Ask a probing question, substantiated with additional background information, evidence, or research using an in-text citation in APA format.
Half of page per response with one reference, use first person, thank you. Discussion attached.
Respond in one or more of the following ways:
Ask a probing question, substantiated with additional background information, evidence, or research using an in-text citation in APA format.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Validate an idea with your own experience and additional research.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Due to the lack of supporting evidence found on either the Walden Library or google scholar, I changed my PICOT question. My PICOT question will now be: In patients undergoing coronary artery bypass grafting or valve replacement, does the use of an amiodarone drip post-operatively have a significant impact on the rate of atrial fibrillation versus not having any prophylactic measures?
With two previous cardiothoracic surgeons, the use of amiodarone post-operatively was the gold standard. Every patient came back on an amiodarone drip, and the patients would be switched to oral amiodarone within a day or two. They would then go home on the medication for a couple weeks. The surgeon we recently hired does not practice this, nor do the previous locum surgeons we had prior to our permanent surgeon. There is one locum physician who will use amiodarone depending on where the bypass is required and the patient’s overall heart function.
My initial search in the Walden Library revealed a total of 13 articles after narrowing down the dates to 2002-2015. The majority of the articles available are from the first three levels of the pyramid, with most of them being critically-appraised individual articles. They focus on one study that was done on a group of patients and the results of using amiodarone post-operatively versus not using it. These seem to have the most in-depth information and provide good support on the use or non-use of this medication. One such article examined giving IV and oral amiodarone through the perioperative period (Kerstein, et. al, 2004). Another article found was a meta-analysis which provided an abundance of information about the topic in question. This particular type of article is beneficial because it provides a very detailed literature search with a lot of supporting evidence, and it does not focus only on one study. Having multiple studies to look at helps to add support because there can be one randomized study that shows benefits while multiple others do not. This particular article was more focused on Sotalol vs Amiodarone post-operatively, but the evidence supports that some sort of prophylaxis is necessary because it does have a control group that does not receive either medication (Lenz, Mohiuddin, Mooss, & Wurdeman, 2002).
I found two sources that would be considered expert opinion. They did not provide an extensive literature search nor did they focus on any particular study. The articles simply discussed the methods for atrial fibrillation control and prevention, and they discussed the reason why prophylaxis is necessary. One article discussed using bet-blockers, amioadrone, and magnesium as a method for prophylaxis post-operatively, and it further went on to say that cardioversion was a more effect method of control after the development of atrial fibrillation (Dugs & Therapy Perspectives, 2006). While these provide helpful information, they do not really provide sound evidence to support the use or lack of use of amiodarone post-operatively. They are an expert’s opinion, not a study performed showing evidence of one method or the other.
The key words that I used to conduct my search were atrial fibrillation, bypass, and amiodarone. These provided very specific search results that pertained directly to my topic. I believe when conducting further research I will keep my focus on the first three levels of the pyramid. These provide the best resutls for my topic because they focus directly on evidence based studies that have been conducted that show if it is necessary to use amiodarone postoperatively. It would be difficult to perform any sort of research in my facility given the smaller patient population and the fact that the current cardiothoracic surgeon would most likely not be willing to participate in such a study due to not wanting to change his practice.
Drugs & Therapy Perspectives. (2006). Managing Atrial Fibrillation After Coronary Artery Bypass
Graft Surgery Involves Prophylaxis, Cardioversion and/or Ventricular Rate Control.
Retrieved June 8, 2015: http://web.a.ebscohost.com.
Kerstein, J., Hollander, G., Lichstein, E., Majid, M., Qamar, M., Shani, J., & Soodan, A. (2004).
Giving IV and Oral Amiodarone Perioperatively for the Prevention of Postoperative Atrial
Fibrillation in Patients Undergoing Coronary Artery Bypass Surgery: the GAP Study. CHEST.
Retrieved June 8, 2015: http://web.a.ebscohost.com.
Lenz, T., Mohiuddin, S., Mooss, A., & Wurdeman, R. (2002). Amiodarone vs Sotalol as Prophylaxis
Against Atrial Fibrillation/Flutter After Heart Surgery: a Meta-Analysis. CHEST. Retrieved
June 8, 2015: http://web.a.ebscohost.com.
Literature Search
A literature search consist of searching through all types of published literature to accumulate pertinent data on a specific topic. For my literature search, I chose the term “hypothermia therapy” from my previous PICOT question: “In adult patients comatose within six hours after successful resuscitation from cardiopulmonary arrest undergoing induced hypothermia therapy would a noninvasive cooling method such as a cooling blanket compared to an invasive cooling method such as a cooling catheter lead to a lower morality or morbidity rate? Is there a significant difference from either cooling method?”
