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Randhawa VK, Lee R, Alviar CL, Rali AS, Arias A, Vaidya A, Zern EK, Fagan A, Proudfoot AG, Katz JN. Extra-cardiac management of cardiogenic shock in the intensive care unit. J Heart Lung Transplant 2024; 43:1051-1058. [PMID: 38823968 DOI: 10.1016/j.healun.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 06/03/2024] Open
Abstract
Cardiogenic shock (CS) is a heterogeneous clinical syndrome characterized by low cardiac output leading to end-organ hypoperfusion. Organ dysoxia ranging from transient organ injury to irreversible organ failure and death occurs across all CS etiologies but differing by incidence and type. Herein, we review the recognition and management of respiratory, renal and hepatic failure complicating CS. We also discuss unmet needs in the CS care pathway and future research priorities for generating evidence-based best practices for the management of extra-cardiac sequelae. The complexity of CS admitted to the contemporary cardiac intensive care unit demands a workforce skilled to care for these extra-cardiac critical illness complications with an appreciation for how cardio-systemic interactions influence critical illness outcomes in afflicted patients.
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Affiliation(s)
- Varinder K Randhawa
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Division of Cardiology, St Michael's Hospital, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ran Lee
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Sections of Critical Care Cardiology and Advanced Heart Failure and Transplant Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carlos L Alviar
- The Leon H Charney Division of Cardiovascular Medicine, NYU Langone Medical Center, New York, New York
| | - Aniket S Rali
- Department of Internal Medicine, Division of Cardiovascular Diseases, and Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexandra Arias
- Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program, Division of Cardiology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Emily K Zern
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medicine Center, Los Angeles General Medical Center, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Andrew Fagan
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Jason N Katz
- Division of Cardiology, NYU Grossman School of Medicine and Bellevue Hospital Center, New York, New York.
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2
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Symonds NE, Meng EXM, Boyd JG, Boyd T, Day A, Hobbs H, Maslove DM, Norman PA, Semrau JS, Sibley S, Muscedere J. Ceragenin-coated endotracheal tubes for the reduction of ventilator-associated pneumonia: a prospective, longitudinal, cross-over, interrupted time, implementation study protocol (CEASE VAP study). BMJ Open 2024; 14:e076720. [PMID: 38309761 PMCID: PMC10840065 DOI: 10.1136/bmjopen-2023-076720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 01/11/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Critically ill patients are at high risk of acquiring ventilator-associated pneumonia (VAP), which occurs in approximately 20% of mechanically ventilated patients. VAP results either from aspiration of pathogen-contaminated oropharyngeal secretions or contaminated biofilms that form on endotracheal tubes (ETTs) after intubation. VAP results in increased duration of mechanical ventilation, increased intensive care unit and hospital length of stay, increased risk of death and increased healthcare costs. Because of its impact on patient outcomes and the healthcare system, VAP is regarded as an important patient safety issue and there is an urgent need for better evidence on the efficacy of prevention strategies. Modified ETTs that reduce aspiration of oropharyngeal secretions with subglottic secretion drainage or reduce the occurrence of biofilm with a coating of ceragenins (CSAs) are available for clinical use in Canada. In this implementation study, we will evaluate the efficacy of these two types of Health Canada-licensed ETTs on the occurrence of VAP, and impact on patient-centred outcomes. METHODS In this ongoing, pragmatic, prospective, longitudinal, interrupted time, cross-over implementation study, we will compare the efficacy of a CSA-coated ETT (CeraShield N8 Pharma) with an ETT with subglottic secretion drainage (Taper Guard, Covidien). The study periods consist of four alternating time periods of 11 or 12 weeks or a total of 23 weeks for each ETT. All patients intubated with the study ETT in each time period will be included in an intention-to-treat analysis. Outcomes will include VAP incidence, mortality and health services utilisation including antibiotic use and length of stay. ETHICS AND DISSEMINATION This study has been approved by the Health Sciences Research Ethics Board at Queen's University. The results of this study will be actively disseminated through manuscript publication and conference presentations. TRIAL REGISTRATION NUMBER NCT05761613.
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Affiliation(s)
| | | | - John Gordon Boyd
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Tracy Boyd
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Andrew Day
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Hailey Hobbs
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - David M Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Joanna S Semrau
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stephanie Sibley
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
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3
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Ehrenzeller S, Klompas M. Association Between Daily Toothbrushing and Hospital-Acquired Pneumonia: A Systematic Review and Meta-Analysis. JAMA Intern Med 2024; 184:131-142. [PMID: 38109100 PMCID: PMC10728803 DOI: 10.1001/jamainternmed.2023.6638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/11/2023] [Indexed: 12/19/2023]
Abstract
Importance Hospital-acquired pneumonia (HAP) is the most common and morbid health care-associated infection, but limited data on effective prevention strategies are available. Objective To determine whether daily toothbrushing is associated with lower rates of HAP and other patient-relevant outcomes. Data Sources A search of PubMed, Embase, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and 3 trial registries was performed from inception through March 9, 2023. Study Selection Randomized clinical trials of hospitalized adults comparing daily oral care with toothbrushing vs regimens without toothbrushing. Data Extraction and Synthesis Data extraction and risk of bias assessments were performed in duplicate. Meta-analysis was performed using random-effects models. Main Outcomes and Measures The primary outcome of this systematic review and meta-analysis was HAP. Secondary outcomes included hospital and intensive care unit (ICU) mortality, duration of mechanical ventilation, ICU and hospital lengths of stay, and use of antibiotics. Subgroups included patients who received invasive mechanical ventilation vs those who did not, toothbrushing twice daily vs more frequently, toothbrushing provided by dental professionals vs general nursing staff, electric vs manual toothbrushing, and studies at low vs high risk of bias. Results A total of 15 trials met inclusion criteria, including 10 742 patients (2033 in the ICU and 8709 in non-ICU departments; effective population size was 2786 after shrinking the population to account for 1 cluster randomized trial in non-ICU patients). Toothbrushing was associated with significantly lower risk for HAP (risk ratio [RR], 0.67 [95% CI, 0.56-0.81]) and ICU mortality (RR, 0.81 [95% CI, 0.69-0.95]). Reduction in pneumonia incidence was significant for patients receiving invasive mechanical ventilation (RR, 0.68 [95% CI, 0.57-0.82) but not for patients who were not receiving invasive mechanical ventilation (RR, 0.32 [95% CI, 0.05-2.02]). Toothbrushing for patients in the ICU was associated with fewer days of mechanical ventilation (mean difference, -1.24 [95% CI, -2.42 to -0.06] days) and a shorter ICU length of stay (mean difference, -1.78 [95% CI, -2.85 to -0.70] days). Brushing twice a day vs more frequent intervals was associated with similar effect estimates. Results were consistent in a sensitivity analysis restricted to 7 studies at low risk of bias (1367 patients). Non-ICU hospital length of stay and use of antibiotics were not associated with toothbrushing. Conclusions The findings of this systematic review and meta-analysis suggest that daily toothbrushing may be associated with significantly lower rates of HAP, particularly in patients receiving mechanical ventilation, lower rates of ICU mortality, shorter duration of mechanical ventilation, and shorter ICU length of stay. Policies and programs encouraging more widespread and consistent toothbrushing are warranted.
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Affiliation(s)
- Selina Ehrenzeller
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Kho ME, Reid J, Molloy AJ, Herridge MS, Seely AJ, Rudkowski JC, Buckingham L, Heels-Ansdell D, Karachi T, Fox-Robichaud A, Ball IM, Burns KEA, Pellizzari JR, Farley C, Berney S, Pastva AM, Rochwerg B, D'Aragon F, Lamontagne F, Duan EH, Tsang JLY, Archambault P, English SW, Muscedere J, Serri K, Tarride JE, Mehta S, Verceles AC, Reeve B, O'Grady H, Kelly L, Strong G, Hurd AH, Thabane L, Cook DJ. Critical Care C ycling to Improve Lower Extremity Strength (CYCLE): protocol for an international, multicentre randomised clinical trial of early in-bed cycling for mechanically ventilated patients. BMJ Open 2023; 13:e075685. [PMID: 37355270 PMCID: PMC10314658 DOI: 10.1136/bmjopen-2023-075685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/26/2023] Open
Abstract
INTRODUCTION In-bed leg cycling with critically ill patients is a promising intervention aimed at minimising immobility, thus improving physical function following intensive care unit (ICU) discharge. We previously completed a pilot randomised controlled trial (RCT) which supported the feasibility of a large RCT. In this report, we describe the protocol for an international, multicentre RCT to determine the effectiveness of early in-bed cycling versus routine physiotherapy (PT) in critically ill, mechanically ventilated adults. METHODS AND ANALYSIS We report a parallel group RCT of 360 patients in 17 medical-surgical ICUs and three countries. We include adults (≥18 years old), who could ambulate independently before their critical illness (with or without a gait aid), ≤4 days of invasive mechanical ventilation and ≤7 days ICU length of stay, and an expected additional 2-day ICU stay, and who do not fulfil any of the exclusion criteria. After obtaining informed consent, patients are randomised using a web-based, centralised system to either 30 min of in-bed cycling in addition to routine PT, 5 days per week, up to 28 days maximum, or routine PT alone. The primary outcome is the Physical Function ICU Test-scored (PFIT-s) at 3 days post-ICU discharge measured by assessors blinded to treatment allocation. Participants, ICU clinicians and research coordinators are not blinded to group assignment. Our sample size estimate was based on the identification of a 1-point mean difference in PFIT-s between groups. ETHICS AND DISSEMINATION Critical Care Cycling to improve Lower Extremity (CYCLE) is approved by the Research Ethics Boards of all participating centres and Clinical Trials Ontario (Project 1345). We will disseminate trial results through publications and conference presentations. TRIAL REGISTRATION NUMBER NCT03471247 (Full RCT); NCT02377830 (CYCLE Vanguard 46 patient internal pilot).
