A randomized clinical trial of an intervention to relieve thirst and dry mouth in intensive care unit patients

The Effect of Thirst, Dry Mouth, Mouth Taste, and Bad Mouth Odor in Laparoscopic Cholecystectomy Patients: A Randomized Controlled Trial

PURPOSE

This study aimed to determine the effect of menthol ice application on thirst, dry mouth, mouth taste, and bad mouth odor in patients who underwent laparoscopic cholecystectomy in the postoperative period.

DESIGN

The study was conducted as a randomized controlled trial with an experimental design.

METHODS

The study sample consisted of 90 patients who underwent laparoscopic cholecystectomy and met the inclusion criteria. Patients were divided into three groups by randomization program. Patients in the menthol ice and ice popsicle (ice prepared with drinking water only) group were administered menthol ice/ice popsicle (10 mL) twice at 20 minutes intervals. Patients in the control group did not receive any intervention. Routine practices of the clinic were performed by the nurses of the general surgery clinic. Postoperative thirst intensity, severity of dry mouth, bad taste, and bad odor in the mouth were evaluated at 0, 20, and 40 minutes.

FINDINGS

No statistically significant difference was found between the sociodemographic and clinical characteristics of the patients in the control group, menthol ice group, and ice popsicle group (P > .05). A statistically significant difference was found between the 3 groups in terms of thirst intensity and severity of dry mouth at times at the 20th and 40th minutes after the application (P < .01). We found a statistically significant difference between the bad taste and bad odor sensation scores of the patients in the control and intervention groups at the 20th and 40th minutes after the application (P < .05).

CONCLUSIONS

The study concluded that menthol ice and ice popsicle application are effective strategies to reduce the intensity of thirst, severity of dry mouth, bad taste, and bad odor in postoperative patients.

Oral care practices for patients in intensive care unit: A systematic review

OBJECTIVES

To critically analyse and discuss oral hygiene protocols in the hospital environment in patients admitted to the ICU, through a systematic review of the literature.

METHODS

The electronic search was performed on Pubmed, Cochrane, Web of Science and Google Scholar databases. The indexing keywords according to the PRISMA protocol were: 'hospital dentistry', 'oral health', 'oral care' and 'intensive care unit'.

RESULTS

The initial search resulted in a total of 2671 articles. Pre-selection based on titles led to the exclusion of 2510 articles and the remaining 36 were selected for abstract reading. After analysing the eligibility of the articles, eight studies were included in the review and submitted to qualitative analysis.

CONCLUSION

It can be concluded that cleaning with a soft bristle brush, use of chlorhexidine and lip moisturizing are methods commonly used in dental care actions in patients hospitalized in intensive care units.

Effects of cold spray on thirst, frequency of oral care, and pain of general surgery intensive care unit patients

This study aims to investigate the effects of intraoral cold water spray on thirst, frequency of oral care and postoperative period pain at surgical incision site in patients having abdominal surgery. The study was carried out as a randomized controlled trial, registered under Clinical Trial Number: NCT05940818. The study involved 110 participants, divided equally into two groups (n = 55): the experimental group and the control group. Data were collected using patient information form, NRS, Intensive Care Oral Care Frequency Assessment Scale (ICOCFAS) and Visual Analog Scale (VAS). The severity of thirst at 1st, 8th, 16th h of post-operative period (p < 0.01) and the frequency of oral care application at 16th h were statistically significantly decreased in the experimental group when compared to the control group (p < 0.01).There wasn't statistically significant difference between the patients in the experimental and control groups in terms of pain at surgical incision site (p > 0.05). The patient's thirst and need for frequent oral care in the postoperative period were reduced by the application of a cold water spray. In patients undergoing abdominal surgery, the use of cold water spray application may be recommended to reduce thirst and the need for frequency of oral care application.

Timing of early water intake post-general anaesthesia: a systematic review and meta-analysis

BACKGROUND

Early water intake has gained widespread attention considering enhanced recovery after surgery (ERAS). In the present systematic evaluation and meta-analysis, we assessed the effects of early water intake on the incidence of vomiting and aspiration in adult patients who received general anaesthesia on regaining consciousness during the resuscitation period.

OBJECTIVE

To systematically analyse the results of randomised controlled trials on early postoperative water intake in patients who underwent different types of surgery under general anaesthesia, both at home and abroad, to further explore the safety and application of early water intake and provide an evidence-based foundation for clinical application.

DESIGN

Systematic review and meta-analysis.

METHODS

To perform the systematic evaluation and meta-analysis, we searched the Web of Science, CINAHL, Embase, PubMed, Cochrane Library, Sinomed, China National Knowledge Infrastructure (CNKI), Wanfang, and Vipshop databases to identify randomised controlled trial studies on early water intake in adult patients who received general anaesthesia.

RESULTS

Herein, we included 10 publications with a total sample size of 5131 patients. Based on statistical analysis, there was no statistically significant difference in the incidence of vomiting (odds ratio [OR] = 0.81; 95% confidence interval [CI] [0.58-1.12]; p = 0.20; I-squared [I2] = 0%) and aspiration (OR = 0.78; 95%CI [0.45-1.37]; p = 0.40; I2 = 0%) between the two groups of patients on regaining consciousness post-general anaesthesia.

CONCLUSION

Based on the available evidence, early water intake after regaining consciousness post-anaesthesia did not increase the incidence of adverse complications when compared with traditional postoperative water abstinence. Early water intake could effectively improve patient thirst and facilitate the recovery of gastrointestinal function.

The Effect of Cold Oral Applications in the Management of Postoperative Thirst: A Systematic Review

PURPOSE

Thirst is one of the most bothersome symptoms experienced by surgical patients. Effective thirst intervention and management in the Post Anesthesia Care Unit (PACU) and hospital wards is critical because patients are less sedated and more aware than in the past. There is a need to review the literature on the identification and management of thirst in the inpatient and PACU settings. The aim of this systematic review was to examine the available evidence on the effectiveness of oral cold applications on thirst in postoperative patients.

DESIGN

This was a systematic review study. Articles in PUBMED, Web of Science, ScienceDirect, TÜBİTAK-ULAKBİM, and TRDizin databases between January 2008 and January 2023 that included oral cold applications to relieve the thirst of patients in the postoperative period were included.

METHODS

The PICOT-SD (Patients Interventions Comparison Outcome Time-Study Design) method was used as an eligibility criterion for inclusion in the study. The eligibility criteria included that the articles were written in English-Turkish and within the target dates, the studies included nursing interventions, the primary outcome of the studies was thirst, and the study sample included postoperative patients. The risk of bias was assessed using the RoB2 tool developed by Cochrane.

FINDINGS

A total of 254 articles were retrieved from the databases using the specified keywords. 244 articles did not meet the study criteria: 30 were excluded because they were not interventional studies, 61 were not conducted in a postoperative population, 56 were duplicates, and 79 were not on a related topic. A total of 10 studies consisting of randomized controlled trials and quasi-experimental articles met the criteria for our review. Oral cold applications effectively reduced the thirst rate of postoperative patients and improved their health-related quality of life. The intervention has also been shown to reduce other anesthesia-related complications.

CONCLUSIONS

This systematic review concluded that cold oral applications have promising effects on thirst, dry mouth, and health-related quality of life. Cold oral applications are cost-effective and suitable for large-scale health care applications.

Effects of Oral Cryotherapy on Anticipatory, and Acute Nausea and Vomiting in Patients With Breast Cancer Undergoing Adjuvant Chemotherapy: A Randomized Controlled Clinical Trial

PURPOSE

To determine the effects of oral cryotherapy (OC) on the anticipatory, and acute nausea and vomiting of patients with breast cancer who are receiving adjuvant chemotherapy.

