Related factors to semi-recumbent position compliance and pressure ulcers in patients with invasive mechanical ventilation: An observational study (CAPCRI study)

Impact of head-of-bed elevation angle on the development of pressure ulcers and pneumonia in patients on mechanical ventilation: a systematic review and meta-analysis

BACKGROUND

Mechanical ventilation is crucial for patient management in intensive care units, but it comes with complications such as pressure ulcers and ventilator-associated pneumonia (VAP). The impact of head-of-bed elevation angles on these complications remains a critical area for investigation.

METHODS

This systematic review and meta-analysis followed PRISMA guidelines and involved searches across PubMed, Embase, Web of Science, and Cochrane Library, conducted on September 19, 2023, with no date or language restrictions. We included randomized controlled trials that compared different head-of-bed elevation angles in adult ICU patients on mechanical ventilation. Data were extracted on study characteristics, quality assessed using the Cochrane risk of bias tool, and statistical analyses performed using chi-square tests for heterogeneity and fixed or random-effects models based on heterogeneity results.

RESULTS

Six studies met inclusion criteria out of an initial 601 articles. These studies showed minimal heterogeneity (I2 = 0.0% for pressure ulcers, p = 0.930; and for VAP, p = 0.797), supporting the use of fixed-effect models. Results indicated that a higher elevation angle (45°) significantly increased the risk of pressure ulcers (OR = 1.95, 95% CI: 1.12-3.37, p < 0.05) and decreased the incidence of VAP compared to a lower angle (30°) (OR = 0.51, 95% CI: 0.31-0.84, p < 0.05).

CONCLUSIONS

While higher head-of-bed elevation can reduce the risk of VAP in mechanically ventilated patients, it may increase the risk of pressure ulcers. Clinical strategies should carefully balance these outcomes to optimize patient care in ICU settings.

REGISTRATION

PROSPERO 2024 CRD42024570232.

Can Cardiopulmonary Rehabilitation Facilitate Weaning of Extracorporeal Membrane Oxygenation (CaRe-ECMO)? Study Protocol for a Prospective Multidisciplinary Randomized Controlled Trial

Background: Mortality of patients suffering from critical illness has been dramatically improved with advanced technological development of extracorporeal membrane oxygenation (ECMO) therapy. However, the majority of ECMO-supported patients failed to wean from ECMO therapy. As one of several options, cardiopulmonary rehabilitation serves as effective intervention in the improvement of cardiovascular and respiratory function in various major critical illness. Nonetheless, its role in facilitating ECMO weaning has not yet been explored. The purpose of this study is to investigate the effectiveness of cardiopulmonary rehabilitation on rate of ready for ECMO weaning in ECMO-supported patients (CaRe-ECMO).

Methods: The CaRe-ECMO trial is a randomized controlled, parallel group, clinical trial. This trial will be performed in a minimum number of 366 ECMO-supported eligible patients. Patients will be randomly assigned to either: (1) the CaRe-ECMO group, which will be treated with usual care including pharmacotherapy, non-pharmacotherapy, and specific nursing for ECMO therapy and the CaRe-ECMO program; or (2) the control group, which will receive usual care only. The CaRe-ECMO program consists of protocolized positioning, passive range of motion (PROM) training, neuromuscular electrical stimulation (NMES), surface electrical phrenic nerve stimulation (SEPNS), and pulmonary rehabilitation. The primary outcome of the CaRe-ECMO trial is the rate of ready for ECMO weaning at CaRe-ECMO day 7 (refers to 7 days after the CaRe-ECMO program initiation). Secondary outcomes include rate of ECMO and mechanical ventilation weaning, total length in day of ready for ECMO weaning, ECMO weaning and mechanical ventilation, all-cause mortality, rate of major post-ECMO complications, ECMO unit length of stay (LOS) and hospital LOS, total cost for hospitalization, cerebral performance category (CPC), activities of daily living (ADL), and health-related quality of life (HRQoL).

Discussion: The CaRe-ECMO is designed to answer the question “whether cardiopulmonary rehabilitation can facilitate weaning of ECMO (CaRe-ECMO).” Should the implementation of the CaRe-ECMO program result in superior primary and secondary outcomes as compared to the controls, specifically the add-on effects of cardiopulmonary rehabilitation to the routine ECMO practice for facilitating successful weaning, the CaRe-ECMO trial will offer an innovative treatment option for ECMO-supported patients and meaningfully impact on the standard care in ECMO therapy.

Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT05035797.

Risk Factors for Pressure Injury Development Among Critical Care Patients

Identification of the appropriate pressure injury (PI) risk factors is the first step in successful PI prevention. Measuring PI risk through formalized PI risk assessment is an essential component of any PI prevention program. Major PI risk factors identified in the empirical literature in the critical care population include age, diabetes, hypotension, mobility, prolonged intensive care unit admission, mechanical ventilation and vasopressor administration. Future risk assessment using sophisticated data analytics available in the electronic medical record may result in earlier, targeted PI prevention and will improve our understanding of risk factors that may contribute to unavoidable PIs.