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Affiliation(s)
- Michelle E Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
| | - Julie Reid
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alexander J Molloy
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
| | - Margaret S Herridge
- University Health Network, Toronto General Research Institute, Toronto, Ontario, Canada
| | - Andrew J Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jill C Rudkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Lisa Buckingham
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Diane Heels-Ansdell
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tim Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Ian M Ball
- Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Karen E A Burns
- Li Sha King Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, Unity Health Toronto, Toronto, Ontario, Canada
| | - Joseph R Pellizzari
- Consultation-Liaison Psychiatry Service, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Christopher Farley
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Sue Berney
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amy M Pastva
- Departments of Medicine and Orthopedic Surgery, Duke University, Durham, North Carolina, USA
| | - Bram Rochwerg
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Frédérick D'Aragon
- Department of Anesthesiology, Universite de Sherbrooke Faculte de medecine et des sciences de la sante, Sherbrooke, Quebec, Canada
- Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Francois Lamontagne
- Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
- Medicine, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Erick H Duan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Division of Critical Care Medicine, Niagara Health System, St Catharines, Ontario, Canada
| | - Jennifer L Y Tsang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care Medicine, Niagara Health System, St Catharines, Ontario, Canada
| | - Patrick Archambault
- Anesthesiology and Intensive Care, Faculty of Medicine, Université Laval, Quebec, Québec, Canada
- Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec, Québec, Canada
| | - Shane W English
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Karim Serri
- Critical Care Division, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Montreal, Québec, Canada
| | - Jean-Eric Tarride
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Programs for the Assessment of Technology in Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Sinai Health System, Toronto, Ontario, Canada
| | - Avelino C Verceles
- Department of Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brenda Reeve
- Medicine, Brantford General Hospital, Brantford, Ontario, Canada
| | - Heather O'Grady
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Laurel Kelly
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Geoff Strong
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Abby H Hurd
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
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5
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Lau VI, Xie F, Fowler RA, Rochwerg B, Johnstone J, Lauzier F, Marshall JC, Basmaji J, Henderson W, Khwaja K, Loubani O, Niven DJ, Zarychanski R, Arabi YM, Cartin-Ceba R, Thabane L, Heels-Ansdell D, Cook DJ. Health economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (E-PROSPECT): a cost-effectiveness analysis. Can J Anaesth 2022; 69:1515-1526. [PMID: 36289153 DOI: 10.1007/s12630-022-02335-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/06/2022] [Accepted: 06/21/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We sought to compare the cost-effectiveness of probiotics and usual care with usual care without probiotics in mechanically ventilated, intensive care unit patients alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT). METHODS We conducted a health economic evaluation alongside the PROSPECT randomized control trial (October 2013-March 2019). We adopted a public healthcare payer's perspective. Forty-four intensive care units in three countries (Canada/USA/Saudi Arabia) with adult critically ill, mechanically ventilated patients (N = 2,650) were included. Interventions were probiotics (Lactobacillus rhamnosus GG) vs placebo administered enterally twice daily. We collected healthcare resource use and estimated unit costs in 2019 United States dollars (USD) over a time horizon from randomization to hospital discharge/death. We calculated incremental cost-effectiveness ratios (ICERs) comparing probiotics vs usual care. The primary outcome was incremental cost per ventilator-associated pneumonia (VAP) event averted; secondary outcomes were costs per Clostridioides difficile-associated diarrhea (CDAD), antibiotic-associated diarrhea (AAD), and mortality averted. Uncertainty was investigated using nonparametric bootstrapping and sensitivity analyses. RESULTS Mean (standard deviation [SD]) cost per patient was USD 66,914 (91,098) for patients randomized to probiotics, with a median [interquartile range (IQR)] of USD 42,947 [22,239 to 76,205]. By comparison, for those not receiving probiotics, mean (SD) cost per patient was USD 62,701 (78,676) (median [IQR], USD 41,102 [23,170 to 75,140]; incremental cost, USD 4,213; 95% confidence interval [CI], -2,269 to 10,708). Incremental cost-effectiveness ratios for VAP or AAD events averted, probiotics were dominated by usual care (more expensive, with similar effectiveness). The ICERs were USD 1,473,400 per CDAD event averted (95% CI, undefined) and USD 396,764 per death averted (95% CI, undefined). Cost-effectiveness acceptability curves reveal that probiotics were not cost-effective across wide ranges of plausible willingness-to-pay thresholds. Sensitivity analyses did not change the conclusions. CONCLUSIONS Probiotics for VAP prevention among critically ill patients were not cost-effective. Study registration data www. CLINICALTRIALS gov (NCT01782755); registered 4 February 2013.
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Affiliation(s)
- Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada. .,Department of Critical Care, Faculty of Medicine and Dentistry, University of Alberta, 8440 112 Street, Edmonton, AB, Canada.
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Programs for Health Economics and Outcomes Measures, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jennie Johnstone
- Department of Infection Prevention and Control, Sinai Health, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - François Lauzier
- Departments of Medicine, Anesthesiology & Critical Care, Université Laval, Quebec, QC, Canada
| | - John C Marshall
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - John Basmaji
- Division of Critical Care Medicine, Department of Medicine, Western University, London, ON, Canada
| | - William Henderson
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kosar Khwaja
- Departments of Surgery and Critical Care Medicine, McGill University, Montreal, QC, Canada
| | - Osama Loubani
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ryan Zarychanski
- Sections of Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Yaseen M Arabi
- Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary Medicine and Critical Care, Department of Critical Care, Mayo Clinic, Phoenix, AZ, USA
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Biostatistics Unit, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Deborah J Cook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
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Positive Airway Cultures in Dogs and Cats Receiving Mechanical Ventilation for Tick Paralysis. Animals (Basel) 2022; 12:ani12233304. [PMID: 36496825 PMCID: PMC9738334 DOI: 10.3390/ani12233304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Animals with tick paralysis often require mechanical ventilation (MV) but previous publications have identified knowledge gaps regarding the development of bacterial pneumonia, and the specific pathogens involved. The objectives of this study were to describe the clinical course and culture and susceptibility profiles of bacteria isolated from airway samples of dogs and cats mechanically ventilated for tick paralysis that had positive airway cultures. Medical records were reviewed, and cases included if they had a positive airway sample culture during MV for tick paralysis. Twenty-four dogs and two cats were included. Most (85%) received empirical antimicrobials before airway sampling. The most common organisms isolated included Staphylococcus spp. (11), Klebsiella spp. (9), Enterococcus faecalis (8), Escherichia coli (6), Enterococcus faecium (3), Pseudomonas aeruginosa (4), and Mycoplasma spp. (3). Evidence of aspiration pneumonia was present in 22/25 (88%) cases that had thoracic radiographs performed. Seventy-seven percent of cases received antimicrobials to which the cultured bacteria were susceptible during hospitalisation. The median duration of MV was 4 days (range 1-10). Most (77%) survived to discharge, 19% were euthanised, and one died. In a multivariable logistic regression analysis it was identified that selection of antimicrobials to which the causative bacteria are susceptible was associated with survival to discharge (Odds ratio 45.8, p = 0.014; 95%CI 1.98-14,808), as was length of MV, with every day an animal is ventilated associated with a 4.7 times increased chance of survival (p = 0.015; 95% CI 1.21-78.4).
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7
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Effectiveness of Continuous Cuff Pressure Control in Preventing Ventilator-Associated Pneumonia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2022; 50:1430-1439. [PMID: 35880890 DOI: 10.1097/ccm.0000000000005630] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Microaspiration of subglottic secretions is the main pathogenic mechanism for ventilator-associated pneumonia (VAP). Adequate inflation of the endotracheal cuff is pivotal to providing an optimal seal of the extraluminal airway. However, cuff pressure substantially fluctuates due to patient or tube movements, which can induce microaspiration. Therefore, devices for continuous cuff pressure control (CCPC) have been developed in recent years. The purpose of this systematic review and meta-analysis is to assess the effectiveness of CCPC in VAP prevention. DATA SOURCES A systematic search of Embase, the Cochrane Central Register of Controlled Trials, and the International Clinical Trials Registry Platform was conducted up to February 2022. STUDY SELECTION Eligible studies were randomized controlled trials (RCTs) and quasi-RCTs comparing the impact of CCPC versus intermittent cuff pressure control on the occurrence of VAP. DATA EXTRACTION Random-effects meta-analysis was used to calculate odds ratio (OR) and 95% CI for VAP incidence between groups. Secondary outcome measures included mortality and duration of mechanical ventilation (MV) and ICU stay. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. DATA SYNTHESIS Eleven RCTs with 2,092 adult intubated patients were included. The use of CCPC was associated with a reduced risk of VAP (OR, 0.51). Meta-analyses of secondary endpoints showed no significant difference in mortality but significant differences in durations of MV (mean difference, -1.07 d) and ICU stay (mean difference, -3.41 d) in favor of CCPC. However, the risk of both reporting and individual study bias was considered important. The main issues were the lack of blinding, potential commercial conflicts of interest of study authors and high heterogeneity due to methodological differences between studies, differences in devices used for CCPC and in applied baseline preventive measures. Certainty of the evidence was considered "very low." CONCLUSIONS The use of CCPC was associated with a reduction in VAP incidence; however, this was based on very low certainty of evidence due to concerns related to risk of bias and inconsistency.
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Sanaie S, Rahnemayan S, Javan S, Shadvar K, Saghaleini SH, Mahmoodpoor A. Comparison of Closed vs Open Suction in Prevention of Ventilator-associated Pneumonia: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022; 26:839-845. [PMID: 36864859 PMCID: PMC9973182 DOI: 10.5005/jp-journals-10071-24252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Ventilator-associated events (VAEs) are one of the main sources of concern in critically ill patients due to the high frequency and mortality. We conducted this analysis to compare the effects of open endotracheal suctioning system with closed one on the incidences of VAEs in adult patients receiving mechanical ventilation (MV). Materials and methods A comprehensive literature search was performed in PubMed, Scopus, Cochrane Library, and hand searching bibliographies of retrieved articles. The search was confined to randomized controlled trials with human adults comparing closed tracheal suction systems (CTSS) vs open tracheal suction systems (OTSS) in prevention of ventilator-associated pneumonia (VAP). Full-text articles were used in order to extract the data. Data extraction was only started after completing the quality assessment. Results The search resulted in 59 publications. Among them, 10 were identified as eligible for meta-analysis. There was a significant increase in incidence of VAP when using OTSS compared to CTSS, so that OCSS increased the incidence of VAP by 57% (OR 1.57, 95% CI 1.063-2.32, p = 0.02). Discussion Our results showed that using CTSS can significantly decrease VAP development compared to OTSS. This conclusion does not yet mean the routine use of CTSS as a standard VAP prevention measure for all patients since individual patient's disease and cost are other factors that should be in mind when determining the choice of the suctioning system. High-quality trials with a larger sample size are highly recommended. How to cite this article Sanaie S, Rahnemayan S, Javan S, Shadvar K, Saghaleini SH, Mahmoodpoor A. Comparison of Closed vs Open Suction in Prevention of Ventilator-associated Pneumonia: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022;26(7):839-845.
