body punctuation in oral presentation or simple conversation, all of the African American students understood the meaning of the movements. Body punctuation, the art of physically punctuating speech, is a part of the African American urban dialect. Teachers must recognize body punctuation as a valid response, acknowledge the occurrences, and ask for expansion when appropriate.

Recurrent pleural effusion is a symptom of several end-stage diseases and is associated with limited life expectancy. Patients with this condition have disabling symptoms resulting in reduced quality of life and often receive inconsistent treatment due to delayed recognition of pleural effusion, repeat procedures, and lengthy hospitalizations. Placement of a tunneled pleural catheter allows the patient to manage his or her symptoms at home, yet this treatment remains underused because of provider misconceptions and unfamiliarity with the intervention. This article provides an overview of the indications for placement of a tunneled pleural catheter, possible complications, and management strategies, and introduces evidence-based clinical decision support tools to enhance provider knowledge. In addition, the article describes the implementation and evaluation of a performance improvement initiative on the use of tunneled pleural catheters in a multifaceted health care system.

In 2015, the Surviving Sepsis Campaign six-hour bundle was updated. The revised version now recommends documenting the reassessment of volume status and tissue perfusion after initial fluid resuscitation through a repeated focused examination. This article addresses the practice and interpretation of two components of this examination in adults: capillary refill time and skin mottling score. It further discusses how to best integrate these noninvasive parameters into the care of patients undergoing resuscitation for septic shock.

The backbone of military aeromedical evacuation (AE) is provided by highly trained flight nurses (FNs) and aeromedical evacuation technicians (AETs). Between 2001 and 2014, 127,433 individual patients were transported on 81,869 flights. Most of these patients receive en route care from an AE crew consisting of two FNs and three AETs, with less than 5% of patients cared for by specialty teams: Critical Care Air Transport Team (CCATT), Burn Team, etc. These AE patients have a diversity of diagnoses, ranging from trauma to mental health issues. There is a growing body of science informing AE nursing, leading to the refinement of care related to systematic preflight patient preparation and handoffs, and the identification of patients at increased risk for en route adverse events. The epidemiology of patients transported in AE, the ongoing education and training requirements for FNs and AETs, and mission preparation and handoff strategies are presented. The chapter also addresses the modification of en route nursing care related to the stresses of flight (e.g., hypobaria, hypoxia, humidity, noise, etc.) and unique evidence-based aspects of en route care, including the transport of patients with acute coronary syndrome, pain management, pressure injury prevention, mitigation of risk for venous thromboembolism, mental health considerations, cardiac arrest response, and patient and crew safety.

Background ClinicalTrials.gov reviews have evaluated research trends for specific conditions and age groups but not for specific populations of research participants. No ClinicalTrials.gov reviews have evaluated research with military service member participants. Purpose Study objectives were (a) to use ClinicalTrials.gov to identify trends in biomedical research from 2005 to 2014 in which U.S. military service members actively participated as research participants and (b) to describe a search strategy for adaptation in future ClinicalTrials.gov reviews of specific participant populations. Methods A systematic review of ClinicalTrials.gov was performed to identify studies that included U.S. service members as participants, either exclusively or with other groups of participants. Results U.S. service members were identified as participants in 512 studies. Service members participated together with other groups in 392 studies, while 120 studies included only service members. The top five conditions of interest were post-traumatic stress disorder, traumatic brain injury, amputations, burns, and ocular injuries/disorders. The number of studies started each year peaked in 2011 and declined from 2012 to 2014. Twenty-five percent of studies exclusive to service members aimed to enroll 500 or more participants. Research exclusive to Guard and Reserve service members during this period was limited. Conclusions U.S. military service members participate in biomedical research. To address the health needs of U.S. service members, it is important to ensure there is not a prolonged decline in research among this population. The search strategy may be adapted to ClinicalTrials.gov reviews of specific participant populations for which straightforward searches are not possible.