Evidence Hierarchy
As I was doing a literature search on my selected topic, I incorporated the seven levels of evidence hierarchy, which includes filtered and unfiltered searches (Polit & Beck, 2012, p. 27-28; Walden University Library, 2012). I noticed during my search that Level I results could be held at the highest value because the results were more precise with the supportive data. It is very important to understand that the higher the level on the hierarchy pyramid, the results possess the strongest supportive evidence (Polit & Beck, 2012, p. 27). It was also known that the closer my search results became to level seven, the more results appeared. As I was researching, the filtered searches would usually limit my results a great deal, so being specific and using terms that pertain to the main topic will provide more relevant results. I have grown very comfortable and prefer to use the MEDLINE and CINAHL database because it is very easy to retrieve the APA formatted article citation. I recommend utilizing this tool to give one the comfort of citing references correctly and reduce the time spent on them. Post-cardiac hypothermia therapy is new to my facility and I am really interested in finding new research to help my facility ensure the highest quality of care to the patients and ensure a protocol that will provide the highest level of outcomes. After researching this topic, I have a better understanding of the results at each level and how they are supported. I have created a format that will help explain the way I conducted my research on hypothermia therapy.
1. Level I- Systemic reviews- 8 results showed up at this level. The results in this level provided some evidence that a clinical problem was identified and information was gathered, evaluated and synthesized which resulted in conclusions. The article was electronically researched utilizing MEDLINE, Pubmed, EMBASE, and Cochrane Library. In this analysis, information on mortality and adverse events was extracted from published trials to determine the outcomes of hypothermia therapy in pediatric patients. The results showed that a slight increase in the risk of mortality existed after hypothermia therapy.
• MEDLINE with full text, filtered with journal, peer reviewed, within the past 5 years
• Ma, C., He, X., Wang, L., Wang, B., Li, Q., Jiang, F., & Ma, J. (2013). Is therapeutic hypothermia beneficial for pediatric patients with traumatic brain injury? A meta-analysis. Child’s Nervous System: Chns: Official Journal Of The International Society For Pediatric Neurosurgery, 29(6), 979-984. doi:10.1007/s00381-013-2076-x
2. Level II- Critically Appraised Topics- 1 result showed up at this level. The results at this level indicated the quality of precise effects, benefits, and the financial cost of the evidence.
• Evidence-Based Resources retrieved from the Joanna Briggs Institute- filtered within past 5 years, peer reviewed
• Childs, C. & Lunn K.W. (2012). A systematic review of differences between brain temperature and core body temperature in adult patients with severe traumatic brain injury. The JBI Library of Systematic Reviews. 10(24):1410-1451, 2012.
3. Level III- Critically Appraised Individual Articles- 3 results showed up at this level. The results of this level indicated areas of adequacy and inadequacy. The article below describes data from studies on the effectiveness of therapeutic hypothermia in adult patients post cardiac arrest.
• The ACP Journal Club via CINAHL Plus with full text- filtered within the past 5 years, peer reviewed
• Searched “acp journal” and “hypothermia therapy”
• Lang, E. S. (2010). Review: Therapeutic hypothermia improves neurologic outcome and survival to discharge after cardiac arrest. ACP Journal Club, 152(2), 1.
4. Level IV- Randomized Control Trials- 26 results showed up at this level. The results at this level described areas of observational studies from randomized trials.
• MEDLINE with full text- filtered within the past 5 years, and research control
• Sayre, M., Cantrell, S., White, L., Hiestand, B., Keseg, D., & Koser, S. (2009). Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival. Prehospital Emergency Care: Official Journal Of The National Association Of EMS Physicians And The National Association Of State EMS Directors, 13(4), 469-477. doi:10.1080/10903120903144965
5. Level V- Cohort Study- 5 results showed up at this level. The results at this level described a cohort study that was done with a specific group over a specific time. The article below describes the data collected from a cohort study done on infants who underwent hypothermia therapy for moderate to severe neonatal encephalopathy.
• MEDLINE with full text- unfiltered
• Chalak, L., DuPont, T., Sánchez, P., Lucke, A., Heyne, R., Morriss, M., & Rollins, N. (2014). Neurodevelopmental outcomes after hypothermia therapy in the era of Bayley-III.Journal Of Perinatology: Official Journal Of The California Perinatal Association, 34(8), 629-633. doi:10.1038/jp.2014.67
6. Level VI- Case-Controlled Studies- 135 results showed up at this level. The results described the use of controlled groups that were being studied.
• CINAHL Plus with full text- unfiltered
• Matsuhashi, T., Sato, T., Aizawa, Y., & Takatsuki, S. (2010). Recurrent Torsade de Pointes during mild hypothermia therapy for a survivor of sudden cardiac arrest due to drug-induced Long-QT syndrome. Journal Of Cardiovascular Electrophysiology, 21(4), 462-463. doi:10.1111/j.1540-8167.2009.01636.x
7. Level VII- Background information/ Expert opinions- 74 results showed up at this level.
• Clinicaltrials.gov- unfiltered
• Zeiner A, Holzer M, Sterz F, Behringer W, Schörkhuber W, Müllner M, Frass M, Siostrzonek P, Ratheiser K, Kaff A, Laggner AN. Mild resuscitative hypothermia to improve neurological outcome after cardiac arrest. A clinical feasibility trial. Hypothermia After Cardiac Arrest (HACA) Study Group. Stroke. 2000 Jan;31(1):86-94.
• http://clinicaltrials.gov/ct2/show/NCT00843297?term=hypothermia+therapy+cardiac+arrest&rank=8
References
Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (Laureate Education, Inc., custom ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Walden University Library. (2012). Levels of evidence. Retrieved from http://libraryguides.waldenu.edu/evidencepyramid