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Affiliation(s)
- Sarvin Sanaie
- Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, East Azerbaijan, Iran
| | - Sama Rahnemayan
- Research Center for Evidence-based Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, East Azerbaijan, Iran
| | - Sahar Javan
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, East Azerbaijan, Iran
| | - Kamran Shadvar
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, East Azerbaijan, Iran
| | - Seied-Hadi Saghaleini
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, East Azerbaijan, Iran
| | - Ata Mahmoodpoor
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, East Azerbaijan, Iran,Ata Mahmoodpoor, Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, East Azerbaijan, Iran, Phone: +98 4133330049, e-mail:
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9
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Escobar‐Salom M, Torrens G, Jordana‐Lluch E, Oliver A, Juan C. Mammals' humoral immune proteins and peptides targeting the bacterial envelope: from natural protection to therapeutic applications against multidrug‐resistant
Gram
‐negatives. Biol Rev Camb Philos Soc 2022; 97:1005-1037. [PMID: 35043558 PMCID: PMC9304279 DOI: 10.1111/brv.12830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/12/2021] [Accepted: 12/15/2021] [Indexed: 12/11/2022]
Abstract
Mammalian innate immunity employs several humoral ‘weapons’ that target the bacterial envelope. The threats posed by the multidrug‐resistant ‘ESKAPE’ Gram‐negative pathogens (Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) are forcing researchers to explore new therapeutic options, including the use of these immune elements. Here we review bacterial envelope‐targeting (peptidoglycan and/or membrane‐targeting) proteins/peptides of the mammalian immune system that are most likely to have therapeutic applications. Firstly we discuss their general features and protective activity against ESKAPE Gram‐negatives in the host. We then gather, integrate, and discuss recent research on experimental therapeutics harnessing their bactericidal power, based on their exogenous administration and also on the discovery of bacterial and/or host targets that improve the performance of this endogenous immunity, as a novel therapeutic concept. We identify weak points and knowledge gaps in current research in this field and suggest areas for future work to obtain successful envelope‐targeting therapeutic options to tackle the challenge of antimicrobial resistance.
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Affiliation(s)
- María Escobar‐Salom
- Department of Microbiology University Hospital Son Espases‐Health Research Institute of the Balearic Islands (IdISBa) Carretera de Valldemossa 79 Palma Balearic Islands 07010 Spain
| | - Gabriel Torrens
- Department of Microbiology University Hospital Son Espases‐Health Research Institute of the Balearic Islands (IdISBa) Carretera de Valldemossa 79 Palma Balearic Islands 07010 Spain
| | - Elena Jordana‐Lluch
- Department of Microbiology University Hospital Son Espases‐Health Research Institute of the Balearic Islands (IdISBa) Carretera de Valldemossa 79 Palma Balearic Islands 07010 Spain
| | - Antonio Oliver
- Department of Microbiology University Hospital Son Espases‐Health Research Institute of the Balearic Islands (IdISBa) Carretera de Valldemossa 79 Palma Balearic Islands 07010 Spain
| | - Carlos Juan
- Department of Microbiology University Hospital Son Espases‐Health Research Institute of the Balearic Islands (IdISBa) Carretera de Valldemossa 79 Palma Balearic Islands 07010 Spain
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10
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Li Y, Yuan X, Sun B, Li HC, Chu HW, Wang L, Zhao Y, Tang X, Wang R, Li XY, Tong ZH, Wang C. Rapid-flow expulsion maneuver in subglottic secretion clearance to prevent ventilator-associated pneumonia: a randomized controlled study. Ann Intensive Care 2021; 11:98. [PMID: 34165661 PMCID: PMC8222955 DOI: 10.1186/s13613-021-00887-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/14/2021] [Indexed: 11/25/2022] Open
Abstract
Background Following endotracheal intubation, clearing secretions above the endotracheal tube cuff decreases the incidence of ventilator-associated pneumonia (VAP); therefore, subglottic secretion drainage (SSD) is widely advocated. Our group developed a novel technique to remove the subglottic secretions, the rapid-flow expulsion maneuver (RFEM). The objective of this study was to explore the effectiveness and safety of RFEM compared with SSD. Methods This study was a single-center, prospective, randomized and controlled trial, conducted at Respiratory Intensive Care Unit (ICU) of Beijing Chao-Yang Hospital, a university-affiliated tertiary hospital. The primary outcome was the incidence of VAP, assessed for non-inferiority. Results Patients with an endotracheal tube allowing drainage of subglottic secretions (n = 241) were randomly assigned to either the RFEM group (n = 120) or SSD group (n = 121). Eleven patients (9.17%) in the RFEM group and 13 (10.74%) in the SSD group developed VAP (difference, − 1.59; 95% confidence interval [CI] [− 9.20 6.03]), as the upper limit of 95% CI was not greater than the pre-defined non-inferiority limit (10%), RFEM was declared non-inferior to SSD. There were no statistically significant differences in the duration of mechanical ventilation, ICU mortality, or ICU length of stay and costs between groups. In terms of safety, no accidental extubation or maneuver-related barotrauma occurred in the RFEM group. The incidence of post-extubation laryngeal edema and reintubation was similar in both groups. Conclusions RFEM is effective and safe, with non-inferiority compared to SSD in terms of the incidence of VAP. RFEM could be an alternative method in first-line treatment of respiratory ICU patients. Trial registration This study has been registered on ClinicalTrials.gov (Registration Number: NCT02032849, https://clinicaltrials.gov/ct2/show/NCT02032849); registered on January 2014 Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00887-5.
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Affiliation(s)
- Ying Li
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Xue Yuan
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Bing Sun
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China. .,Beijing Institute of Respiratory Medicine, Beijing, China. .,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China. .,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China.
| | - Hai-Chao Li
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Hui-Wen Chu
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Li Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Yu Zhao
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Xiao Tang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Rui Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Xu-Yan Li
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Zhao-Hui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Respiratory Medicine, Capital Medical University, Beijing, China
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11
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Güner CK, Kutlutürkan S. Role of head-of-bed elevation in preventing ventilator-associated pneumonia bed elevation and pneumonia. Nurs Crit Care 2021; 27:635-645. [PMID: 33884691 DOI: 10.1111/nicc.12633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 04/01/2021] [Accepted: 04/03/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Elevating the head of bed (HOB) to 30° to 45° is an evidence-based recommendation to prevent ventilator-associated pneumonia (VAP). However, the available scientific data are inconclusive regarding the optimal degree of HOB elevation which is safe and effective for mechanically ventilated patients. AIMS AND OBJECTIVES To investigate the impact a of semirecumbent position at 30° and 45°on the development of VAP as compared with aHOB elevation to <30°. METHODS A 5-day, single centre, prospective, randomized, controlled, parallel group, three-arm study was conducted in adult patients on mechanical ventilation staying in the intensive care unit. Patients were randomly placed in <30°, 30°, or 45° HOB elevation position on the day of intubation and followed up for 5 days. They were assessed in terms of the development of microbiologically confirmed VAP (by the culture of endotracheal aspirate) over the study period. RESULTS Sixty patients (20 in each arm) completed the study. VAP occurred in 55%, 25%, and 20% of patients in the HOB elevation to <30°, 30°, and 45°study arms, respectively. The frequency of VAP was significantly lower in the 45° compared with the <30° study arm (P = .022); there were no significant differences between the <30° and 30° as well as the 45° and 30° study groups. Unlike the frequency of VAP, the timing of the VAP (early or late) was not dependent on the degree of HOB elevation (P = .703). CONCLUSIONS Keeping the mechanically ventilated patients in a semirecumbent position as close to 45°as possible should be the goal to prevent the development of VAP. The backrest elevation <30° should be avoided unless medically indicated. RELEVANCE TO CLINICAL PRACTICE The study results reaffirm the crucial role of patient positioning, an essential nursing care intervention, in preventing VAP. Intensive care nurses can contribute to improving the VAP rates and outcomes by placing and keeping the patients in the correct position.
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Affiliation(s)
- Canan Kaş Güner
- Medical Documentation and Secretarial Department, Medical Services and Techniques Program, Taşköprü Vocational School of Higher Education, Kastamonu University, Kastamonu, Turkey
| | - Sevinç Kutlutürkan
- Department of Nursing, Faculty of Nursing, Ankara University, Ankara, Turkey
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12
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Zhao T, Wu X, Zhang Q, Li C, Worthington HV, Hua F. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev 2020; 12:CD008367. [PMID: 33368159 PMCID: PMC8111488 DOI: 10.1002/14651858.cd008367.pub4] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in people who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, swab, toothbrush, or combination, together with suction of secretions, may reduce the risk of VAP in these patients. OBJECTIVES To assess the effects of oral hygiene care (OHC) on incidence of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation in hospital intensive care units (ICUs). SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 25 February 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 1), MEDLINE Ovid (1946 to 25 February 2020), Embase Ovid (1980 to 25 February 2020), LILACS BIREME Virtual Health Library (1982 to 25 February 2020) and CINAHL EBSCO (1937 to 25 February 2020). We also searched the VIP Database (January 2012 to 8 March 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, gel, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation for at least 48 hours. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed search results, extracted data and assessed risk of bias in included studies. We contacted study authors for additional information. We reported risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, using the random-effects model of meta-analysis when data from four or more trials were combined. MAIN RESULTS We included 40 RCTs (5675 participants), which were conducted in various countries including China, USA, Brazil and Iran. We categorised these RCTs into five main comparisons: chlorhexidine (CHX) mouthrinse or gel versus placebo/usual care; CHX mouthrinse versus other oral care agents; toothbrushing (± antiseptics) versus no toothbrushing (± antiseptics); powered versus manual toothbrushing; and comparisons of other oral care agents used in OHC (other oral care agents versus placebo/usual care, or head-to-head comparisons between other oral care agents). We assessed the overall risk of bias as high in 31 trials and low in two, with the rest being unclear. Moderate-certainty evidence from 13 RCTs (1206 participants, 92% adults) shows that CHX mouthrinse or gel, as part of OHC, probably reduces the incidence of VAP compared to placebo or usual care from 26% to about 18% (RR 0.67, 95% confidence intervals (CI) 0.47 to 0.97; P = 0.03; I2 = 66%). This is equivalent to a number needed to treat for an additional beneficial outcome (NNTB) of 12 (95% CI 7 to 128), i.e. providing OHC including CHX for 12 ventilated patients in intensive care would prevent one patient developing VAP. There was no evidence of a difference between interventions for the outcomes of mortality (RR 1.03, 95% CI 0.80 to 1.33; P = 0.86, I2 = 0%; 9 RCTs, 944 participants; moderate-certainty evidence), duration of mechanical ventilation (MD -1.10 days, 95% CI -3.20 to 1.00 days; P = 0.30, I2 = 74%; 4 RCTs, 594 participants; very low-certainty evidence) or duration of intensive care unit (ICU) stay (MD -0.89 days, 95% CI -3.59 to 1.82 days; P = 0.52, I2 = 69%; 5 RCTs, 627 participants; low-certainty evidence). Most studies did not mention adverse effects. One study reported adverse effects, which were mild, with similar frequency in CHX and control groups and one study reported there were no adverse effects. Toothbrushing (± antiseptics) may reduce the incidence of VAP (RR 0.61, 95% CI 0.41 to 0.91; P = 0.01, I2 = 40%; 5 RCTs, 910 participants; low-certainty evidence) compared to OHC without toothbrushing (± antiseptics). There is also some evidence that toothbrushing may reduce the duration of ICU stay (MD -1.89 days, 95% CI -3.52 to -0.27 days; P = 0.02, I2 = 0%; 3 RCTs, 749 participants), but this is very low certainty. Low-certainty evidence did not show a reduction in mortality (RR 0.84, 95% CI 0.67 to 1.05; P = 0.12, I2 = 0%; 5 RCTs, 910 participants) or duration of mechanical ventilation (MD -0.43, 95% CI -1.17 to 0.30; P = 0.25, I2 = 46%; 4 RCTs, 810 participants). AUTHORS' CONCLUSIONS Chlorhexidine mouthwash or gel, as part of OHC, probably reduces the incidence of developing ventilator-associated pneumonia (VAP) in critically ill patients from 26% to about 18%, when compared to placebo or usual care. We did not find a difference in mortality, duration of mechanical ventilation or duration of stay in the intensive care unit, although the evidence was low certainty. OHC including both antiseptics and toothbrushing may be more effective than OHC with antiseptics alone to reduce the incidence of VAP and the length of ICU stay, but, again, the evidence is low certainty. There is insufficient evidence to determine whether any of the interventions evaluated in the studies are associated with adverse effects.