Background Intravenous fluid boluses are administered to patients in shock to improve tissue hypoperfusion. However, fluid boluses result in clinically significant stroke volume increases in only about 50% of patients. Hemodynamic responses to passive leg raising measured with invasive and minimally invasive methods are accurate predictors of fluid responsiveness. However, few studies have used noninvasive blood pressure measurement to evaluate responses to passive leg raising. Objective To determine if passive leg raising-induced increases in pulse pressure or systolic blood pressure can be used to predict clinically significant increases in stroke volume index in healthy volunteers. Methods In a repeated-measures study, hemodynamic measurements were obtained in 30 healthy volunteers before, during, and after passive leg raising. Each participant underwent the procedure twice. Results In the first test, 20 participants (69%) were responders (stroke volume index increased by ≥ 15%); 9 (31%) were nonresponders. In the second test, 15 participants (50%) were responders and 15 (50%) were nonresponders. A passive leg raising-induced increase in pulse pressure of 9% or more predicted a 15% increase in stroke volume index (sensitivity, 50%; specificity, 44%). There was no association between passive leg raising-induced changes in systolic blood pressure and fluid responsiveness. Conclusion A passive leg raising-induced change in stroke volume index measured by bioreactance differentiated fluid responders and nonresponders. Pulse pressure and systolic blood pressure measured by oscillometric noninvasive blood pressure monitoring were not sensitive or specific predictors of fluid responsiveness in healthy volunteers.

BACKGROUND Combat casualties undergoing aeromedical evacuation are at increased risk for pressure injuries. The risk factors pressure and shear are potentially modifiable via solutions appropriate for en route care. OBJECTIVES To compare transcutaneous oxygen levels and skin temperatures in healthy participants under offloaded (side lying) and loaded (supine or supine with 30° backrest elevation) under 4 conditions: control (no intervention), Mepilex sacral and heel dressings, LiquiCell pad, and Mepilex plus LiquiCell. METHODS Participants were randomly assigned to 4 groups according to ideal body weight. Backrest positions were randomized. Transcutaneous oxygen level and temperature were measured on the sacrum and the heel; skin interface pressure was measured with an XSensor pressure imaging system. Measurements were obtained for 5 minutes at baseline (offloaded), 40 minutes with participants supine, and 15 minutes offloaded. RESULTS In the 40 healthy participants, interface pressure, transcutaneous oxygen level, and skin temperature did not differ between the 4 groups. Peak interface pressures were approximately 43 mm Hg for the sacrum and 50 mm Hg for the heel. Sacral transcutaneous oxygen level differed significantly between unloaded (mean, 79 mm Hg; SD, 16.5) and loaded (mean, 57 mm Hg; SD, 25.2) conditions (P < .001) in a flat position (mean, 85.2 mm Hg; SD, 13.6) and with 30° backrest elevation (mean, 66.7 mm Hg; SD, 24.2) conditions (P < .001). Results for the heels and the sacrum were similar. Sacral skin temperature increased significantly across time (approximately 1.0°C). CONCLUSIONS The intervention strategies did not differ in prevention of pressure injuries.

Sepsis is a leading cause of critical illness and hospital mortality. Early recognition and intervention are essential for the survival of patients with this syndrome. In 2002, the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) launched the Surviving Sepsis Campaign (SSC) to reduce overall patient morbidity and mortality from sepsis and septic shock by driving practice initiatives based on current best evidence. The SSC guidelines have been updated every four years, with the most recent update completed in 2016. The new guidelines have increased the focus on early identification of infection, risks for sepsis and septic shock, rapid antibiotic administration, and aggressive fluid resuscitation to restore tissue perfusion.In 2014, the SCCM and the ESICM convened a task force of specialists to reexamine the definitions of terms used to identify patients along the sepsis continuum. In 2016, this task force published the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The new definitions and recommendations included tools, based on an updated understanding of the pathobiology of sepsis, that can be used to predict adverse outcomes in patients with infection.This article discusses the new SSC treatment guidelines, changes in the sepsis bundle interventions, and the Sepsis-3 definitions and tools, all of which enable nurses to improve patient outcomes through timely collaborative action.