PATIENTS AND METHODS

Seventy eligible patients with breast cancer were assigned to 2 groups by stratified randomization. This parallel grouped, randomized, clinical trial used the ice application protocol. OC application for an intervention group (IG, n = 35) was performed in 3 stages: i) instructions on by the investigator at the hospital; ii) the implementation accompanied by the investigator at the hospital; iii) the individual application of at home by patients. The IG had been doing the application for 12 weeks. The patients in the control group (CG, n = 35) received standard care. Additionally, Rhodes Index of Nausea Vomiting, and Retching, and EORTC QLQ-C30 Life Quality Index were conducted on the first (T1 = cycle 1 day 0), second (T2 = cycle 2 day 21), third (T3 = cycle 3 day 42), and fourth (T4 = cycle 4 day 63) cycles of adjuvant chemotherapy.

RESULTS

The anticipatory nausea scores in the T2 and T4, IG were significantly lower than the CG (P < .05). In the T3, all symptom sub-dimensions except symptom occurrence (t = -0,48; P = .63) of the IG were significantly lower than those of the CG (P < .05). In the T1, T2, T3, and T4, acute nausea, acute vomiting, acute retching, and anticipatory retching scores, were significantly lower than the CG (P < .05).

CONCLUSION

OC alone was effective and safe for the treatment of nausea and vomiting. The results of this study showed the clinical applicability of OC in the management of nausea and vomiting.

Origins of thirstiness sensation and current food solutions

The sensation of thirstiness is the desire to drink water. In certain situations, the ingestion of liquid water can be restricted. As a result, thirstiness is not relieved, resulting in an uncomfortable and distressing situation. The present review describes thirstiness and hydration, the food products and beverages that cause thirstiness, and the beverages and food products currently available to quench thirstiness in individuals with restricted access to liquid ingestion. It also discusses how to measure the effectiveness of calming thirstiness. To diminish thirstiness distress, different alternatives to liquids are proposed. Individuals with swallowing disorders are given thickened water, individuals with restricted water ingestion are given ice cubes or ice popsicles of different flavors, and sportspeople are given energy gels. However, current beverage solutions seem not to relieve thirst fully, although some stimuli like iced water, flavors (especially lemon and mint), or acids seem to work better than plain stimuli and could be added to existing products. Therefore, there is still a need to incorporate these strategies into beverage and food formulations and to test their effectiveness.

Self-reported symptoms experienced by intensive care unit patients: a prospective observational multicenter study

PURPOSE

The purpose of this study is to describe the prevalence, intensity and distress of five symptoms in intensive care unit (ICU) patients and to investigate possible predictive factors associated with symptom intensity.

METHODS

This is a prospective cohort study of ICU patients. A symptom questionnaire (i.e., Patient Symptom Survey) was used to describe the prevalence, intensity and distress of pain, thirst, anxiousness, tiredness, and shortness of breath over seven ICU days. Associations between symptom intensity and possible predictive factors were assessed using the general estimating equation (GEE) model.

RESULTS

Out of 603 eligible patients, 353 (Sample 2) were included in the present study. On the first ICU day, 195 patients (Sample 1) reported thirst as the most prevalent symptom (66%), with the highest mean intensity score (6.13, 95% confidence interval (CI) [5.7-6.56]). Thirst was the most prevalent (64%) and most intense (mean score 6.05, 95%CI [5.81-6.3]) symptom during seven days in the ICU. Anxiousness was the most distressful (mean score 5.24, 95%CI [4.32-6.15]) symptom on the first day and during seven days (mean score 5.46, 95%CI [4.95-5.98]). During seven days, analgesic administration and sepsis diagnosis were associated with increased thirst intensity. Older age and being mechanically ventilated were associated with decreased pain intensity, and analgesic administration was associated with increased pain intensity. Family visits and female gender were associated with increased intensity of anxiousness and shortness of breath, respectively.

CONCLUSIONS

Self-reporting ICU patients experienced a high and consistent symptom burden across seven days. Certain variables were associated with the degree of symptom intensity, but further research is required to better understand these associations.

A Novel Approach to Managing Thirst and Dry Mouth in Palliative Care: A Prospective Randomized Cross-Over Trial

CONTEXT

Thirst and xerostomia are significant and highly distressing symptoms experienced by patients receiving palliative and end-of-life care.

OBJECTIVES

Determine a reduction of thirst intensity and perceptions of dry mouth on a numerical scale following both the experimental intervention (mini mint ice cubes) and control (plain ice chips).

METHODS

Cross-over Randomized Controlled Trial (RCT) to assess the effectiveness of novel intervention in the treatment of dry mouth and the sensation of thirst in palliative care patients.

RESULTS

Patients rated the severity of their symptoms of dry mouth and thirst using a numeric rating scale (NRS). On commencing the study and preintervention, all patients suffered severe dry mouth and thirst (≥5/10). Mint and plain ice cubes produced improvement of symptoms immediately after interventions. Results from dry mouth ratings show, a decrease of 1.6 points for plain ice cubes (P < 0.0001), on average, ratings for mint ice cubes decreased 3.7 (P < 0.0001). For the sensation of thirst, the plain ice cube intervention group rating decreased 1.7 points (P < 0.006), ratings for mint ice cubes decreased 3.4 points (P < 0.0001). The average decrease in dry mouth and thirst intensity scores from preintervention to postintervention were significantly greater for mint ice cubes (P < 0.05) and 86.6% of patients preferred mint ice cubes.

CONCLUSION

This trial found that while usual mouth care and the intervention were both able to reduce the intensity of dry mouth and the sensation of thirst, the mint intervention had a greater response.

Anticholinergic Burden and Xerostomia in Critical Care Settings

BACKGROUND

Although previous studies have established the association of medications with anticholinergic adverse effects and xerostomia, anticholinergic burden and xerostomia in critical care settings are poorly characterized. The objective of this study was to determine the impact of medication burdens associated with anticholinergic adverse effects, particularly the occurrence of xerostomia (dry mouth) in a critical care setting. In addition, this study explored the correlation between the timing of the first instance of xerostomia and the administration timing of medication known to have anticholinergic adverse effects.

METHODS

A retrospective case-control study was used with the MIMIC (Medical Information Mart for Intensive Care) III database. The MIMIC-III clinical database is a publicly available, deidentified, health-related database with more than 40 000 patients in critical care units from 2001 to 2012. Cases of xerostomia (n = 1344) were selected from clinical notes reporting "dry mouth," "xerostomia," or evidence of pharmacological treatment for xerostomia; control (n = 4032) was selected using the propensity analysis with 1:3 matching on covariates (eg, age, sex, race, ethnicity, and length of stay). The anticholinergic burden was quantified as the cumulative effect of anticholinergic activities using the Anticholinergic Burden Scale.

RESULTS

Anticholinergic burden significantly differed between xerostomia patients and control subjects (P = .04). The length of stay was a statistically significant factor in xerostomia. The probability of developing the symptom of xerostomia within 24 hours was .95 (95%) for patients of xerostomia.

CONCLUSIONS

Anticholinergic Burden Scale is associated with xerostomia in the critical care setting, particularly within 24 hours after admission. It is crucial to carefully evaluate alternative options for medications that may have potential anticholinergic adverse effects. This evaluation should include assessing the balance between the benefits and harms, considering the probability of withdrawal reactions, and prioritizing deprescribing whenever feasible within the initial 24-hour period.

Use of a menthol popsicle in managing postoperative thirst in patients undergoing radical prostatectomy: A randomized clinical trial

Background and aim: Thirst is a real bother that most patients feel in the immediate postoperative period when they still need to fast. Many approaches regarding symptomatic relief strategies have been described in the literature, but strategies with cold water and/or menthol are effective in quenching thirst, as they act on pre-absorptive mechanisms. This study aims to evaluate the effectiveness of using menthol popsicles in relieving postoperative thirst in patients undergoing radical prostatectomy. Material and methods: This is a randomized controlled clinical trial with a quantitative approach. In all, 44 patients were evaluated in the immediate postoperative period of radical prostatectomy, with the intensity and discomfort of thirst being evaluated initially and subsequently. The study consisted of two groups: (1) the placebo group, popsicles without the addition of menthol substrates and (2) the experimental group, popsicles with the addition of 0.05% minty substrates. Results: The results demonstrate that the sociodemographic and clinical characteristics were homogeneous at the α = 5% significance level, except the occupation variable. The test detected changes in the intensity and discomfort of thirst in relation to the pre- and post-intervention times for the primary outcome when the groups were analyzed separately and for the interaction of the group versus time, there was no statistical difference between the groups. Conclusion: It was possible to prove that both the menthol popsicle and the popsicle without the addition of menthol were effective in relieving postoperative thirst in patients undergoing radical prostatectomy, but there was no statistically significant difference when comparing the two groups. Trial registration: The Brazilian Registry of Clinical Trials (RBR-8c3chr7).

Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU

Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.

Relieving Perception of Thirst and Xerostomia in Patients with Palliative and End-of-life Care Needs: A Rapid Review

CONTEXT

Thirst and dry mouth are interlinked symptoms that frequently cause significant distress for patients with life-limiting conditions.

OBJECTIVES

The objective of this rapid review was to identify and synthesize effective interventions that relieve perceptions of thirst and dry mouth of patients with palliative care and end-of-life care needs.

METHODS

Eligible studies were undertaken in clinical settings, with patients experiencing thirst-related distress and/or dry mouth. This review of peer-reviewed literature was conducted following aspects of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. The main outcomes of interest were: 1) efficacy of thirst and dry mouth interventions for patient, and 2) patient, caregiver, and staff acceptability and satisfaction of the interventions. Scientific journal articles were retrieved through searches in electronic databases of MEDLINE (Ovid), CINAHL (EBSCO), and AgeLine (EBSCO).

RESULTS

Eleven studies were included for analysis and synthesis of the results. Most studies either focused on a dry mouth intervention or reported dry mouth outcomes within a broader thirst intervention (n = 9/11 studies). Standard oral care was the common intervention type (n = 5/11). All but one dry mouth intervention reported statistical improvement in outcomes of interest. All studies that reported on thirst were conducted in an Intensive Care Unit (ICU) setting (n = 4/4). No studies specifically addressed thirst in patients in specialist palliative care settings.

CONCLUSION

Evidence from this review suggests that thirst interventions established within the ICU setting may prove effective for treatment of terminally ill patients receiving specialist palliative care.

Development of the Thirst Discomfort Scale: A Validity and Reliability Study

BACKGROUND

Thirst is a sensation associated with a dry mouth and the desire or craving to drink water. Surgical patients are among those hospitalized individuals who are at high risk of developing both osmotic and hypovolemic thirst.

OBJECTIVES

To develop a new measurement tool for evaluating the thirst-related discomfort of surgical patients and to assess its validity and reliability.

METHODS

The study population consisted of patients admitted to the surgical clinics of a research hospital in Turkey between January and March 2022. The new measurement tool was developed in several stages: a pilot implementation phase with 51 patients and the main implementation phase with 198 patients. Data were collected by means of face-to-face interviews with patients. Exploratory factor and confirmatory factor analyses were performed using IBM SPSS Statistics, version 22, and IBM SPSS Amos.

RESULTS

The final Thirst Discomfort Scale consisted of 12 items in 3 subdimensions. The Cronbach α values of the scale subdimensions ranged from 0.787 to 0.848, and the Cronbach α value for the scale as a whole was 0.886. The scale explained 66.237% of the total variance of the data.

CONCLUSION

The Thirst Discomfort Scale consisting of 12 items and 3 subdimensions is a valid and reliable measurement tool for evaluating thirst-related discomfort of surgical patients.

Effect of sterile ice water versus menthol spray on thirst symptoms of fasted children in the intensive care unit: A prospective cohort study

BACKGROUND

Thirst is a very common symptom in fasted children in intensive care unit (ICU). This study aimed to evaluate the effect of sterile ice water versus menthol spray in ICU fasted children, to provide insights to the clinical care of fasted children.

METHODS

The children admitted to the ICU of our hospital from June 1, 2021 to August 31, 2022 and needed to fast were included. Children were randomly assigned to the ice water group or menthol group. We evaluated and compared the thirst distress scale (TDS), oral mucosa wetness scale (OMWS), children medical fear scale (CMFS), numerical rating scale (NRS), unstimulated whole saliva (UWS) flow rate between 2 groups.

RESULTS

A total of 139 children were included, involving 69 children in ice water group and 70 children in menthol group. There were no significant differences in the baseline characteristics, TDS, OMWS, OMWS, CMFS, and NRS score, UWS flow rate before intervention between ice water group and menthol group (all P > .05). After intervention, the TDS, OMWS, NRS score of menthol group was statistically less than that of ice water group (all P < .05), the UWS flow rate of menthol group was statistically higher than that of ice water group (P = .034).

CONCLUSIONS

Compared with ice water spray, menthol spray may be more beneficial to relieve the thirst and increase the comfort in ICU fasted children. Future studies with larger sample size and rigorous design are needed to evaluate the effects and safety of ice water and menthol spray in the nursing care of children.

Prevalence of and risk factors for thirst in the intensive care unit: An observational study

AIM AND OBJECTIVES

This study investigated the incidence of thirst and contributing factors in intensive care unit (ICU) patients by analysing differences in physiologic, psychological, and disease- and environment-related parameters in ICU patients with vs without thirst.

BACKGROUND

Little is known about the factors that influence thirst, and there are no standardised methods for identifying at-risk patients in the ICU. Previous studies generalised the risk of thirst in ICU patients because of a lack of data on relevant variables. Here, we examined the factors contributing to thirst based on symptom management theory.

DESIGN

Prospective descriptive design.

METHODS

Physiologic, psychological, disease-related and environment-related data were collected for 301 patients from 4 ICUs (medical, surgical, cardiac and emergency ICUs) of a hospital from 15 December 2017-10 July 2019 through a screening interview, questionnaires and from electronic medical records. The data were analysed with descriptive statistics, the t-test and chi-squared test, and by logistic regression. Binary stepwise logistic regression was used to identify thirst-associated factors. The findings are reported according to the STROBE checklist for cross-sectional studies.

RESULTS

In total, 210/301 (69.8%) ICU patients experienced thirst. Risk factors were nil per os order (odds ratio [OR] = 4.10, 95% confidence interval [CI]: 1.44-11.69), surgery (OR = 2.96, 95% CI: 1.11-7.93), high glucose (OR = 3.36, 95% CI: 1.01-11.17) and greater disease severity (OR = 1.13, 95% CI: 1.02-1.24).

CONCLUSION

Thirst is common in ICU patients. Timely detection of patients' thirst and identification of those at high risk by ICU nurses can ensure the implementation of effective and safe interventions.

RELEVANCE TO CLINICAL PRACTICE

The results of this study highlight the need to evaluate thirst symptoms in patients with severe disease and develop relief strategies for fasting, perioperative, and hyperglycaemic patients and others who are at high risk of thirst.

Effect of high-flow nasal cannula therapy on thirst sensation and dry mouth after extubation: A single-centre prospective cohort study

OBJECTIVES

Little is known regarding the association between the type of oxygen therapy and thirst sensation after extubation. This study aimed to assess the effect of post-extubation high-flow nasal cannula on thirst.

RESEARCH METHODOLOGY/DESIGN AND SETTING

This single-centre prospective cohort study included 100 ventilated patients. After extubation, patients received either high-flow nasal cannula (n = 19) or conventional oxygen therapy (n = 81). Thirst intensity was evaluated by a self-reporting numeric rating scale, and dry mouth was defined objectively using an oral moisture checking device.

MAIN OUTCOME MEASURES

The primary outcome was thirst intensity 24 hours post-extubation. Secondary outcomes were thirst intensity at 4 hours post-extubation and prevalence of dry mouth at 4 hours and 24 hours post-extubation.