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Affiliation(s)
- Tingting Zhao
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Xinyu Wu
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Qi Zhang
- Department of Oral Implantology, The Affiliated Stomatology Hospital, Zhejiang University School of Medicine, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Hangzhou, China
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Helen V Worthington
- Cochrane Oral Health, Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Fang Hua
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Centre for Evidence-Based Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
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13
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Oral carbohydrate solution cause an inflammatory response when aspirated into the lungs in mice. J Anesth 2020; 35:86-92. [PMID: 33221959 DOI: 10.1007/s00540-020-02873-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 11/02/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Many studies have been published on the beneficial effects of oral carbohydrate solutions (OCS) administered prior to surgery. However, the risk of pulmonary aspiration cannot be excluded in all patients undergoing anesthesia. But, there are few studies on the safety of OCS at lung aspiration. METHODS Experiments were conducted with mice (Nine- to ten-week-old male BALB/c mice weighted 23-26 g). Lung aspiration was performed by intratracheal administration of OCS and its major constituents, fructose and maltodextrin. Bronchoalveolar lavage fluid (BALF) was collected 3 and 24 h after lung aspiration. The level of Tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and macrophage inflammatory protein-2 (MIP-2) were measured in BALF. The total white blood cell, neutrophil counts, wet to dry ratio and histological examination were performed in BALF and lung tissue, respectively, at 24 h after aspiration. RESULTS The OCS increased the level of TNF-α, IL-6 and MIP-2 at 3 h and the neutrophil count at 24 h in BALFs, compared to a phosphate-buffered saline (PBS) group. The increase in IL-6 level induced by OCS was maintained for 24 h. The OCS also increased the number of white blood cells and the percentage of neutrophils in BALFs. Compared to fructose, maltodextrin significantly increased the production of MIP-2 in BALFs. OCS and maltodextrin also increased neutrophil recruitment in lung tissue. CONCLUSION Aspiration of OCS may cause inflammation of the lungs. The preoperative use of OCS may require caution under specific clinical conditions, such as patients at risk of lung aspiration.
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Bello G, Bisanti A, Giammatteo V, Montini L, Eleuteri D, Fiori B, La Sorda M, Spanu T, Grieco DL, Pennisi MA, De Pascale G, Antonelli M. Microbiologic surveillance through subglottic secretion cultures during invasive mechanical ventilation: a prospective observational study. J Crit Care 2020; 59:42-48. [DOI: 10.1016/j.jcrc.2020.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/22/2020] [Accepted: 05/23/2020] [Indexed: 10/24/2022]
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15
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Lau VI, Cook DJ, Fowler R, Rochwerg B, Johnstone J, Lauzier F, Marshall JC, Basmaji J, Heels-Ansdell D, Thabane L, Xie F. Economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (E-PROSPECT): study protocol. BMJ Open 2020; 10:e036047. [PMID: 32595159 PMCID: PMC7322334 DOI: 10.1136/bmjopen-2019-036047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection in the intensive care unit (ICU). Probiotics are defined as live microorganisms that may confer health benefits when ingested. Prior randomised trials suggest that probiotics may prevent infections such as VAP and Clostridioides difficile-associated diarrhoea (CDAD). PROSPECT (Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial) is a multicentre, double-blinded, randomised controlled trial comparing the efficacy of the probiotic Lactobacillus rhamnosus GG with usual care versus usual care without probiotics in preventing VAP and other clinically important outcomes in critically ill patients admitted to the ICU. METHODS AND ANALYSIS The objective of E-PROSPECT is to determine the incremental cost-effectiveness of L. rhamnosus GG plus usual care versus usual care without probiotics in critically ill patients. E-PROSPECT will be performed from the public healthcare payer's perspective over a time horizon from ICU admission to hospital discharge.We will determine probabilities of in-ICU and in-hospital events from all patients alongside PROSPECT. We will retrieve unit costs for each resource use item using jurisdiction-specific public databases, supplemented by individual site unit costs if such databases are unavailable. Direct costs will include medications, personnel costs, radiology/laboratory testing, operative/non-operative procedures and per-day hospital 'hoteling' costs not otherwise encompassed. The primary outcome is the incremental cost per VAP prevented between the two treatment groups. Other clinical events such as CDAD, antibiotic-associated diarrhoea and in-hospital mortality will be included as secondary outcomes. We will perform pre-specified subgroup analyses (medical/surgical/trauma; age; frailty status; antibiotic use; prevalent vs no prevalent pneumonia) and probabilistic sensitivity analyses for VAP, then generate confidence intervals using the non-parametric bootstrapping approach. ETHICS AND DISSEMINATION Study approval for E-PROSPECT was granted by the Hamilton Integrated Research Ethics Board of McMaster University on 29 July 2019. Informed consent was obtained from the patient or substitute decision-maker in PROSPECT. The findings of this study will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT01782755; Pre-results.
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Affiliation(s)
- Vincent Issac Lau
- Department of Critical Care, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Robert Fowler
- Sunnybrook Health Sciences Institute, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Jennie Johnstone
- Public Health Ontario, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Centre de Recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - John Basmaji
- Department of Medicine, Division of Critical Care, Western University, London, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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De Seta D, Carta F, Puxeddu R. Management of tracheostomy during COVID-19 outbreak: Heat and moisture exchanger filter and closed suctioning system. Oral Oncol 2020; 106:104777. [PMID: 32402655 PMCID: PMC7203057 DOI: 10.1016/j.oraloncology.2020.104777] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Daniele De Seta
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Italy.
| | - Filippo Carta
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Italy
| | - Roberto Puxeddu
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Italy
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Dale CM, Rose L, Carbone S, Smith OM, Burry L, Fan E, Amaral ACKB, McCredie VA, Pinto R, Quiñonez CR, Sutherland S, Scales DC, Cuthbertson BH. 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. Trials 2019; 20:603. [PMID: 31651364 PMCID: PMC6814100 DOI: 10.1186/s13063-019-3673-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/21/2019] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada.,Sunnybrook Research Institute, Toronto, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, London, UK
| | - Sarah Carbone
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Orla M Smith
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Department of Critical Care, St. Michael's Hospital, Toronto, Canada.,Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Lisa Burry
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Susan Sutherland
- Department of Dentistry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Damon C Scales
- Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Brian H Cuthbertson
- Sunnybrook Research Institute, Toronto, Canada. .,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
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18
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Letchford E, Bench S. Ventilator-associated pneumonia and suction: a review of the literature. ACTA ACUST UNITED AC 2019; 27:13-18. [PMID: 29323990 DOI: 10.12968/bjon.2018.27.1.13] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIM to identify the most effective suctioning technique for the prevention of ventilator-associated pneumonia. BACKGROUND ventilator-associated pneumonia is an important hospital-acquired infection associated with increased mortality and morbidity. METHOD a rapid review included an electronic database search of articles published between January 2009 and March 2016. The quality of the seven included studies was appraised and data were subjected to tabular and narrative syntheses. RESULTS closed suction systems have no clear advantage over open suction, but may better prevent late-onset ventilator-associated pneumonia. Subglottic secretion drainage reduces ventilator-associated pneumonia incidence. CONCLUSION open versus closed suction combined with subglottic secretion drainage requires ongoing research. Alongside this, policy guidance, education, behavioural and managerial strategies must be implemented.
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Affiliation(s)
- Emma Letchford
- Staff Nurse, Post-Anaesthetic Care Unit, Royal Brompton Hospital, London
| | - Suzanne Bench
- Associate Professor, School of Health and Social Care, London South Bank University
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19
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Chen J, Martin C, McIntyre CW, Ball IM, Duffin J, Slessarev M. Impact of Graded Passive Cycling on Hemodynamics, Brain, and Heart Perfusion in Healthy Adults. Front Med (Lausanne) 2019; 6:186. [PMID: 31552250 PMCID: PMC6736571 DOI: 10.3389/fmed.2019.00186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/05/2019] [Indexed: 01/28/2023] Open
Abstract
Purpose: Passive in-bed cycling (PC) can provide the benefits of early mobilization to critically ill patients who are unable to exercise actively. However, the effect of PC on global hemodynamics and perfusion of ischemia-prone organs, such as the brain and the heart, is unknown. Therefore, prior to studying the effects of PC in hemodynamically fragile critically ill patients, we characterized hemodynamic, brain blood flow, and cardiac function responses to a graded increase in PC cadence in a cohort of healthy subjects. Methods: We measured global hemodynamic indices, middle cerebral artery velocity (MCAv), and cardiac function in response to a graded increase in PC cadence. Using 5 min stages, we increased cadence from 5 to 55 RPM in increments of 10 RPM, preceded and followed by 5 min baseline and recovery periods at 0 RPM. The mean values obtained during the last 2 min of each stage were compared within and between subjects for all metrics using repeated measures ANOVA. Results: 11 healthy subjects (6 females) completed the protocol. Between subjects, there was no change in MCAv, cardiac function or hemodynamics with the graded increase in cadence with one exception. There was a 7% increase in mean arterial pressure (MAP) from baseline to 55RPM, that persisted through the recovery period. Across subjects, responses were heterogeneous, with some experiencing reduction in cardiac index, cerebral blood flow (CBF) and cardiac function, especially at higher cadence. Conclusions: In healthy adults, increasing PC cadence increased MAP in all subjects, while cardiac index, CBF, and cardiac function responses varied between subjects. Application of PC to critically ill patients must therefore consider individual variation in responses and tailor the PC to the patient. It is essential to further characterize these responses to PC in the critically ill prior to wide-scale clinical implementation.