Over the past 13 years, the military health care system has made improvements that are associated with an unprecedented survival rate for severely injured casualties. Monitoring for indications of deterioration as the critically injured patient moves across the continuum of care is difficult given the limitations of routinely used vital signs. Research by both military and civilian researchers is revolutionizing monitoring, with an increased focus on noninvasive, continuous, dynamic measurements to provide earlier, more sensitive indications of the patient's perfusion status.

Editor's note: This is part of an ongoing series of columns from nurses at the University of Washington that will examine in depth the research related to critical care practices. Keywords: cardiac arrest, cardiopulmonary resuscitation, in-hospital cardiac arrest, quality improvement

Fluid boluses are often administered with the aim of improving tissue hypoperfusion in shock. However, only approximately 50% of patients respond to fluid administration with a clinically significant increase in stroke volume. Fluid overload can exacerbate pulmonary edema, precipitate respiratory failure, and prolong mechanical ventilation. Therefore, it is important to predict which hemodynamically unstable patients will increase their stroke volume in response to fluid administration, thereby avoiding deleterious effects. Passive leg-raising (lowering the head and upper torso from a 45° angle to lying supine [flat] while simultaneously raising the legs to a 45° angle) is a transient, reversible autotransfusion that simulates a fluid bolus and is performed to predict a response to fluid administration. The article reviews the accuracy, physiological effects, and factors affecting the response to passive-leg raising to predict fluid responsiveness in critically ill patients.

Editor's note: This is part of an ongoing series of columns from nurses at the University of Washington that will examine in depth the research related to critical care practices.

Presented by royal engineer Wolfgang von Kempelen, “The Turk” was a chess-playing automaton that debuted in the court of Maria Theresa in 1770 and defied skeptics of the illusion for decades. This article contends that, viewed in terms of the specific time and place of its creation, the automaton serves as a nexus of mixed nostalgic and fearful associations with the Ottoman world. On the one hand, the Turk’s stereotypical—yet, in that period, stylish—appearance and von Kempelen’s playful presentations of the automaton reflected evolving perceptions of the Ottomans that had developed during the relative peace after the 1739 Treaty of Belgrade. On the other hand, the automaton would also have invoked equally powerful associations of Turks as warlike and inscrutable, drawing on memories of a series of bloody conflicts. Beyond the fantasy of winning lost battles and regaining lost territories, the chess-playing Turk also offers a template for understanding nostalgia more generally: as an inherently unwinnable scenario that seeks to recapture a golden past.

Hemodynamic monitoring has traditionally relied on such static pressure measurements as pulmonary artery occlusion pressure and central venous pressure to guide fluid therapy. Over the past 15 years, however, there's been a shift toward less invasive or noninvasive monitoring methods, which use �functional� hemodynamic indicators that reflect ventilator-induced changes in preload and thereby more accurately predict fluid responsiveness. The author reviews the physiologic principles underlying functional hemodynamic indicators, describes how the indicators are calculated, and discusses when and how to use them to guide fluid resuscitation in critically ill patients.

To describe the accuracy and precision of noninvasive hemoglobin measurement (SpHb) compared with laboratory or point-of-care Hb, and SpHb ability to trend in seriously injured casualties.Observational study in a convenience sample of combat casualties undergoing resuscitation at two US military trauma hospitals in Afghanistan. SpHb was obtained using the Masimo Rainbow SET (Probe Rev E/Radical-7 Pulse CO-Oximeter v 7.6.2.1). Clinically indicated Hb was analyzed with a Coulter or iStat and compared with simultaneous SpHb values.Twenty-three patients were studied (ISS 20 ± 9.8; age 29 ± 9 years; male 97%; 100% intubated). Primary injury cause: improvised explosive device (67%) or gunshot (17%). There were 49 SpHb-Hb pairs (median 2 per subject). Bias: 0.3 ± 1.6 g/dL (95% LOA -2.4, 3.4 g/dL). The SpHb-Hb difference± 1 g/dL in 37% of pairs. Eighty-six percent of pairs changed in a similar direction. Using an absolute change in Hb of1 g/dL, a concurrent absolute change in SpHb of1 g/dL had a sensitivity: 61%, specificity 85%, positive predictive value: 80%, and a negative predictive value: 69%. The SpHb signal was present in 4643 of 6137 min monitored (76%).This was the first study to describe continuous SpHb in seriously injured combat casualties. Using a threshold of 1 g/dL previously specified in the literature, continuous SpHb is not precise enough to serve as sole transfusion trigger in trauma patients. Further research is needed to determine if it is useful for trending Hb changes or as an early indicator of deterioration in combat casualties.