RESULTS

At 24 hours post-extubation, the median (interquartile range) thirst intensity was 5 (1, 7) in the high-flow nasal cannula group and 5 (4, 6) in the conventional oxygen group. After adjustment, high-flow nasal cannula therapy was significantly associated with lower thirst intensity (adjusted odds ratio, 0.14; 95 % confidence interval (CI) 0.04-0.49; P = 0.002). At 4 hours post-extubation, high-flow nasal cannula was also associated with lower thirst intensity (adjusted odds ratio, 0.19; 95 % CI, 0.06-0.60; P = 0.005). The number of patients with dry mouth was not significantly different between the two groups (high-flow vs conventional oxygen therapy, 42.1 % vs 30.9 % [4 hours after extubation]; 47.4 % vs 34.6 % [24 hours after extubation]).

CONCLUSIONS

High-flow nasal cannula therapy was associated with lower thirst intensity than conventional oxygen therapy following extubation. However, there was no significant difference in the prevalence of dry mouth.

Comparison of the effect of psychosocial skills training on acute and chronic musculoskeletal pain intensity: The effectiveness of early intervention in the reduction of acute musculoskeletal pain

BACKGROUND

Pain, as a psychological experience, is caused by complex interactions among sensory-discriminative, motivational-affective, and cognitive-evaluative dimensions. The psychosocial approach is one of the important approaches in managing musculoskeletal pain in patients. Therefore, this study aimed to determine and compare the effects of psychosocial skills training on pain intensity in patients with acute and chronic musculoskeletal pain.

METHODS

In this quasi-experimental study, 64 patients with acute and chronic musculoskeletal pain were selected using convenience sampling. Both groups received psychosocial training in pain management in groups of 8-10 people over six 1-h sessions. The data were collected at baseline, after the intervention, and 3 months later using a numerical rating scale (NRS). Then, the data were entered into the SPSS 22 software and were analysed using descriptive and inferential statistics.

RESULTS

In this study, the mean age of the participants was 50.10 ± 10.63 years and 60.9% of them were female. Based on the results, time had a significant effect on pain intensity (p < 0.001), but the effect of group on pain intensity was not statistically significant (p = 0.07). The group × time effect on pain intensity was also statistically significant (p < 0.001).

CONCLUSION

Psychosocial training had a positive impact on the reduction of pain among the patients with acute and chronic musculoskeletal pain. Additionally, the training was more effective in patients with acute pain due to early training. These findings can help healthcare providers in the field of musculoskeletal pain management, especially in patients with acute pain.

Efficacy and Safety of Oral Hydration 1 Hour After Extubation of Patients Undergoing Cardiac Surgery: A Randomized Controlled Trial

BACKGROUND

Thirst is one of the most common and uncomfortable symptoms in patients after cardiac surgery. The postextubation time for early oral hydration (EOH) remains unclear, and there is a lack of studies on its safety and effectiveness.

OBJECTIVE

The aim of this study was to investigate the effects of oral hydration 1 hour after extubation on thirst, salivary pH, salivary flow, oral mucosa, halitosis, gastrointestinal adverse reactions, aspiration pneumonia, and satisfaction in patients undergoing cardiac surgery.

METHODS

Eighty-four patients who underwent cardiac surgery were randomly assigned into 2 groups, for either conventional oral hydration (COH) or EOH. The EOH group drank 30 mL of warm water 1 hour post extubation and thereafter 50 mL hourly for 4 hours. The COH group had nil per os for 4 hours after extubation. If no dysphagia was evident after 4 hours, the patients were instructed to slowly drink water. Thirst intensity was evaluated every hour before the intervention. Nausea and vomiting were recorded after drinking water. The salivary pH, unstimulated salivary flow rate, oral odor, and oral mucosal moisture were evaluated at 1 hour post extubation, immediately before the intervention, and at 4 hour post intervention. Aspiration pneumonia data were collected within 72 hours post intervention. Satisfaction was assessed before leaving the intensive care unit.

RESULTS

The scores for thirst (3.38 ± 1.04; F = 306.21, P < .001), oral mucosa (2.03 ± 0.74; P < .001), and halitosis (2.77 ± 0.63; P < .001) in the EOH group were significantly lower than those in the COH group. The EOH group had significantly higher salivary pH (6.44 ± 1.06; P < .001), unstimulated salivary flow rates (0.18 ± 0.08; P < .001), and patient satisfaction (4.28 ± 0.45; P < .001) than the COH group. Nausea and vomiting did not differ significantly between groups (P = .60). Aspiration pneumonia was not observed in either group.

CONCLUSIONS

Oral hydration 1 hour after extubation significantly alleviated thirst and stabilized the oral environment without gastrointestinal adverse reactions or aspiration pneumonia, and with increased patient satisfaction.

Study on the Efficacy and Safety of Oral Care in ICU Patients Based on Meta-Analysis

The effectiveness and safety of oral care in Intensive Care Unit (ICU) patients by meta-analysis are explored. According to the research direction of the effectiveness and safety of oral nursing in ICU patients, the corresponding literature studies are retrieved in literature databases and meta-analysis is performed. A total of 17 Chinese and English literature studies are included, and the literature has no obvious publication bias. The experimental results show that the improvement effect of dry mouth and halitosis in the improved group is significantly higher than that in the traditional group, and the dry mouth score, plaque index, and complications such as oral mucosa infection, oral mucosa damage, and halitosis are significantly reduced in the improved group, and the differences are statistically significant (P < 0.05). Improved oral care can significantly improve the symptoms of dry mouth and halitosis in ICU patients, quickly remove dental plaque and effectively reduce the incidence of complications such as halitosis, oral mucosal infection, and oral mucosal damage. Improved oral care is an effective and safe ICU nursing program.

Discomfort improvement for critically ill patients using electronic relaxation devices: results of the cross-over randomized controlled trial E-CHOISIR (Electronic-CHOIce of a System for Intensive care Relaxation)

Purpose

To assess the impact of different electronic relaxation devices on common stressful patient symptoms experienced in intensive care unit (ICU).

Methods

Sixty critically ill patients were enrolled in four relaxation sessions using a randomized cross-over design: standard relaxation (TV/radio), music therapy (MUSIC-CARE©), and two virtual reality systems using either real motion pictures (DEEPSEN©) or synthetic motion pictures (HEALTHY-MIND©). The goal was to determine which device was the best to reduce overall patient discomfort intensity (0–10 Numeric Rating Scale (NRS); primary endpoint). Secondary endpoints were specific stressful symptoms (pain, anxiety, dyspnea, thirst, and lack of rest feeling) and stress response measured by Analgesia/Nociception Index (ANI). Multivariate mixed-effect analysis was used, taking into account patient characteristics and multiple measurements.

Results

Fifty patients followed the full research protocol, and ten patients did at least one research planned session of relaxation. HEALTHY-MIND© was associated with a significant decrease in overall discomfort, the primary endpoint (median NRS = 4[2–6] vs. 2[0–5]; p = 0.01, mixed-effect model), accompanied by a significant decrease in stress response (increase in ANI, secondary endpoint; p < 0.01). Regarding other secondary endpoints, each of the two virtual reality systems was associated with a decrease in anxiety (p < 0.01), while HEALTHY-MIND© was associated also with a decrease in pain (p = 0.001) and DEEPSEN© with a decrease in lack of rest (p = 0.01). Three incidents (claustrophobia/dyspnea/agitation) were reported among 109 virtual reality sessions. Cybersickness was rare (NRS = 0[0–0]).

Conclusion

Electronic relaxation therapy is a promising, safe, and effective non-pharmacological solution that can be used to improve overall discomfort in alert and non-delirious ICU patients. Its effectiveness depends on technical characteristics (virtual reality using a synthetic imagined world versus a real world or music therapy alone without virtual reality), as well as the type of symptoms.

Electronic relaxation therapies are effective supportive care tools for improving stressful symptoms in ICU patients.

Effectiveness depends on the type of symptom and the characteristics of the devices.

Overall discomfort and adrenergic stress response are more significantly improved by virtual reality using a synthetic imagined world than using a real world or music therapy alone.

