Decision fatigue is an applicable concept to healthcare psychology. Due to a lack of conceptual clarity, we present a concept analysis of decision fatigue. A search of the term “decision fatigue” was conducted across seven research databases, which yielded 17 relevant articles. The authors identified three antecedent themes (decisional, self-regulatory, and situational) and three attributional themes (behavioral, cognitive, and physiological) of decision fatigue. However, the extant literature failed to adequately describe consequences of decision fatigue. This concept analysis provides needed conceptual clarity for decision fatigue, a concept possessing relevance to nursing and allied health sciences.

Decision fatigue: A conceptual analysis:

Security fatigue has been used to describe experiences with online security. This study identifies the affective manifestations resulting from decision fatigue and the role it plays in users' security decisions. A semistructured interview protocol was used to collect data (N = 40). Interview questions addressed online activities; computer security perceptions; and the knowledge and use of security icons, tools, and terminology. Qualitative data techniques were used to code and analyze the data identifying security fatigue and contributing factors, symptoms, and outcomes of fatigue. Although fatigue was not directly part of the interview protocol, more than half of the participants alluded to fatigue in their interviews. Participants expressed a sense of resignation, loss of control, fatalism, risk minimization, and decision avoidance, all characteristics of security fatigue. The authors found that the security fatigue users experience contributes to their cost-benefit analyses in how to incorporate security practices and reinforces their ideas of lack of benefit for following security advice.

Security Fatigue

Dear editor, We have read with exceptional interest the manuscript of Lin Ding et al. because the use of noninvasive ventilation (NIV) and high flow-nasal cannula (HFNC) combined with the prone position (PP) could avoid intubation of patients with acute respiratory distress syndrome (ARDS) [1]. The prone position is associated with a decrease in mortality in patients with ARDS, as demonstrated by Guerin in 2013 and the Formal Guide to the treatment of ARDS recommended the use of the PP for at least 16 h a day when P/F < 150 (moderate-severe ARDS) [2]. A study with a sample of 20 healthy patients shows an increase in lung volume at the end of expiration (LVEE) and a decrease in respiratory rate using HFNC demonstrated by electrical impedance tomography and that a PP resulted a more homogeneous distribution of the LVEE than the supine position [3]. The etiology of ARDS reported by Ding and colleagues [1] includes infectious pathologies in all cases, demonstrating that an early PP strategy with HFNC or NIV is safe and effective in patients with moderate ARDS and with SpO2 > 95% in which intubation could be avoided. The mortality of ARDS associated with infectious etiology (pneumonia, influenza, and sepsis) is considerably higher (35.1% for pulmonary infection and 28.1% for sepsis) than that reported for noninfectious causes such as pneumonitis (6.4%) and trauma (2.5%) [4]; therefore, an early PP strategy combined with HFNC could theoretically be effective in these cases, even with P/F < 100. We present a multicenter retrospective series of 6 cases of patients with severe ARDS with a noninfectious etiology compiled in 2017 and 2018 in hospitals of the 2nd level of care to which the PP was applied with HFNC or NIV. The PP was applied for 2–3 h every 12 h for 2 days, and in 3 cases, it was possible to avoid intubation; the causes were thoracic trauma with pulmonary contusions, lupus pneumonitis, bone marrow transplantation, and atelectasis of unknown cause (Table 1) (Fig. 1). The PP with HFNC or NIV seems to be a promising strategy to avoid intubation and its complications in patients with severe ARDS of noninfectious etiology, and a randomized controlled study is required to assess its safety and efficacy. The results of the OPTIPRONE study on the use of PP combined with HFNC in patients with ARDS with PaO2/FiO2 < 200 [5] are expected.

/pdf/prone-positioning-combined-with-high-flow-nasal-cannula-in-p3u00ae9vj.pdf

Prone positioning combined with high-flow nasal cannula in severe noninfectious ARDS

Background: Prone positioning for acute respiratory distress syndrome (ARDS) has no impact on mortality despite significant improvements in oxygenation. However, a recent trial demonstrated reduced mortality rates in the prone position for severe ARDS. We evaluated effects of prone position duration and protective lung strategies on mortality rates in ARDS. Methods: We extensively searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials (RCTs) reporting on prone positioning during acute respiratory failure in adults for inclusion in our meta-analysis. Results: Eight trials met our inclusion criteria, Totals of 1,099 and 1,042 patients were randomized to the prone and supine ventilation positions. The mortality rates associated with the prone and supine positions were 41% and 47% [risk ratio (RR), 0.90; 95% confidence interval (CI), 0.82-0.98, P=0.02], but the heterogeneity was moderate (P=0.01, I 2 =61%). In a subgroup analysis, the mortality rates for lung protective ventilation (RR 0.73, 95% CI 0.62-0.86, P=0.0002) and duration of prone positioning >12 h (RR 0.75, 95% CI 0.65-0.87, P<0.0001) were reduced in the prone position. Prone positioning was not associated with an increased incidence of cardiac events (RR 1.01, 95% CI 0.87-1.17) or ventilator associated pneumonia (RR 0.88, 95% CI 0.71-1.09), but it was associated with an increased incidence of pressure sores (RR 1.23, 95% CI 1.07-1.41) and endotracheal dislocation (RR 1.33, 95% CI 1.02-1.74). Conclusions: Prone positioning tends to reduce the mortality rates in ARDS patients, especially when used in conjunction with a lung protective strategy and longer prone position durations. Prone positioning for ARDS patients should be prioritized over other invasive procedures because related life-threatening complications are rare. However, further additional randomized controlled design to study are required for confirm benefit of prone position in ARDS.