During the past year, studies were published that will lead to practice change, address challenges at the bedside, and introduce new care strategies. This article summarizes some of this important work and considers it in the context of previous research and practice. Examples of research-based practice changes include the performance and assessment of septic shock resuscitation, and the integration of tourniquets and massive transfusions in civilian trauma. Care challenges addressed include ethical considerations in light of the Ebola epidemic, infection prevention associated with chlorhexidine bathing, bedside alarm management, evidence to enhance moral courage, and interventions to mitigate thirst in critically ill patients. Research that portends future care includes a discussion of fecal microbiota transplant for patients with refractory infection with refractory infection with Clostridium difficile.

Just as data from civilian trauma registries have been used to benchmark and evaluate civilian trauma care, data contained within the Joint Theater Trauma Registry (JTTR) present a unique opportunity to benchmark combat care. Using the iterative steps of the benchmarking process, we evaluated data in the JTTR for suitability and established benchmarks for 24-hour mortality in casualties with polytrauma and a moderate or severe blunt traumatic brain injury (TBI). Mortality at 24 hours was greatest in those with polytrauma and a severe blunt TBI. No mortality was seen in casualties with polytrauma and a moderate blunt TBI. Secondary insults after TBI, especially hypother- mia and hypoxemia, increased the odds of 24-hour mortality. Data contained in the JTTR were found to be suitable for establishing benchmarks. JTTR data may be useful in establishing benchmarks for other outcomes and types of combat injuries.

We sought to describe the accuracy and precision of buccal pulse oximetry (SbpO(2)) compared with arterial oxygen saturation (SaO(2)) and pulse oximetry (SpO(2)) in healthy adults at normoxemia and under 3 induced hypoxemic conditions.In this prospective, correlational study, SbpO(2), SaO(2), and SpO(2) values were recorded at normoxemia and at three hypoxemic conditions (SpO(2)=90%, 80%, and 70%) for 53 healthy, nonsmoking adults who were without cardiac or pulmonary disease, baseline hypoxemia, peripheral edema, dyshemoglobinemia, and fever. Bland-Altman analyses were used to assess agreement and precision between SbpO(2) and SaO(2) measures and between SbpO(2) and SpO(2) measures. Data were adjusted to account for a lag time between buccal and finger sites.When comparing SbpO(2) and SaO(2) values, mean differences of -1.8%, .3%, 2.4%, and 2.6% were evident at the normoxemia, 90%, 80%, and 70% levels, respectively. When comparing SbpO(2) and SpO(2) values, the mean differences were -1.4%, .1%, 3.3%, and 4.7% at the normoxemia, 90%, 80%, and 70% levels, respectively. The SbpO(2) and SaO(2) values met a priori precision criteria (1.6%; 95% confidence limit, -4.9% to 1.3%) at normoxemia. The SbpO(2) and SpO(2) values met precision criteria at normoxemia (1.5%; 95% confidence limit, -4.4% to 1.5%) and 90% (1.9%; 95% confidence limit, -3.6% to 3.8%) conditions, but exceeded precision criteria at the other tested conditions. On average, SpO(2) lagged 21 seconds behind SbpO(2).Buccal oximetry is an inaccurate and imprecise method of assessing SpO(2) when oxygen saturation is90%. The divergence between SbpO(2) and both SaO(2) or SpO(2) values increased as hypoxemia worsened. The buccal method overestimated oxygen saturation in proportion to the degree of hypoxemia. Such overestimates may lead nurses to conclude falsely that a patient's arterial oxygen saturation is acceptable when further assessment or intervention is warranted.