Physical oral care prevents ventilator-associated pneumonia in Vietnam: A prospective interventional study

BACKGROUND

Ventilator-associated pneumonia (VAP) has emerged as a critical issue in the intensive care unit (ICU) because of its high burden on patients and medical staff. Here, we examined the potential for reducing VAP incidence through physical oral care interventions without any medication.

METHODS

This prospective interventional study compared VAP incidence during an 8-month baseline period (usual oral care) and a 9-month intervention period (physical oral care with sponge brush) among patients who received mechanical ventilation for >48 h in a tertiary care hospital in Vietnam from 2017 to 2019. Physical oral care was provided by general ICU nurses who had been trained by dentists and infection control nurses. VAP was diagnosed using the Clinical Pulmonary Infection Score.

RESULTS

In total, 423 patients were enrolled in the baseline group and 454 patients were enrolled in the intervention group; 303 and 300 patients, respectively, were included in the analysis. Two hundred thirty-eight VAP episodes were identified: 135 (44.6%) during the baseline period and 103 (34.3%) during the intervention period. Univariate analysis revealed significant reduction of VAP occurrence in the intervention period (odds ratio = 0.65; 95% confidence interval = 0.47-0.90; P = 0.010). The incidences of VAP per 1000 ventilator-days were 63.4 (135/2128) during the baseline period and 48.4 (103/2128) during the intervention period (P = 0.038).

CONCLUSIONS

Physical oral care without any medication (e.g., chlorhexidine) reduced VAP incidence in the ICU. This method could be used to reduce VAP incidence, particularly in countries with limited medical resources.

Effects of carbohydrate use on preoperative thirst: a randomized clinical trial

OBJECTIVES

to evaluate the effectiveness of carbohydrate popsicles, carbohydrate solution, and usual care (fasting) on the intensity and discomfort of preoperative thirst.

METHODS

a randomized clinical trial with 60 preoperative patients aged between 18 and 60 years, randomized into three groups: control (fasting), carbohydrate solution (100 ml), and carbohydrate popsicle (100 ml). The outcomes were thirst intensity and discomfort.

RESULTS

there was a difference between groups for final thirst intensity (p = 0.01) and final thirst discomfort (p = 0.001). The effect size for both the Solution Group and the Popsicle Group was robust: 0.99 and 1.14, respectively.

CONCLUSIONS

the groups that received the carbohydrate fasting abbreviation showed a reduction in thirst discomfort compared to the control group. The carbohydrate popsicle proved more effective in reducing the intensity of thirst. NCT: 3.209.283.

A Narrative of Oral Care in Palliative Patients

Painful oral conditions represent a significant problem for most patients with a serious disease and palliative care needs. The main causes of such conditions may be associated with the underlying disease and its treatment, but primarily with adverse side effects of drugs. Oral conditions can lead to worsening of the illness and reduced quality of life. The objective of this narrative is to present an overview of oral care problems of this group, including present clinical practice. The evidence base for procedures and efficient products is weak. There is therefore an obvious need for research within this field.

Symptom management to alleviate thirst and dry mouth in critically ill patients: A randomised controlled trial

BACKGROUND

Critically ill patients often experience coexisting symptoms. Thirst, in particular, appears to be an important symptom, having the highest prevalence, intensity, and induction of distress, and is significantly correlated with other symptoms. However, thirst and dry mouth are not usually assessed or treated.

OBJECTIVES

The aim of the study was to demonstrate the effectiveness of an intervention bundle to relieve thirst and dry mouth.

METHODS

The present study was a randomised controlled trial in which critically ill patients were allocated to an experimental or control group. The intervention bundles, including vitamin C sprays, peppermint water mouthwash, and a lip moisturiser, were provided to the experimental group for 3 days, whereas patients in the control group were exposed to the placebo interventions, including saline sprays, 40 °C water mouthwash, and wetting the lips with water.

RESULTS

A total of 61 patients were recruited to the study; 65.6% (n = 41) were men, and the average age was 64.2 ± 16.8 years. The average decrease in thirst intensity and oral mucosa situation scores after the interventions was larger in the experimental group patients relative to controls (1.27 and 0.36 vs. 0.19 and 0.1 points, respectively; p < 0.05). Being male, scoring highly on the Acute Physiology and Chronic Health Evaluation II scale, not receiving diuretics, and having higher serum sodium levels were potential predictors of thirst and oral dryness.

CONCLUSIONS

The interventional bundle used in this study was shown to be a promising approach that can relieve thirst intensity and dry mouth, which are pervasively distressful to critically ill patients.

CLINICAL TRIAL REGISTRATION NUMBERS

The study was registered on the www.Chictr.org.cn under the identification number ChiCTR1900022873.

Thirst Interventions in Adult Acute Care-What Are the Recommended Management Options and How Effective Are They?: A Systematic Review

PURPOSE

The aim of this study was to review the scope and quality of evidence for thirst treatment in adult acute care.

METHODS

A systematic review was completed by 2 independent reviewers using MEDLINE, PubMed, BNI, EMBASE, EMCARE, and CINAHL databases and additional hand searching in June 2020. Interventions to relieve thirst for inpatients receiving acute care were included. Evidence was appraised against the levels of evidence for therapeutic studies, and a risk-of-bias assessment was completed for included studies. Outcomes are presented via narrative synthesis. Meta-analysis was planned.

RESULTS

Four studies (out of 844) were eligible reporting thirst outcomes from 611 critical care patients. Meta-analysis could not be completed because a priori criteria were not met. Two randomized controlled trials represented the highest level of evidence. Thirst assessment was completed via a self-reported scale in all reviewed works. Interventions included cold water sprays or swabs, menthol lip moisturizer, and use of humidification. Three works demonstrate reduced thirst scores; all interventions in these studies exploit cooling effects to the oropharynx with the aim of preabsorptive satiation of thirst. A humidified oxygen circuit showed a neutral response when compared with a nonhumidified circuit.

CONCLUSIONS

There is a limited but growing evidence base related to thirst treatment in the acute setting. Studies using a "bundle" of topical interventions incorporating cooling and menthol treatments showed positive effects in reducing symptom burden. Work to explore the scope of application for thirst treatment for patients unable to self-report, consideration of sustained effects, and a study of individual versus combined effects of bundle elements would be welcomed as the evidence base continues to develop.

Efeitos da utilização do carboidrato sobre a sede no pré-operatório: ensaio clínico randomizado

RESUMO Objetivos: avaliar a efetividade do picolé de carboidrato, solução de carboidrato e cuidado usual (jejum) sobre a intensidade e desconforto da sede no pré-operatório. Métodos: ensaio clínico randomizado, com 60 pacientes no pré-operatório, idade entre 18 e 60 anos, aleatorizados em três grupos: controle (jejum); solução de carboidrato (100 ml); picolé de carboidrato (100 ml). Os desfechos foram a intensidade e o desconforto da sede. Resultados: houve diferença entre os grupos quanto à intensidade final da sede (p = 0,01) e ao desconforto final da sede (p = 0,001). O tamanho do efeito tanto para o Grupo Solução quanto para o Grupo Picolé foi forte: 0,99 e 1,14, respectivamente. Conclusões: os grupos que receberam a abreviação do jejum com carboidrato apresentaram redução no desconforto da sede quando comparados ao grupo-controle. O picolé de carboidrato mostrou-se mais efetivo na redução da intensidade da sede. NCT: 3.209.283

A qualitative study of nurses' perception on patients' thirst in intensive care units

BACKGROUND

Thirst is a prevalent and intense symptom among patients in intensive care units. Occurrence of thirst in the intensive care unit cannot be avoided because of the nature of critical illnesses and their treatments like the side effects of administered medication or dehydration. In the intensive care unit, nurses have the opportunity and responsibility to prevent and reduce thirst by recognizing the different types of thirst. Thus, knowing nurses' perception on patients' thirst is crucial.

OBJECTIVES

Exploration of intensive care nurses' perception on patients' thirst.

RESEARCH DESIGN

A qualitative descriptive study.