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Affiliation(s)
- Jennifer Chen
- Departments of Medical Biophysics, Western University, London, ON, Canada
| | - Claudio Martin
- Departments of Medicine, Western University, London, ON, Canada
| | - Christopher W McIntyre
- Departments of Medical Biophysics, Western University, London, ON, Canada.,Departments of Medicine, Western University, London, ON, Canada
| | - Ian M Ball
- Departments of Medicine, Western University, London, ON, Canada.,Departments of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - James Duffin
- Departmet of Physiology, University of Toronto, Toronto, ON, Canada
| | - Marat Slessarev
- Departments of Medical Biophysics, Western University, London, ON, Canada.,Departments of Medicine, Western University, London, ON, Canada
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Abstract
Hospital-acquired infections are common in neurointensive care units. We sought to review interventions which may reduce infection rates in neurocritically ill populations. We conducted a systematic review of studies targeting adult patients in neuro-intensive care units (neuro-ICUs) with an intervention designed to prevent ICU-acquired infections. Our outcome of interest was change in the prevalence or rates of infection between active and control arms of these studies. We excluded studies based on the following criteria: no English full-text version available; pediatric population; non-neurosciences ICU population; pre- or intraoperative methods to prevent infection; lack of discrete data for infection rates/prevalence; studies that were purely observational in nature and did not test an intervention; and studies performed in resource limited settings. We initially retrieved 3716 results by searching the following databases: PubMed/MEDLINE, EMBASE via Ovid, and Cochrane CENTRAL via Ovid. No date or language limits were used in the search. Computerized deduplication was conducted using EndNote followed by a confirmatory manual review resulting in 3414 citations. An additional 19 manuscripts were identified through review of references. The screening process followed a standard protocol, using two screeners at the title/abstract level to determine relevance and at the full-text level to determine eligibility for inclusion. The 3427 titles/abstracts were independently screened by two board-certified neurointensivists to determine relevance for full-text review, and 3248 were rejected. The remaining 179 abstracts were reviewed in full text using predetermined inclusion/exclusion criteria. Ultimately, 75 articles met our inclusion criteria and were utilized in the final analysis. The reviewed literature highlights the need for collaborative, multi-disciplinary, and multi-pronged approaches to reduce infections. Rates of VRI, SSI, VAP, CAUTI, and CLABSI can approach zero with persistence and a team-based approach.
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Affiliation(s)
- Aaron Sylvan Lord
- Departments of Neurology and Neurosurgery, New York University School of Medicine, New York, NY, USA.
| | - Joseph Nicholson
- NYU Health Sciences Library, New York University School of Medicine, New York, NY, USA
| | - Ariane Lewis
- Departments of Neurology and Neurosurgery, New York University School of Medicine, New York, NY, USA
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21
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Prevention of Ventilator-Associated and Early Postoperative Pneumonia Through Tapered Endotracheal Tube Cuffs: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2019; 46:316-323. [PMID: 29206767 DOI: 10.1097/ccm.0000000000002889] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Microaspiration of subglottic secretions is considered a major pathogenic mechanism of hospital-acquired pneumonia, either early postoperative or ventilator-associated pneumonia. Tapered endotracheal tube cuffs have been proposed to provide a better seal of the extraluminal airway, thereby preventing microaspiration and possibly hospital-acquired pneumonia. We performed a systematic review and meta-analysis to assess the value of endotracheal tubes with tapered cuffs in the prevention of hospital-acquired pneumonia. DATA SOURCES A systematic search of MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, and ICTRP was conducted up to March 2017. STUDY SELECTION Eligible trials were randomized controlled clinical trials comparing the impact of tapered cuffs versus standard cuffs on hospital-acquired pneumonia. DATA EXTRACTION Random-effects meta-analysis calculated odds ratio and 95% CI for hospital-acquired pneumonia occurrence rate between groups. Secondary outcome measures included mortality, duration of mechanical ventilation, length of hospital and ICU stay, and cuff underinflation. DATA SYNTHESIS Six randomized controlled clinical trials with 1,324 patients from intensive care and postoperative wards were included. Only two studies concomitantly applied subglottic secretion drainage, and no trial performed continuous cuff pressure monitoring. No significant difference in hospital-acquired pneumonia incidence per patient was found when tapered cuffs were compared with standard cuffs (odds ratio, 0.97; 95% CI, [0.73-1.28]; p = 0.81). There were likewise no differences in secondary outcomes. CONCLUSIONS Application of tapered endotracheal tube cuffs did not reduce hospital-acquired pneumonia incidence among ICU and postoperative patients. Further research should examine the impact of concomitant use of tapered cuffs with continuous cuff pressure monitoring and subglottic secretion drainage.
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22
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Nates JL, Price KJ. Nosocomial Infections and Ventilator-Associated Pneumonia in Cancer Patients. ONCOLOGIC CRITICAL CARE 2019:1419-1439. [PMCID: PMC7122096 DOI: 10.1007/978-3-319-74588-6_125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Nosocomial infections or healthcare-acquired infections are a common cause of increased morbidity and mortality among hospitalized patients. Cancer patients are at an increased risk for these infections due to their immunosuppressed states. Considering these adverse effects on and the socioeconomic burden, efforts should be made to minimize the transmission of these infections and make the hospitals a safer environment. These infection rates can be significantly reduced by the implementing and improving compliance with the “care bundles.” This chapter will address the common nosocomial infections such as ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSI), including preventive strategies and care bundles for the same.
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Affiliation(s)
- Joseph L. Nates
- Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Kristen J. Price
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX USA
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23
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Wan K, Liang H, Yan G, Zou B, Huang C, Jiang M. A quality assessment of evidence-based guidelines for the prevention and management of ventilator-associated pneumonia: a systematic review. J Thorac Dis 2019; 11:2795-2807. [PMID: 31463108 DOI: 10.21037/jtd.2019.06.56] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Numerous evidence-based guidelines (EBGs) pertaining to ventilator-associated pneumonia (VAP) have been published by domestic and international organizations, but their qualities have not been reported. Methods A systematic search of the literature was performed up to July 2018 for relevant guidelines. Guidelines were eligible for inclusion if they incorporated recommendation statements for prevention and/or management in adults or children with VAP and were developed on a systematic evidence-based method. Four reviewers evaluated each guideline using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, which comprises 23 items organized into six domains in addition to two overall items. Results Thirteen EBGs were identified for review. An overall high degree of agreement among reviewers was reached [intra-class correlation coefficient (ICC), 0.885; 95% CI, 0.862-0.905] during their review. The scores (mean, range) for the six AGREE domains were: scope and purpose (61%, 51-74%), stakeholder involvement (36%, 18-68%), rigor of development (41%, 22-59%), clarity and presentation (56%, 47-71%), applicability (38%, 21-59%) and editorial independence (50%, 0-77%). Only two EBGs (15.4%) were rated "recommended" for clinical practice. Approximately 86% of recommendations were based on moderate or low levels of evidence (levels B-D were 46.2%, 19.0%, and 21.2%, respectively). The recommendations for prevention and management of VAP were similar among the different EBGs. Conclusions The overall quality of the identified EBGs pertaining to VAP was classified as moderate. The management of VAP varied by guideline. More high-quality evidence is needed to improve guideline recommendations.
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Affiliation(s)
- Kairui Wan
- Nanshan School, Guangzhou Medical University, Guangzhou 511436, China.,State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Hengrui Liang
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Guolin Yan
- Nanshan School, Guangzhou Medical University, Guangzhou 511436, China.,State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Bangyu Zou
- Nanshan School, Guangzhou Medical University, Guangzhou 511436, China.,State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Chuxin Huang
- Nanshan School, Guangzhou Medical University, Guangzhou 511436, China.,State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Mei Jiang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
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24
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Johnstone J, Heels-Ansdell D, Thabane L, Meade M, Marshall J, Lauzier F, Duan EH, Zytaruk N, Lamarche D, Surette M, Cook DJ. Evaluating probiotics for the prevention of ventilator-associated pneumonia: a randomised placebo-controlled multicentre trial protocol and statistical analysis plan for PROSPECT. BMJ Open 2019; 9:e025228. [PMID: 31227528 PMCID: PMC6596980 DOI: 10.1136/bmjopen-2018-025228] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in critically ill patients. Prior studies suggest that probiotics may reduce VAP and other infections in critically ill patients; however, most previous randomised trials were small, single centre studies. The Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT) aims to determine the impact of the probiotic Lactobacillus rhamnosus GG on VAP and other clinically important outcomes in critically ill adults. METHODS PROSPECT is a multicentre, concealed, randomised, stratified, blinded, controlled trial in patients ≥18 years old, anticipated to be mechanically ventilated ≥72 hours, in intensive care units (ICUs) in Canada, the USA and Saudi Arabia. Patients receive either 1×1010 colony forming units of L. rhamnosus GG twice daily or an identical appearing placebo. Those at increased risk of probiotic infection are excluded. The primary outcome is VAP. Secondary outcomes are other ICU-acquired infections including Clostridioides difficile infection, diarrhoea (including antibiotic-associated diarrhoea), antimicrobial use, ICU and hospital length of stay and mortality. The planned sample size of 2650 patients is based on an estimated 15% VAP rate and will provide 80% power to detect a 25% relative risk reduction. ETHICS AND DISSEMINATION This protocol and statistical analysis plan outlines the methodology, primary and secondary analyses, sensitivity analyses and subgroup analyses. PROSPECT is approved by Health Canada (#9427-M1133-45C), the research ethics boards of all participating hospitals and Public Health Ontario. Results will be disseminated via academic channels (peer reviewed journal publications, professional healthcare fora including international conferences) and conventional and social media. The results of PROSPECT will inform practice guidelines worldwide. TRIALREGISTRATION NUMBER NCT02462590; Pre-results.
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Affiliation(s)
- Jennie Johnstone
- Public Health Ontario, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Maureen Meade
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - John Marshall
- Surgery/Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Francois Lauzier
- Critical Care, CHU de Quebec-Universite Laval, Quebec, Quebec, Canada
| | | | - Nicole Zytaruk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daphnee Lamarche
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Michael Surette
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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25
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Azab SRE, Sayed AEE, Abdelkarim M, Mutairi KBA, Saqabi AA, Demerdash SE. Combination of ventilator care bundle and regular oral care with chlorhexidine was associated with reduction in ventilator associated pneumonia. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Samia Ragab El Azab
- Specialist at king Fahd Hospital, Buryada, Saudi Arabia
- Anesthesia & Intensive Care, Al Azhar University , Cairo, Egypt
| | | | - Mutaz Abdelkarim
- Director of Informatics and CPD, Ayoun Aljawa Hospital , Saudi Arabia
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26
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Belley-Cote EP, Whitlock RP, Ulic DV, Honarmand K, Khalifa A, McClure GR, Gibson A, Alshamsi F, D'Aragon F, Rochwerg B, Duan E, Savija N, Karachi T, Lamontagne F, Kavsak P, Cook DJ. The PROTROPIC feasibility study: prognostic value of elevated troponins in critical illness. Can J Anaesth 2019; 66:648-657. [PMID: 31037586 DOI: 10.1007/s12630-019-01375-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/22/2018] [Accepted: 11/26/2018] [Indexed: 10/26/2022] Open
Abstract
PURPOSE Elevated cardiac troponin concentrations in people with critical illness are associated with an increased risk of death. We aimed to assess the feasibility of a larger study to ascertain the utility of cardiac troponin as a prognostic tool for mortality in critically ill patients. METHODS Patients admitted to participating intensive care units during the one-month enrolment period were eligible. We excluded cardiac surgical patients and patients who were admitted and either died or were discharged within 12 hr. In enrolled patients, we measured high-sensitivity cardiac troponin I (hs-cTnI) and obtained electrocardiograms to ascertain the incidence of myocardial infarction (MI) and isolated troponin elevation. Our feasibility objectives were to measure recruitment rate, the proportion of patients who consented under a deferred consent model, and time required for data collection and study procedures. RESULTS Over a four-week enrolment period, 280 patients were enrolled using a deferred consent model. We obtained subsequent consent from 81% of patients. Study procedures and data collection required 1.7 hr per participant. Overall, 86 (38%) suffered a MI, 23 (10%) had an isolated hs-cTnI elevation, and 117 (52%) had no hs-cTnI elevation. The crude hospital mortality rate was 10% without an hs-cTnI elevation, 29% with an isolated hs-cTnl elevation (relative risk [RR]) 2.2; 95% confidence interval [CI], 1.0 to 6.0) and 29% with an MI (RR, 2.6; 95% CI, 1.4 to 5.1). CONCLUSION Myocardial injury with elevated hs-cTnI concentrations and MIs occur frequently during critical illness. This pilot study has established the feasibility of conducting a large-scale investigation addressing this issue.