https://ir.ymlib.yonsei.ac.kr/bitstream/22282913/139965/1/T201501152.pdf

The efficacy and safety of prone positioning in adults patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials

Acute respiratory distress syndrome (ARDS) has a reported incidence of 34–43% in ventilated burn patients and is associated with a mortality of 59% in the severe form. The use and experience with extracorporeal membrane oxygenation (ECMO) in burn patients developing ARDS are still limited. We present our results and discuss the significance of ECMO in treating burn patients. A retrospective analysis of burn patients treated with ECMO for ARDS between January 2017 and January 2019 was performed. Demographic, clinical, and outcome data were collected and analyzed. Eight burn patients were treated at our institution with ECMO in the designated time period. Of these, all but one patient had inhalation injury, burn percentage of TBSA was 37 ± 23%, ABSI score was 8.4 ± 2, and R-Baux-score was 98 ± 21. Seven patients developed severe ARDS and one patient moderate ARDS according to the Berlin classification with a PaO2/FiO2 ratio upon initiation of ECMO therapy of 62 ± 22 mmHg. ECMO duration was 388 ± 283 h. Three patients died from severe sepsis while five patients survived to hospital discharge. ECMO is a viable therapy option in burn patients developing severe ARDS and can contribute to survival rates similar to ECMO therapy in non-burn-associated severe ARDS. Consequently, patients with severe respiratory insufficiency with unsuccessful conventional treatment and suspected worsening should be transferred to burn units with the possibility of ECMO treatment to improve outcome.

/pdf/extracorporeal-membrane-oxygenation-for-acute-respiratory-r7h2npw2zy.pdf

Extracorporeal membrane oxygenation for acute respiratory distress syndrome in burn patients: a case series and literature update

When thinking is hard: managing decision fatigue..

Objectives
The objectives were to review published reports of secondary neurologic deterioration in the early stages of care after blunt spinal trauma and describe its nature, context, and associated risk factors.

Methods
The authors searched the MEDLINE, EMBASE, and CINAHL databases for English-language studies. Cases were included meeting the criteria age 16 years or older, nonpenetrating trauma, and experiencing neurologic deterioration during prehospital or emergency department (ED) care prior to definitive management (e.g., discharge, spinal clearance by computed tomography, admission to an inpatient service, or surgical intervention). Results were qualitatively analyzed for characteristics and themes.

Results
Forty-one qualifying cases were identified from 12 papers. In 30 cases, the new deficits were apparently spontaneous and were not detected until routine reassessment. In 12 cases the authors did attribute deterioration to temporally associated precipitants, seven of which were possibly iatrogenic; these included removal of a cervical collar, placement of a halo device, patient agitation, performance of flexion/extension films, “unintentional manipulation,” falling in or near the ED, and forced collar application in patients with ankylosing spondylitis. Thirteen cases occurred during prehospital care, none of them sudden and movement-provoked, and all reported by a single study.

Conclusions
Published reports of early secondary neurologic deterioration after blunt spinal trauma are exceptionally rare and generally poorly documented. High-risk features may include altered mental status and ankylosing spondylitis. It is unclear how often events are linked with spontaneous patient movement and whether such events are preventable.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/acem.12765

Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature.

Acute respiratory distress syndrome (ARDS) is a common sequela of severe burns and inhalation injury. The massive inflammatory reaction that follows deep burn injury, compounded by episodes of sepsis and organ dysfunction, predisposes patients to the development of ARDS. Prone positioning as a means of improving gas exchange has shown benefit in refractory cases of ARDS, but it is not well described in the burn population. We present a case report of a patient with severe ARDS who underwent prone positioning, review the relevant literature, and provide a discussion of practical concerns.

Brandon Oto

Papers

When thinking is hard: managing decision fatigue..

Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature.

Prone Positioning of the Burn Patient With Acute Respiratory Distress Syndrome: A Review of the Evidence and Practical Considerations.