METHODS

Data were collected from December 2020 to January 2021 and analyzed by using a phenomenographic methodology. Data were transcribed verbatim and thematic analysis was performed.

RESULTS

Sixteen nurses, in Chongqing, China, aged 25-48 years, were interviewed. Four themes emerged: (1) perceived barriers for thirst; (2) perceived signs of thirst; (3) perceived reasons of thirst; (4) perceived consequences for thirst. Overall nurses' perception of patients' thirst is poor. Nurses give a low priority and insufficient attention to the issue of thirst in intensive care patients.

CONCLUSION

Intensive care nurses' perception on thirst in patients should be evaluated and, if necessary, this issue should be given more attention in training in order to create sufficient awareness about the topic.

Thirst in patients admitted to intensive care units: an observational study

Background

Despite various studies reporting a high prevalence, reaching 71%, the sensation of thirst in intensive care unit (ICU) patients, its prevention, detection, and management, is not well known nor considered. Limited research has examined the causes of thirst in ICU patients, while it has been examined in other patient populations.

Aim

To determine the incidence and intensity of thirst in patients admitted to ICU and its association with airway devices (endotracheal tube, tracheostomy, oxygen mask), airway humidification, patients’ characteristics, and therapy (serum sodium concentration, hematocrit, fluid balance, possibility of oral hydration, and dosage of diuretics).

Methods

Patients were interviewed daily to report the presence of thirst and rate its intensity on a Numeric Rating Scale (NRS) from 0 (no thirst) –10 (intolerable thirst). Other data were obtained through direct evaluation or by consulting medical records. Patients admitted to three ICUs from May to August 2014 in a university hospital in Italy were included.

Results

A total of 220 Patients were enrolled. Thirst was found in 76.1% of patients’ observations, with a mean thirst score of 5.37. Thirst intensity was predicted by high doses of diuretics (> 100 mg/die), increasing serum sodium concentration, absence of oral hydration and the presence of xerostomia. Thirst was associated with the use of humidified Venturi mask.

Conclusions

Thirst is highly prevalent among patients in this population of intensive care patients. It would be desirable to evaluate this stressor at least daily, to eliminate or relieve this sensation.

Measuring thirst distress of patients in the intensive care unit

BACKGROUND

Thirst is one of the most intense and distressing symptoms experienced by patients in the intensive care unit (ICU), and no validated measurement tools exist. Validating a thirst measurement tool for the ICU population could be a first step in gaining a better understanding of thirst in ICU patients and aid the development and implementation of strategies regarding the prevention and control of thirst.

AIM

The objective of this study was to determine the validity and reliability of the "Thirst distress scale for patients with heart failure (TDS-HF)" in measuring thirst distress in adult ICU patients.

METHODS

Content validity was established by an expert panel consisting of ICU nurses, intensivists and five ICU patients. Concurrent validity, known-groups validity and internal consistency were determined in a consecutive sample of 56 awake and oriented ICU patients with a median age of 70 years (IQR: 57-74).

RESULTS

Content validity of the TDS-HF in the ICU population was low, with item-content validity indexes between 0.25 and 0.75. Concurrent validity was high as Spearman's correlation between TDS-HF and the numeric rating score (0-10) for thirst distress was 0.71. Internal consistency was high (Cronbach's alpha 0.78). When comparing groups, only higher blood urea nitrogen was significantly related to higher scores on the TDS-HF (P = .003).

CONCLUSION

The TDS-HF has high concurrent validity and reliability in measuring thirst distress in ICU patients. Nevertheless, questions remain regarding the applicability and content validity of the scale, which should be further explored before the TDS-HF can be used in the ICU.

RELEVANCE FOR CLINICAL PRACTICE

The TDS-HF can be used to explore thirst distress and to evaluate interventions. Individual items of the scale can be used to explore the nature of thirst distress in individual patients.

Underrecognition and undertreatment of thirst among hospitalized patients with restricted oral feeding and drinking

Thirst is distressing but overlooked by healthcare professionals. Patients experience thirst due to comorbidities, physical or cognitive limitations, and iatrogenesis. Nasogastric tube (NGT) use and nil-by-mouth(NBM) orders are common practices that can lead to thirst. However, thirst in these populations has never been formally studied. We aim to examine prevalence of recognition and treatment of thirst among NGT + NBM and NBM patients. Our descriptive study was conducted intermittently over 25 weeks, across 1.5 years, in 12 adult general medicine wards of a tertiary hospital. Cognitively intact NGT + NBM or NBM inpatients, defined as Abbreviated Mental Test score ≥ 8, were studied. One-time questionnaire was administered. Variables included: demography, co-morbidities, clinical condition, feeding route, thirst defined by thirst distress and/or intensity ≥ 3, pain, hunger and volume status. 88 NGT + NBM and NBM patients were studied. 69.3% suffered from thirst. Thirsty patients experienced significant thirst-related distress (mean score ± SD: 5.7 ± 2.5). Subjects with previous stroke and who were euvolemic tended towards thirst. 13.6% were asked about thirst by doctors or nurses. Thirst was a major source of patient distress in our study. We suggest that thirst needs to be actively identified and targeted to achieve person-centred care.

Impact of oral care on thirst perception and dry mouth assessments in intensive care patients: An observational study

OBJECTIVES

To investigate the impact of oral care on thirst perception and dry mouth assessments.

RESEARCH DESIGN

Single-centre observational study.

SETTING

Intensive care unit in a university hospital.

MAIN OUTCOME

We assessed thirst perception and dry mouth in adult patients before and after oral care. Thirst perception was assessed using a numerical rating scale and dry mouth was assessed using an oral moisture checking device and the modified Revised Oral Assessment Guide including tongue, mucous membranes and saliva.

RESULTS

Eighty-six patients were included. After oral care, thirst scores decreased by 1 (0 to 3, p < 0.01) and remained low only for one hour. Oral moisture was maintained at a normal level ≥ 27.0%, and mROAG was at a low level ≤ 4 before and after the oral care. The numerical rating score did not correlate with oral moisture (ρ = -0.01, p = 0.96) or the modified revised oral assessment guide (ρ = 0.09, p = 0.42). Among patients with thirst, 60 (70%) patients complained of thirst at the assessment timepoints, but only 17 (20%) patients complained independently.

CONCLUSION

Thirst perception was dissociated from dry mouth before and after oral care. Thirst must be frequently assessed and treated.

Concept analysis of Perioperative Thirst for the development of a new nursing diagnosis

OBJECTIVES

to analyze the perioperative thirst concept for the development of a new diagnostic structure according to NANDA International.

METHODS

a concept analysis study based on the framework proposed by Walker and Avant, instrumentalized through an integrative literature review based on SCOPUS, CINAHL, PUBMED, LILACS, and WOS. The elaboration of the diagnostic structure followed NANDA International guidelines.

RESULTS

41 studies were analyzed revealing that perioperative thirst is prevalent and intense, having visceral and behavioral attributes as the core of the concept. Antecedents indicate that surgical patients are vulnerable to thirst; and consequents 16 signs and symptoms were organized and model cases were developed. A diagnostic structure has been developed for perioperative thirst.

FINAL CONSIDERATIONS

concept analysis allowed language standardization that describes thirsty patients, helping the identification, planning of actions and communication of perioperative nursing care.

Use of Mentholated Popsicle in the Management of the Elderly Patient's Thirst in the Immediate Postoperative Period: A Randomized Controlled Trial

PURPOSE

This study aimed to compare a mentholated popsicle with usual care (absolute fasting) in the change in thirst intensity and discomfort in elderly patients in the immediate postoperative period (IPP).

DESIGN

A randomized controlled trial.

METHODS

The sample consisted of 50 elderly patients (60 years or older) in the IPP who were randomly assigned to two groups: experimental group (20 mL mentholated popsicle) and control group (usual care). The outcomes, thirst intensity and discomfort, were assessed at baseline and 20 minutes after the intervention.