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Affiliation(s)
- Emilie P Belley-Cote
- Department of Medicine, McMaster University, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada. .,Population Health Research Institute, Hamilton, ON, Canada. .,David Braley Cardiac, Vascular and Stroke Research Institute, 237 Barton St. E., Hamilton, ON, L8L 2X2, Canada.
| | - Richard P Whitlock
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Diana V Ulic
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kimia Honarmand
- Department of Medicine, Western University, London, ON, Canada
| | - Abubaker Khalifa
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Graham R McClure
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Andrew Gibson
- Department of Medicine, William Osler Health System, Brampton, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, UAE University, Ain, UAE
| | | | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Erick Duan
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Nevena Savija
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | - Tim Karachi
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
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27
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Wang CY, Li BH, Ma LL, Zhao MJ, Deng T, Jin YH, Ren XQ. The Top-100 Highly Cited Original Articles on Drug Therapy for Ventilator-Associated Pneumonia. Front Pharmacol 2019; 10:108. [PMID: 30809150 PMCID: PMC6379351 DOI: 10.3389/fphar.2019.00108] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 01/28/2019] [Indexed: 02/01/2023] Open
Abstract
Background: In recent decades, research on drug therapy for ventilator-associated pneumonia (VAP) remains one of the major hot-spots in the field of critical care medicine, but relevant data are not satisfactory. Our aim was to assess the status and trends of the most cited articles on drug therapy for VAP through bibliometric approaches. Methods: The Institute for Scientific Information (ISI) Web of Science core collection database was searched for the VAP-related articles. The time period for retrieval was from the beginning of the database to September 30, 2018. The top 100 most cited articles were selected to obtain their information on the authors, title, publication, number of citations, author's affiliations, country, etc. These general information and bibliometric data were collected for analysis. VOSviewer software was used to generate a term co-occurrence graph that visualized a reference pattern for different terms in the 100 articles. Results: The number of citations for the 100 selected articles ranged from 142 to 3,218. These articles were published in 31 different journals. The top three journals in terms of the number of our selected articles they published were "Critical Care Medicine" (17 articles), "American Journal of Respiratory and Critical Care Medicine" (11 articles) and "Clinical Infectious Diseases" (10 articles). The most frequently nominated author was Marin H. Kollef from the University of Washington, and of the top 100 articles, 16 listed his name. These top 100 articles were published after the year of 2000. The most common type of article in the top 100 was an original article (53%). The United States and France were the countries that contributed the most articles to the top 100. Gram-negative bacilli, pseudomonas aeruginosa, antibiotics, risk factors and other terms appeared more frequently, suggesting that attentions on this issue currently focused on the rational application and management of antibiotics. Conclusion: This study analyzed the 100 most cited articles on drug-treated VAP, and provided insights into the historical developments and characteristics of the most cited articles in the field of VAP.
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Affiliation(s)
- Chao-Yang Wang
- Department of General Surgery, Huaihe Hospital of Henan University, Kaifeng, China.,Institute of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, China.,Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Department of Evidence-Based Medicine and Clinical Epidemiology, The Second Clinical College of Wuhan University, Wuhan, China
| | - Bing-Hui Li
- Department of General Surgery, Huaihe Hospital of Henan University, Kaifeng, China.,Institute of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, China.,Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Department of Evidence-Based Medicine and Clinical Epidemiology, The Second Clinical College of Wuhan University, Wuhan, China
| | - Lin-Lu Ma
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Department of Evidence-Based Medicine and Clinical Epidemiology, The Second Clinical College of Wuhan University, Wuhan, China.,Center for Evidence-Based Medicine, Henan University of Chinese Medicine, Zhengzhou, China
| | - Ming-Juan Zhao
- Institute of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, China.,Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Department of Evidence-Based Medicine and Clinical Epidemiology, The Second Clinical College of Wuhan University, Wuhan, China.,Department of Cardiology, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Tong Deng
- Department of General Surgery, Huaihe Hospital of Henan University, Kaifeng, China.,Institute of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, China.,Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Department of Evidence-Based Medicine and Clinical Epidemiology, The Second Clinical College of Wuhan University, Wuhan, China
| | - Ying-Hui Jin
- Institute of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, China.,Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Department of Evidence-Based Medicine and Clinical Epidemiology, The Second Clinical College of Wuhan University, Wuhan, China
| | - Xue-Qun Ren
- Department of General Surgery, Huaihe Hospital of Henan University, Kaifeng, China.,Institute of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, China
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Hannan MM, Xie R, Cowger J, Schueler S, de By T, Dipchand AI, Chu VH, Cantor RS, Koval CE, Krabatsch T, Hayward CS, Nakatani T, Kirklin JK. Epidemiology of infection in mechanical circulatory support: A global analysis from the ISHLT Mechanically Assisted Circulatory Support Registry. J Heart Lung Transplant 2019; 38:364-373. [PMID: 30733158 DOI: 10.1016/j.healun.2019.01.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/06/2019] [Accepted: 01/09/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Despite advances in device technology and treatment strategies, infection remains a major cause of adverse events (AEs) in mechanical circulatory support (MCS) patients. To characterize the epidemiology of MCS infection, we examined the type, location, and timing of infection in the International Society for Heart and Lung Transplantation Registry (ISHLT) for Mechanically Assisted Circulatory Support (IMACS) over 3 years, 2013 to 2015. METHODS Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) definitions were used to categorize AE infections occurring in MCS patients within IMACS. The IMACS infection variables were mapped to ISHLT definitions for infection where feasible. Three categories of MCS infection were defined as ventricular assist device (VAD) specific, VAD related, and non-VAD. RESULTS There were 10,171 patients enrolled from January 2013 through December 2015. Infection was the most common AE, with 3,788 patients (37%) experiencing ≥ 1 infection, and 6,758 AE infections reported overall. Non-VAD infection was the largest category, 4,501: 34.0% pneumonias, 30.6% non-VAD-related bloodstream infections (BSIs), 24.15% urinary tract infections (UTIs), and 10.2% gastrointestinal infections. VAD-specific infection was the second largest category, 1,756: 82.9% driveline, 12.8% pocket, and 4.3% pump/or cannula infections. VAD-related infection was the smallest category, 501: 47.5% BSIs, 47.5% mediastinitis, and 5.0% mediastinitis/pocket infections. All 3 categories were more frequently reported ≤ 3 months after implant. CONCLUSIONS Non-VAD infection, including pneumonia, BSI, UTI, and gastrointestinal infection, was the leading category of infection in MCS patients and the most frequently reported ≤ 3 months after implant. These results provide evidence to support resourcing and strengthening infection prevention strategy early after implantation in MCS.
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Affiliation(s)
- Margaret M Hannan
- Department of Clinical Microbiology, Mater Misercordiae University Hospital, University College Dublin, Dublin, Ireland.
| | - Rongbing Xie
- James and John Kirklin Institute for Research in Surgical Outcomes (KIRSO), University of Alabama, Birmingham, Alabama
| | - Jennifer Cowger
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Stephan Schueler
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Theo de By
- EUROMACS, EACTS, Windsor, United Kingdom
| | - Anne I Dipchand
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Ryan S Cantor
- James and John Kirklin Institute for Research in Surgical Outcomes (KIRSO), University of Alabama, Birmingham, Alabama
| | - Christine E Koval
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Thomas Krabatsch
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany
| | - Christopher S Hayward
- Heart Failure and Transplant Unit, Vincent's Hospital, Sydney, New South Wales, Australia
| | | | - James K Kirklin
- James and John Kirklin Institute for Research in Surgical Outcomes (KIRSO), University of Alabama, Birmingham, Alabama
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Lacherade JC, Azais MA, Pouplet C, Colin G. Subglottic secretion drainage for ventilator-associated pneumonia prevention: an underused efficient measure. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:422. [PMID: 30581830 DOI: 10.21037/atm.2018.10.40] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Subglottic secretion drainage (SSD) is one of the recommended strategies to prevent ventilator-associated pneumonia (VAP) with a high level of evidence, especially regarding early-onset pneumonia. All meta-analysis found that the use of SSD reduces VAP occurrence with a relative risk (RR) reduction of 45%. In some of them, SSD reduces the duration of mechanical ventilation (MV) but without beneficial effect on intensive care unit (ICU) or hospital mortality. In spite of the edited recommendations, SSD has not been widely implemented in ICUs and remains underused. Several factors could account for this: doubts on the innocuousness of using SSD, persisting reservations on the SSD effect on other outcomes than VAP, a high variability in the volume of secretions suctioned between patients and, for each individual patient, during the period of MV and the initial increased expense of the specific endotracheal tubes (ETs) allowing SSD which limits the availability of these devices.
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Affiliation(s)
- Jean-Claude Lacherade
- District Hospital Center, Medical-Surgical Intensive Care Unit, La Roche-sur-Yon, France
| | - Marie-Ange Azais
- District Hospital Center, Medical-Surgical Intensive Care Unit, La Roche-sur-Yon, France
| | - Caroline Pouplet
- District Hospital Center, Medical-Surgical Intensive Care Unit, La Roche-sur-Yon, France
| | - Gwenhael Colin
- District Hospital Center, Medical-Surgical Intensive Care Unit, La Roche-sur-Yon, France
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30
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Álvarez-Lerma F, Sánchez García M. "The multimodal approach for ventilator-associated pneumonia prevention"-requirements for nationwide implementation. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:420. [PMID: 30581828 PMCID: PMC6275409 DOI: 10.21037/atm.2018.08.40] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 08/17/2018] [Indexed: 01/06/2023]
Abstract
The multimodal approach for ventilator-associated pneumonia (VAP) prevention has been shown to be a successful strategy in reducing VAP rates in many intensive care units (ICU) in some countries. The simultaneous application of several measures or "bundles" to reduce VAP rates has achieved a higher impact than the progressive implementation of the individual interventions. The ultimate objective of recommendation bundles is their integration in the culture of routine healthcare of the staff in charge of ventilated patients for accomplished rates to persist over time. The noteworthy elements of this new strategy include the selection of the individual recommendations of the bundle, education of care workers (HCW) in the culture of patient safety, audit of compliance with the recommendations, commitment of the hospital management to support implementation, nomination and empowerment of local leaders of the projects in ICUs, both physicians and nurses, and the continuous collection of VAP episodes. The implementation of this new strategy is not an easy task, as both its inherent strength and important barriers to its application have become evident, which need to be overcome for maximal reduction of VAP rates.