Despite the severity and complexity of injuries, survival rates among combat casualties are equal to or better than those from civilian trauma. This article summarizes the evidence regarding innovations from the battlefield that contribute to these extraordinary survival rates, including preventing hemorrhage with the use of tourniquets and hemostatic dressings, damage control resuscitation, and the rapid evacuation of casualties via MEDEVAC and the US Air Force Critical Care Air Transport Teams. Care in the air for critically injured casualties with pulmonary injuries and traumatic brain injury is discussed to demonstrate the unique considerations required to ensure safe en route care. Innovations being studied to decrease sequelae associated with complex orthopedic and extremity trauma are also presented. The role and contributions of the Joint Combat Casualty Research Team and the Joint Theater Trauma System are also discussed.

Purpose: Neonatal transports are infrequent and represent a high risk population for deterioration in transport. Maintaining the skill to stabilize and improve outcomes is challenging. There is no standard team configuration for neonatal air transports, education curriculum, and demographics of this vulnerable population. The Transport Risk Index of Physiologic Stability Version II (TRIPS II) is a tool utilized to describe the severity of illness of neonates transported prior to, during and after transport. The TRIP II score has been validated to a 7 day mortality rate at NICU admission. …

Despite the severity and complexity of injuries, survival rates among combat casualties are equal to or better than those from civilian trauma. This article summarizes the evidence regarding innovations from the battlefield that contribute to these extraordinary survival rates, including preventing hemorrhage with the use of tourniquets and hemostatic dressings, damage control resuscitation, and the rapid evacuation of casualties via MEDEVAC and the US Air Force Critical Care Air Transport Teams. Care in the air for critically injured casualties with pulmonary injuries and traumatic brain injury is discussed to demonstrate the unique considerations required to ensure safe en route care. Innovations being studied to decrease sequelae associated with complex orthopedic and extremity trauma are also presented. The role and contributions of the Joint Combat Casualty Research Team and the Joint Theater Trauma System are also discussed.

This article examines the phenomenon of graphic novels generally, and in particular, their utility in second-language contexts via the example of the graphic adaptation of Klaus Kordoris Der erste Fruhling. This text lends itself especially to bridging thematic gaps in 20th-century German literature courses, as well as the “language/literature divide,” which is a current topic in language pedagogy. The article provides specific classroom techniques, in-class tasks, and writing assignments that will accommodate the varying student proficiency levels that often challenge instructors in second- and third-year college German courses.

Objectives: Describe the characteristics/enroute care of casualties transported by USAF Critical Care Air Transport Teams (CCATT) during Operation Enduring Freedom/Iraqi Freedom (OEF/OIF). Methods: Retrospective review of TRAC2ES and CCATT Mission Reports (Oct 2001-May 2006). Results: 3492 patient moves (2439 patients). Moves by route: within Area of Responsibility (AOR) (n = 261); AOR-Landstuhl (LRMC) (n = 1995), Germany-CONUS (n = 1188). For AOR-LRMC: BI (64%), NBI (8%), Disease (25%). Among injured (n = 1491), 69% suffered polytrauma, primarily d/t explosions. Injury area: extremities (63%), head (55%), thorax (46%), abdomen (31%), neck (17%). Injury type: soft tissue (64%), orthopedic (45%), thoracic (35%), skull fracture (27%), brain injury (25%). Disease diagnoses: cardiac (15%) and pulmonary (8%). Conclusions: This is the first analysis of OEF/OIF CCATT patients. Phase 1 of this study demonstrates the strengths and limitations of TRAC2ES and CCATT Mission Reports to describe the characteri...