FINDINGS

The mentholated popsicle presented a statistically significant (P < .001) decrease in thirst intensity and discomfort by 5.0 in the median and a Cohen's r large effect size for both outcomes. There were no adverse events or side effects.

CONCLUSIONS

The use of a mentholated popsicle decreased the intensity and discomfort of the elderly patient's thirst in the IPP.

Prevalence, risk factors, and optimized management of moderate-to-severe thirst in the post-anesthesia care unit

Post-operative thirst is common and may cause intense patient discomfort. The aims of this retrospective study conducted in a high-volume post-anesthesia care unit (PACU) were as follows: (1) to examine the prevalence of moderate-to-severe post-operative thirst—defined as a numerical rating scale (NRS) score of 4 or higher, (2) to identify the main risk factors for moderate-to-severe post-operative thirst, and (3) to maximize the efficacy and safety of thirst management through a quality improvement program. During a 1-month quality improvement program conducted in August 2018, a total of 1211 adult patients admitted to our PACU were examined. Moderate-to-severe thirst was identified in 675 cases (55.8%). The use of glycopyrrolate during anesthesia was associated with moderate-to-severe thirst (71.7% versus 66.4%, respectively, p = 0.047; adjusted odds ratio: 1.46, p = 0.013). Following a safety assessment, ice cubes, room temperature water, or an oral moisturizer were offered to patients. A generalized estimating equation model revealed that ice cubes were the most effective means for thirst management—resulting in an estimated thirst intensity reduction of 0.93 NRS points at each 15-min interval assessment (p < 0.001)—followed by room temperature water (− 0.92/time-point, p < 0.001) and the oral moisturizer (− 0.60/time-point; p < 0.001). Patient satisfaction (rated from 1 [definitely dissatisfied] to 5 [very satisfied]) followed a similar pattern (ice cubes: 4.22 ± 0.58; room temperature water: 4.08 ± 0.55; oral moisturizer: 3.90 ± 0.55, p < 0.001). The use of glycopyrrolate—an anticholinergic agent that reduces salivary secretion—was the main independent risk factor for moderate-to-severe post-operative thirst. Our findings may provide clues towards an optimized management of thirst in the immediate post-operative period.

Safety and Effectiveness of Early Oral Hydration in Patients After Cardiothoracic Surgery

BACKGROUND

Patients fast after cardiothoracic surgery because of concerns for nausea, vomiting, dysphagia, and aspiration pneumonia; fasting, however, causes thirst, a distressing symptom. To our knowledge, no studies exist to guide hydration practices in this population.

OBJECTIVE

To determine the effect of early oral hydration on adverse events and thirst in patients after cardiothoracic surgery.

METHODS

This study applied a prospective 2-group design in which 149 patients from an 18-bed cardiothoracic intensive care unit were randomized to either usual care (a 6-hour fast) or early oral hydration after extubation. The research protocol involved nurses evaluating patients' readiness for oral hydration and then offering them ice chips. If patients tolerated the ice chips, they were allowed to drink water 1 hour later.

RESULTS

Most patients (91.3%) had undergone coronary artery or valve surgery, or both. Demographic and clinical variables were similar in both groups. No significant between-group differences were found for the incidence of nausea, vomiting, or dysphagia, and no aspiration pneumonia occurred. Significantly more patients with a high thirst level were in the usual care group (81.2%) than in the early oral hydration group (56.5%; P = .002, r2 test). After adjustment for demographic and clinical variables by using logistic regression, early oral hydration was independently and negatively associated with a high thirst level (odds ratio, 0.30 [95% CI, 0.13-0.69]; P = .004).

CONCLUSION

This research provides new evidence that oral hydration (ice chips and water) soon after extubation is safe and significantly reduces thirst in particular patients.

A randomised controlled pilot trial of two interventions to manage dry mouth in pre-operative elective surgical patients

Background

Dry mouth is a common perioperative patient complaint. There are a number of treatments used for dry mouth in other settings which are effective. None have been tested previously in the perioperative setting. Interventions to Manage Dry mouth (IM DRY) compared the effect of water and a saliva substitute on mouth dryness. The primary objective was to demonstrate the feasibility of conducting a large randomised controlled trial and secondary scientific aims were to assess treatment potential efficacy.

Methods

Single blind, pilot randomised controlled trial (RCT) of 101 pre-operative elective surgical patients who were randomised to water or saliva substitute (Biotene oral rinse, GlaxoSmithKline, Australia) at a tertiary, university hospital. Dry mouth was assessed by 100 mm visual analogue scale (VAS) and 5-point Likert score.

Results

One hundred participants completed follow-up and comprised the analysis dataset. All feasibility outcomes were achieved (recruitment rate > 5 participants a week, >95% completeness of the dataset, study protocol acceptability to staff, acceptability to participants > 66% and adherence to time limits within the protocol). Mean recruitment rate was 6 participants per week. These data were 99% complete. There were no adverse side effects or complications noted. There were no concerns raised by staff regarding acceptability. Overall, there was a mean of 30 min (± SD 5 min) between delivery of the intervention and the assessment, 30 min being the target time. The difference in VAS post intervention was - 11.2 mm (95% CI - 17.3 to - 5.1 mm) for water and - 12.7 mm (95% CI - 18.7 to - 6.7 mm) for saliva substitute. The proportion of patients who had improved dry mouth increased from 52% for water to 62% for saliva substitute.

Conclusions

IM DRY successfully achieved its primary feasibility aims: recruitment rate, completeness of these, acceptability and protocol adherence. Saliva substitutes, used in the perioperative management of dry mouth, may be a simple, inexpensive, and low risk solution to help alleviate this common complaint. A large randomised controlled trial is feasible and is currently recruiting (ANZCTR 12619000132145).

Ethics and Trial registration

Northern A New Zealand Health and Disability Ethics Committee (reference 17/NTA/152). Australian New Zealand Clinical Trials Registry (Number: 12618001270202). Registered retrospectively 18 October 2018.

Effect of Comprehensive Pain Management Training Program on Awareness and Attitude of ICU Nurses

Background

Pain is one of the main complaints of many patients in intensive care units. However, most nurses and physicians are unable to properly monitor and relieve pain in these patients. Factors such as patients' inability to describe their pain and insufficient knowledge of nurses and physicians have made pain management difficult. Given that the knowledge and attitude of nurses play an important role in the effective implementation of the pain management process, this study aimed to investigate the effect of comprehensive pain management training program on the awareness and attitude of intensive care unit nurses.

Methods

This quasi-experimental single-group study was conducted in two phases (pre and post-intervention) to investigate the awareness and attitude of all nurses employed in the intensive care unit of Tehran Modarres Hospital, based on the determined inclusion and exclusion criteria. In the pre-intervention phase, the awareness and attitudes of the nurses were assessed using a questionnaire. After conducting the pain management training course, an executive program and algorithm were implemented for pain management in ICUs. Then, the nurses’ awareness and attitude toward pain management were assessed again. Finally, changes in the scores of the nurses’ awareness and attitude were analyzed by SPSS V. 22 software in two phases before and after applying the interventions using the Wilcoxon test. The relationship between some demographic variables and the level of awareness and attitude of nurses was also investigated using the Kruskal-Wallis and Mann-Whitney tests.

Results

The results of this study indicated that the mean score of the nurses’ awareness was significantly different in pre- and post-intervention phases (P < 0.05). Despite an increase in the post-intervention mean score of the nurses’ attitude (71.03), no statistically significant change was observed. Additionally, among the demographic variables, there was only a significant relationship between the nurses' job experience in ICUs and their attitudes.

Conclusions

Based on the results of this study, teaching and implementing a comprehensive program for pain management can play an effective role in promoting the nurses’ awareness. Therefore, it is proposed to use pain management models to improve the nurses' knowledge and attitude toward pain management in ICU patients.

Palliation of Thirst in Intensive Care Unit Patients: Translating Research Into Practice

BACKGROUND

Thirst is prevalent among patients in intensive care units. A research-based "thirst bundle" was shown to significantly decrease thirst in these patients.