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Affiliation(s)
- Francisco Álvarez-Lerma
- Service of Intensive Care Medicine, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M. Sánchez García
- Department of Critical Care, Hospital Clínico San Carlos, Madrid, Spain
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31
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Ambaras Khan R, Aziz Z. The methodological quality of guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia: A systematic review. J Clin Pharm Ther 2018; 43:450-459. [PMID: 29722052 DOI: 10.1111/jcpt.12696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/27/2018] [Indexed: 12/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Clinical practice guidelines serve as a framework for physicians to make decisions and to support best practice for optimizing patient care. However, if the guidelines do not address all the important components of optimal care sufficiently, the quality and validity of the guidelines can be reduced. The objectives of this study were to systematically review current guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), evaluate their methodological quality and highlight the similarities and differences in their recommendations for empirical antibiotic and antibiotic de-escalation strategies. METHODS This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Electronic databases including MEDLINE, CINAHL, PubMed and EMBASE were searched up to September 2017 for relevant guidelines. Other databases such as NICE, Scottish Intercollegiate Guidelines Network (SIGN) and the websites of professional societies were also searched for relevant guidelines. The quality and reporting of included guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument. RESULTS AND DISCUSSION Six guidelines were eligible for inclusion in our review. Among 6 domains of AGREE-II, "clarity of presentation" scored the highest (80.6%), whereas "applicability" scored the lowest (11.8%). All the guidelines supported the antibiotic de-escalation strategy, whereas the majority of the guidelines (5 of 6) recommended that empirical antibiotic therapy should be implemented in accordance with local microbiological data. All the guidelines suggested that for early-onset HAP/VAP, therapy should start with a narrow spectrum empirical antibiotic such as penicillin or cephalosporins, whereas for late-onset HAP/VAP, the guidelines recommended the use of a broader spectrum empirical antibiotic such as the penicillin extended spectrum carbapenems and glycopeptides. WHAT IS NEW AND CONCLUSIONS Expert guidelines promote the judicious use of antibiotics and prevent antibiotic overuse. The quality and validity of available HAP/VAP guidelines would be enhanced by improving their adherence to accepted best practice for the management of HAP and VAP.
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Affiliation(s)
- R Ambaras Khan
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Z Aziz
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Álvarez-Lerma F, Palomar-Martínez M, Sánchez-García M, Martínez-Alonso M, Álvarez-Rodríguez J, Lorente L, Arias-Rivera S, García R, Gordo F, Añón JM, Jam-Gatell R, Vázquez-Calatayud M, Agra Y. Prevention of Ventilator-Associated Pneumonia: The Multimodal Approach of the Spanish ICU "Pneumonia Zero" Program. Crit Care Med 2018; 46:181-188. [PMID: 29023261 PMCID: PMC5770104 DOI: 10.1097/ccm.0000000000002736] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The "Pneumonia Zero" project is a nationwide multimodal intervention based on the simultaneous implementation of a comprehensive evidence-based bundle measures to prevent ventilator-associated pneumonia in critically ill patients admitted to the ICU. DESIGN Prospective, interventional, and multicenter study. SETTING A total of 181 ICUs throughout Spain. PATIENTS All patients admitted for more than 24 hours to the participating ICUs between April 1, 2011, and December 31, 2012. INTERVENTION Ten ventilator-associated pneumonia prevention measures were implemented (seven were mandatory and three highly recommended). The database of the National ICU-Acquired Infections Surveillance Study (Estudio Nacional de Vigilancia de Infecciones Nosocomiales [ENVIN]) was used for data collection. Ventilator-associated pneumonia rate was expressed as incidence density per 1,000 ventilator days. Ventilator-associated pneumonia rates from the incorporation of the ICUs to the project, every 3 months, were compared with data of the ENVIN registry (April-June 2010) as the baseline period. Ventilator-associated pneumonia rates were adjusted by characteristics of the hospital, including size, type (public or private), and teaching (postgraduate) or university-affiliated (undergraduate) status. MEASUREMENTS AND MAIN RESULTS The 181 participating ICUs accounted for 75% of all ICUs in Spain. In a total of 171,237 ICU admissions, an artificial airway was present on 505,802 days (50.0% of days of stay in the ICU). A total of 3,474 ventilator-associated pneumonia episodes were diagnosed in 3,186 patients. The adjusted ventilator-associated pneumonia incidence density rate decreased from 9.83 (95% CI, 8.42-11.48) per 1,000 ventilator days in the baseline period to 4.34 (95% CI, 3.22-5.84) after 19-21 months of participation. CONCLUSIONS Implementation of the bundle measures included in the "Pneumonia Zero" project resulted in a significant reduction of more than 50% of the incidence of ventilator-associated pneumonia in Spanish ICUs. This reduction was sustained 21 months after implementation.
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Affiliation(s)
- Francisco Álvarez-Lerma
- Service of Intensive Care Medicine, Spanish Society of Intensive and Critical Care Medicine and Research Group in Critical Disorders (GREPAC), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Coronary Units (SEMICYUC) Working Group on Infectious Diseases, Hospital del Mar, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mercedes Palomar-Martínez
- Service of Intensive Care Medicine, Spanish Society of Intensive and Critical Care Medicine and Research Group in Critical Disorders (GREPAC), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Coronary Units (SEMICYUC) Working Group on Infectious Diseases, Hospital del Mar, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Miguel Sánchez-García
- Working Group on Infectious Diseases, SEMICYUC, Department of Critical Care, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Joaquín Álvarez-Rodríguez
- Service of Intensive Care Medicine, SEMICYUC Working Group on Safety, Quality and Management, Hospital de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | - Leonardo Lorente
- Service of Intensive Care Medicine, SEMICYUC Working Group on Infectious Diseases, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - Susana Arias-Rivera
- Service of Intensive Care Medicine, Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC), Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - Rosa García
- Service of Anesthesiology and Resuscitation, SEEIUC, Hospital Universitario de Basurto, Bilbao, Bizkaia, Spain
| | - Federico Gordo
- Service of Intensive Care Medicine, SEMICYUC Working Group on Acute Respiratory Insufficiency, Hospital Universitario del Henares, Colsada, Madrid, Spain
| | - José M. Añón
- Service of Intensive Care Medicine, SEMICYUC Working Group on Acute Respiratory Insufficiency, CIBER of Respiratory Diseases, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - Rosa Jam-Gatell
- Critical Care Center, SEEIUC, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Tauli I3P3, Sabadell, Barcelona, Spain
| | - Mónica Vázquez-Calatayud
- Area of Nursing Research Training and Development, SEEIUC, Clínica Universidad de Navarra, Pamplona, Spain
| | - Yolanda Agra
- Patient Safety Unit, Spanish Ministry of Health, Social Policy and Equality, Madrid, Spain
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33
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Weng H, Li JG, Mao Z, Feng Y, Wang CY, Ren XQ, Zeng XT. Probiotics for Preventing Ventilator-Associated Pneumonia in Mechanically Ventilated Patients: A Meta-Analysis with Trial Sequential Analysis. Front Pharmacol 2017; 8:717. [PMID: 29062279 PMCID: PMC5640711 DOI: 10.3389/fphar.2017.00717] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 09/25/2017] [Indexed: 11/13/2022] Open
Abstract
Background and Objective: Ventilator-associated pneumonia (VAP) is still an important cause of morbidity and mortality in mechanically ventilated patients. The efficacy of the probiotics for preventing VAP is still controversial. Present study was conducted to comprehensively evaluate the effect of probiotics on VAP prevention in mechanically ventilated patients. Methods: PubMed, Embase, and CENTRAL were searched up to September 2016. Eligible trials designed with randomized controlled trials (RCTs) comparing probiotics with control in mechanically ventilated patients were included. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were estimated with fixed or random effects models. Trial sequential analysis (TSA) was performed using TSA 0.9beta software. Results: Thirteen RCTs (N = 1969) were included. Overall, probiotics were associated with reduced incidence of VAP (RR = 0.73, 95% CI = 0.60–0.89; P = 0.002), which was confirmed by TSA (TSA adjusted 95% CI = 0.55–0.96). However, no significant difference was observed in 90-day mortality (RR = 1.00, 95% CI = 0.72–1.37; P = 0.99), overall mortality (RR = 0.84, 95% CI = 0.70–1.02; P = 0.09), 28-day mortality (RR = 1.06, 95% CI = 0.72–1.57; P = 0.99), intensive care unit (ICU) mortality (RR = 0.97, 95% CI = 0.74–1.27; P = 0.82), hospital mortality (RR = 0.81, 95% CI = 0.65–1.02; P = 0.07), diarrhea (RR = 0.99, 95% CI = 0.83–1.19; P = 0.92), length of ICU stay (MD = −2.40 days, 95% CI = −6.75 to 1.95; P = 0.28), length of hospital stay (MD = −1.34 days, 95% CI = −6.21 to 3.54; P = 0.59), and duration of mechanical ventilation (MD = −3.32 days, 95% CI = −6.74 to 0.09; P = 0.06). Conclusions: In this meta-analysis, we found that probiotics could reduce the incidence of VAP in mechanically ventilated patients. It seems likely that probiotics provide clinical benefits for mechanically ventilated patients.
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Affiliation(s)
- Hong Weng
- Center of Evidence Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jian-Guo Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhi Mao
- Department of Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Ying Feng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chao-Yang Wang
- Center of Evidence Based Medicine, Huaihe Hospital of Henan University, Kaifeng, China
| | - Xue-Qun Ren
- Center of Evidence Based Medicine, Huaihe Hospital of Henan University, Kaifeng, China
| | - Xian-Tao Zeng
- Center of Evidence Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
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Mehta S, Burns KEA, Machado FR, Fox-Robichaud AE, Cook DJ, Calfee CS, Ware LB, Burnham EL, Kissoon N, Marshall JC, Mancebo J, Finfer S, Hartog C, Reinhart K, Maitland K, Stapleton RD, Kwizera A, Amin P, Abroug F, Smith O, Laake JH, Shrestha GS, Herridge MS. Gender Parity in Critical Care Medicine. Am J Respir Crit Care Med 2017; 196:425-429. [PMID: 28240961 DOI: 10.1164/rccm.201701-0076cp] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. These documents inform and shape patient care around the world. In this Perspective we discuss the importance of diversity on guideline panels, the disproportionately low representation of women on critical care guideline panels, and existing initiatives to increase the representation of women in corporations, universities, and government. We propose five strategies to ensure gender parity within critical care medicine.
