The demand for advanced practice providers (APPs) is increasing across the United
States to meet necessary provider staffing requirements including in intensive
care settings. Currently, participation in formal postgraduate training
programs, or residencies, for APPs is not required for clinical practice, such
that most of the APPs immediately enter into the workforce following completion
of their initial graduate-level training. Consequently, this results in a
supervised training period until APPs develop the necessary competencies to
practice more autonomously. Educational programs that support specialty
competency development may facilitate the transition of APPs into clinical
practice, allowing them to be credentialed to perform essential procedures as
quickly as possible. The goal of this boot camp was to provide training for APPs
in common critical care, high-risk procedures, and to provide leadership
development for high-risk cases to expedite their orientation process. The
following manuscript describes our experience with the development,
implementation, and short-term evaluation of this training program.
Effective care and positive outcomes of the extracorporeal membrane oxygenation (ECMO) patient necessitate optimal interdisciplinary management from the healthcare team, including expert care from specially trained registered nurses (RNs). It is incumbent upon the RN caring for the ECMO patient to excel in both time management and assessment skills, as this population often demands care delivery at the pinnacle of intensive care unit (ICU) acuity. Astute and nuanced monitoring of neurological status, bleeding risk with potential (often massive) transfusions, poor hemodynamics, and integrity of the ECMO pump itself are only the few specialized areas of focus that must share priority with traditional nursing considerations involving the critically ill, such as prevention of pressure injuries and bloodstream infections. These high-intensity medical foci must be balanced with ethical considerations, as the ultimate goal of returning the patient to their normal life is not always possible. These demands highlight the dynamic proficiency of the RN caring for the ECMO patient. The following chapter will highlight the importance of specialized nursing care in the critically ill patient supported with ECMO.
The management of patients after cardiothoracic surgery can be very complex. Variabilities exist in hemodynamic status after cardiac surgery and the use of cardiopulmonary bypass – all of which can have a significant impact on myocardial Frank–Starling curves. Typically, invasive monitoring with pulmonary artery catheters is used to assess the complex physiology that these patients experience in the perioperative setting. However, the use of invasive monitoring is not without risk, and the broader benefits are poorly defined. Furthermore, there is growing evidence to support the use of hemodynamic early goal-directed therapy to optimize outcomes in critically ill patients. The purpose of this editorial statement is the review of some of the current literature with regards to the utility of goal-directed therapy as applied to the postoperative cardiac surgical patient.
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