OBJECTIVE

To implement a research-based thirst intervention performed by intensive care unit nurses and patients' family members.

METHODS

Nurses and family members were taught the thirst intervention through video training and project team reinforcement. The intervention was performed by nurses for 123 patients and by family members for 13 patients. Thirst was measured with a numeric rating scale of 0 to 10, a word scale of 0 to 3, or "yes/no" answers, whichever was easiest for the patient. Inferential statistics were used to assess changes in thirst scores over time. Also assessed were nurse and family member burden levels, family level of satisfaction, and patient enjoyment.

RESULTS

Thirst scores on the numeric rating scale decreased significantly: from a mean (SD) of 7.9 (2.0) before to 3.9 (2.7) after the intervention for nurses (P < .001); and from 9.2 (1.5) to 5.3 (2.6) for family members (n = 13; P = .002). Word scale scores also decreased significantly, from a median (interquartile range) of 3 (3-3) before to 2 (1-2) after the intervention for nurses (P < .001). Most patients (96%) reported enjoying the procedure. Median burden levels were less than 2 on a numeric rating scale of 0 to 10.

CONCLUSIONS

The palliative "thirst bundle" significantly alleviated patients' thirst and resulted in little caregiver burden. Further efforts are warranted to incorporate this intervention into intensive care unit practice.

Protocol for a multi-centered, stepped wedge, cluster randomized controlled trial of the de-adoption of oral chlorhexidine prophylaxis and implementation of an oral care bundle for mechanically ventilated critically ill patients: the CHORAL study

BACKGROUND

Routine application of chlorhexidine oral rinse is recommended to reduce risk of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Recent reappraisal of the evidence from two meta-analyses suggests chlorhexidine may cause excess mortality in non-cardiac surgery patients and does not reduce VAP. Mechanisms for possible excess mortality are unclear. The CHORAL study will evaluate the impact of de-adopting chlorhexidine and implementing an oral care bundle (excluding chlorhexidine) on mortality, infection-related ventilator-associated complications (IVACs), and oral health status.

METHODS

The CHORAL study is a stepped wedge, cluster randomized controlled trial in six academic intensive care units (ICUs) in Toronto, Canada. Clusters (ICU) will be randomly allocated to six sequential steps over a 14-month period to de-adopt oral chlorhexidine and implement a standardized oral care bundle (oral assessment, tooth brushing, moisturization, and secretion removal). On study commencement, all clusters begin with a control period in which the standard of care is oral chlorhexidine. Clusters then begin crossover from control to intervention every 2 months according to the randomization schedule. Participants include all mechanically ventilated adults eligible to receive the standardized oral care bundle. The primary outcome is ICU mortality; secondary outcomes are IVACs and oral health status. We will determine demographics, antibiotic usage, mortality, and IVAC rates from a validated local ICU clinical registry. With six clusters and 50 ventilated patients on average each month per cluster, we estimate that 4200 patients provide 80% power after accounting for intracluster correlation to detect an absolute reduction in mortality of 5.5%. We will analyze our primary outcome of mortality using a generalized linear mixed model adjusting for time to account for secular trends. We will conduct a process evaluation to determine intervention fidelity and to inform interpretation of the trial results.

DISCUSSION

The CHORAL study will inform understanding of the effectiveness of de-adoption of oral chlorhexidine and implementation of a standardized oral care bundle for decreasing ICU mortality and IVAC rates while improving oral health status. Our process evaluation will inform clinicians and decision makers about intervention delivery to support future de-adoption if justified by trial results.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03382730 . Registered on December 26, 2017.

Voluntary Stopping Eating and Drinking

Voluntary stopping of eating and drinking (VSED) is a deliberate, self-initiated attempt to hasten death in the setting of suffering refractory to optimal palliative interventions or prolonged dying that a person finds intolerable. Individuals who consider VSED tend to be older, have a serious but not always imminently terminal illness, place a high value on independence, and have significant illness burden. VSED can theoretically be performed independent of clinician assistance and therefore avoids many of the ethical and legal concerns associated with physician-assisted dying or other palliative measures of last resort, However, VSED is an intense process fraught with new sources of somatic and emotional suffering for individuals and their caregivers, so VSED is best supervised by an experienced, well-informed clinician who can provide appropriate pre-intervention assessment, anticipatory guidance, medical treatment of symptoms, and emotional support. Before initiation of VSED, clinicians should carefully screen for inadequately treated psychiatric conditions, unaddressed symptoms, existential suffering, and evidence of coercion-consultation from palliative medicine, psychiatry, or ethics is often indicated. The most common symptoms encountered after starting VSED are extreme thirst, hunger, dysuria, progressive disability, delirium, and somnolence. Although physiologically similar to cessation of artificial nutrition and hydration, the onset and management of symptoms is often different. We propose an organized system for evaluating individual appropriateness for VSED, anticipatory guidance, and management of symptoms associated with VSED. A brief review of ethical and legal considerations follows.

The relationship between stressors and intensive care unit experiences

BACKGROUND

Patients in intensive care units (ICUs) face many physical and psychological stressors because of the environment of these units and their own critical conditions and experience stress in various degrees. Each stressor may affect patients' experiences in ICUs differently.

AIM AND OBJECTIVES

This study aimed to examine the relationship between stressors and patients' experiences in an ICU.

METHODS

This descriptive, cross-sectional study was conducted between September 2014 and June 2015 in a university hospital and included 116 patients who were admitted to the general ICU for at least 24 hours. Data were collected using the Intensive Care Experience Scale and a questionnaire that included questions about socio-demographic and disease-related characteristics of patients and their stressors.

RESULTS

The mean age of the patients was 57.81 ± 13.81 years, and the mean duration of ICU stay was 2.28 ± 3.88 days. There was a moderate positive relation between the stressors noise (r = .534; P < .01), thirst (r = .438; P < .01), loneliness (r = .410; P < .01), and pain (r = .404; P < .01) and the subscale frightening experiences. However, there was a moderate, negative relation between the stressors inability to speak (r = -.444; P < .01), surrounding speeches (r = -.458; P < .01), equipment noise (r = -.490; P < .01), and physical exercise (r = -.546; P < .01) and the subscale satisfaction with care.

CONCLUSIONS

The patients associated stressors with satisfaction and frightening experiences in the early period of their discharge from the ICU. As stressors increases, so do frightening experiences, and satisfaction with care is affected negatively.

RELEVANCE TO CLINICAL PRACTICE

Currently, stressors to which patients discharged from ICU are exposed during their admission to wards are not evaluated in practice. This study is important in that it can help health professionals be aware of effects of stressors on patients in the early period of their discharge.

Association of Persistent Intense Thirst With Delirium Among Critically Ill Patients: A Cross-sectional Study

CONTEXT

Thirst is a prevalent distressing symptom often reported by patients in the intensive care unit (ICU). Little is known about the association of thirst with delirium.

OBJECTIVE

We aimed to investigate the relationship between thirst and delirium.

METHODS

This retrospective cross-sectional study enrolled 401 patients who were evaluated for thirst intensity in the ICU between March 2017 and October 2017. We assessed thirst intensity on a scale of 0-10 (with 10 being the worst) and defined intense thirst as a score ≥8. If intense thirst persisted for more than 24 hours, we defined it as persistent intense thirst. Delirium was screened using the Intensive Care Delirium Screening Checklist. Propensity score matching and inverse probability of treatment weighting analyses were performed.

RESULTS

Of 401 patients, 66 (16.5%) had intense thirst sensation for more than 24 hours. After matching, patients with persistent intense thirst showed an increased risk for delirium compared with those without persistent intense thirst (odds ratio, 4.95; 95% confidence interval, 2.58-9.48; P < 0.001). Propensity score weighted logistic regression analysis also indicated that persistent intense thirst was significantly associated with delirium (odds ratio, 5.74; 95% confidence interval, 2.53-12.99; P < 0.001).

CONCLUSION

Intense thirst persisting for more than 24 hours was associated with increased risk for delirium.