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Affiliation(s)
- Sangeeta Mehta
- 1 Department of Medicine.,2 Interdepartmental Division of Critical Care Medicine.,3 Sinai Health System
| | - Karen E A Burns
- 4 Canadian Critical Care Society, Markham, Ontario, Canada.,5 Interdepartmental Division of Critical Care Medicine and.,6 Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Flavia R Machado
- 7 Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Alison E Fox-Robichaud
- 4 Canadian Critical Care Society, Markham, Ontario, Canada.,8 Hamilton Health Sciences, Thrombosis and Atherosclerosis Research Institute.,9 Department of Medicine
| | - Deborah J Cook
- 10 Clinical Epidemiology and Biostatistics, and.,11 Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Carolyn S Calfee
- 12 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine and.,13 Cardiovascular Research Institute, University of California, San Francisco, California
| | - Lorraine B Ware
- 14 Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ellen L Burnham
- 15 Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Niranjan Kissoon
- 16 Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - John C Marshall
- 5 Interdepartmental Division of Critical Care Medicine and.,17 Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.,6 Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Jordi Mancebo
- 18 University of Montreal Hospital Center and.,19 Division of Intensive Care, University of Montreal, Montreal, Quebec, Canada
| | - Simon Finfer
- 20 Division of Critical Care and Trauma, The George Institute for Global Health, Sydney, Australia.,21 University of Sydney, Sydney, Australia
| | - Christiane Hartog
- 22 Department of Anesthesiology and Intensive Care, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Konrad Reinhart
- 22 Department of Anesthesiology and Intensive Care, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,23 Global Sepsis Alliance, Jena, Germany
| | - Kathryn Maitland
- 24 Wellcome Trust Centre for Clinical Tropical Medicine, Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Renee D Stapleton
- 25 Division of Pulmonary and Critical Care Medicine, University of Vermont, Burlington, Vermont
| | - Arthur Kwizera
- 26 Department of Anesthesia and Critical Care, Makerere University, Kampala, Uganda
| | - Pravin Amin
- 27 Department of Critical Care Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Fekri Abroug
- 28 Centre Hospitalo-Universitaire Fattouma Bourguiba, Monastir, Tunisia
| | - Orla Smith
- 29 Lawrence S. Bloomberg Faculty of Nursing, and.,5 Interdepartmental Division of Critical Care Medicine and.,6 Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Jon H Laake
- 30 Scandinavian Society of Anaesthesiology and Intensive Care Medicine.,31 Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway; and
| | - Gentle S Shrestha
- 32 Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Margaret S Herridge
- 1 Department of Medicine.,2 Interdepartmental Division of Critical Care Medicine.,33 University Health Network, University of Toronto, Toronto, Ontario, Canada
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Ding C, Zhang Y, Yang Z, Wang J, Jin A, Wang W, Chen R, Zhan S. Incidence, temporal trend and factors associated with ventilator-associated pneumonia in mainland China: a systematic review and meta-analysis. BMC Infect Dis 2017; 17:468. [PMID: 28676087 PMCID: PMC5496595 DOI: 10.1186/s12879-017-2566-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 06/23/2017] [Indexed: 12/17/2022] Open
Abstract
Background Data to date is far from sufficient to describe the recent epidemiology of ventilator-associated pneumonia (VAP) in mainland China. This study aimed to estimate the overall incidence of VAP, with a special focus on its temporal trend and associated factors. Methods Meta-analyses of 195 studies published from 2010 to 2015 were conducted, followed by subgroup analyses by methodological quality, pre-defined setting characteristics and attributes of populations. Results The overall cumulative VAP incidence in mainland China was 23.8% (95% confidence interval (CI) 20.6–27.2%), with the results showing high heterogeneity. The pooled incidence densities were 24.14 (95% CI 21.19–27.51) episodes and 22.83 (95% CI 19.88–26.23) patients per 1000 ventilator-days. A decline in the cumulative incidence was observed from 2006 (49.5%, 95% CI 40.0–59.0%) to 2014 (19.6%, 95% CI 10.4–31.0%); differences in the incidence rates were also documented according to Chinese provinces and diagnostic criteria (p < 0.001). Older age (≥60 years), coma, re-intubation, tracheotomy and prolonged ventilation were the factors significantly associated with the occurrence of VAP. Conclusions The incidence of VAP remains high in mainland China but has decreased since 2006. The reported rates vary considerably across individual studies, probably due to variations in diagnosis and geographical region. More studies using standard definitions and cut-off points are needed to better clarify the epidemiology of VAP across the country. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2566-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chengyi Ding
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, 38 Xueyuan Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yuelun Zhang
- Division of Epidemiology, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Zhirong Yang
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridgeshire, UK
| | - Jing Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, 38 Xueyuan Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Aoming Jin
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, 38 Xueyuan Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Weiwei Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, 38 Xueyuan Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Ru Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, 38 Xueyuan Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, 38 Xueyuan Road, Haidian District, Beijing, 100191, People's Republic of China.
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Huyett P, Rowan NR, Ferguson BJ, Lee S, Wang EW. The Relationship of Paranasal Sinus Opacification to Hospital-Acquired Pneumonia in the Neurologic Intensive Care Unit Patient. J Intensive Care Med 2017; 34:844-850. [PMID: 28675112 DOI: 10.1177/0885066617718458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The association between intensive care unit (ICU) sinusitis and the development of lower airway infections remains unclear. The objective of this study was to determine the correlation between the development of radiographic sinus opacification and pneumonia in the neurologic ICU setting. METHODS A retrospective review of head computed tomography or magnetic resonance imaging of 612 patients admitted to the neurocritical care unit at a tertiary care center from April 2013 through April 2014 was performed. Paranasal sinus opacification was measured using Lund-Mackay scores (LMS). A diagnosis of pneumonia was determined by the ICU team from radiographic, laboratory, and pulmonary data. Exclusion criteria included a history of endonasal surgery, sinonasal malignancy, facial fractures, ICU admission less than 3 days, or inadequate imaging. RESULTS Worsening sinus opacification occurred in 42.6% of patients and pneumonia in 18.5% of patients during ICU admission. Of the patients who developed pneumonia, 71.7% also developed worsening sinus opacification (P < .001). In 80.2% of cases, the sinus opacification developed prior to the diagnosis of pneumonia. The mean highest LMS for patients who developed pneumonia was 4.24 compared to 1.99 in patients who did not develop pneumonia (P < .001). Sinus air-fluid levels or complete sinus opacification occurred in a larger proportion of patients who developed pneumonia (46.9% vs 19.4%, P < .001). Mortality rates for patients with no pneumonia or sinusitis, pneumonia only, sinusitis only, and sinusitis with pneumonia were 7.6%, 15.6%, 18.3%, and 25.9%, respectively (P < .001). CONCLUSIONS This study finds a strong relationship between worsening sinus opacification in the neurologic ICU patient to the development of hospital-acquired pneumonia and increased mortality.
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Affiliation(s)
- Phillip Huyett
- 1 Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nicholas R Rowan
- 1 Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Berrylin J Ferguson
- 1 Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stella Lee
- 1 Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Eric W Wang
- 1 Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Effect of Prior Atorvastatin Treatment on the Frequency of Hospital Acquired Pneumonia and Evolution of Biomarkers in Patients with Acute Ischemic Stroke: A Multicenter Prospective Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5642704. [PMID: 28357403 PMCID: PMC5357518 DOI: 10.1155/2017/5642704] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 12/23/2016] [Accepted: 01/04/2017] [Indexed: 02/05/2023]
Abstract
Objective. To investigate whether prior treatment of atorvastatin reduces the frequency of hospital acquired pneumonia (HAP). Methods. Totally, 492 patients with acute ischemic stroke and Glasgow Coma Scale ≤ 8 were enrolled in this study. Subjects were assigned to prior atorvastatin treatment group (n = 268, PG) and no prior treatment group (n = 224, NG). All the patients were given 20 mg atorvastatin every night during their hospital stay. HAP frequency and 28-day mortality were measured. Levels of inflammatory biomarkers [white blood cell (WBC), procalcitonin (PCT), tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6)] were tested. Results. There was no significant difference in the incidence of HAP between PG and NG (25.74% versus. 24.55%, p > 0.05) and 28-day mortality (50.72% versus 58.18%, p > 0.05). However, prior statin treatment did modify the mortality of ventilator associated pneumonia (VAP) (36.54% versus 58.14%, p = 0.041) and proved to be a protective factor (HR, 0.564; 95% CI, 0.310~0.825, p = 0.038). Concentrations of TNF-α and IL-6 in PG VAP cases were lower than those in NG VAP cases (p < 0.01). Conclusions. Prior atorvastatin treatment in patients with ischemic stroke was associated with a lower concentration of IL-6 and TNF-α and improved the outcome of VAP. This clinical study has been registered with ChiCTR-ROC-17010633 in Chinese Clinical Trial Registry.
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Holubar SD, Hedrick T, Gupta R, Kellum J, Hamilton M, Gan TJ, Mythen MG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery. Perioper Med (Lond) 2017; 6:4. [PMID: 28270910 PMCID: PMC5335800 DOI: 10.1186/s13741-017-0059-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 01/11/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Colorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections. METHODS With input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients. DISCUSSION As a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).
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Affiliation(s)
- Stefan D. Holubar
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
| | - Traci Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA USA
| | - Ruchir Gupta
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, NY USA
| | - John Kellum
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Mark Hamilton
- Department of Intensive Care Medicine and Anaesthesia, St. George’s Hospital and Medical School, London, UK
| | - Tong J. Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, NY USA
| | - Monty G. Mythen
- Department of Anesthesia, UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D. Shaw
- Department of Anesthesiology, Vanderbilt University, Nashville, TN USA
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC USA
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Tabaeian SM, Yazdannik A, Abbasi S. Compliance with the Standards for Prevention of Ventilator-Associated Pneumonia by Nurses in the Intensive Care Units. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2017; 22:31-36. [PMID: 28382055 PMCID: PMC5364749 DOI: 10.4103/1735-9066.202073] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is the most common infection in the intensive care unit, and has many side effects such as increased mortality, increased length of hospital stay, and increased health costs. This study aimed to evaluate the compliance with the standards for prevention of VAP by nurses in the intensive care units. MATERIALS AND METHODS In this descriptive cross-sectional study, 120 nurses in 11 intensive care units of hospitals affiliated to Isfahan university of Medical Sciences, Iran, were assessed for 4 months from July to October 2014. The implementation of all measures for the prevention of VAP was investigated through observation and using a checklist. RESULTS The mean compliance with the standards for the prevention of VAP in the intensive care unit by the nurses was 56.32%; analysis of variance test showed significant difference between the hospitals (P < 0.001). Disposable ventilator circuit was performed for all patients; however, reviewing the patient readiness for separation from the ventilator was not conducted on a daily basis. CONCLUSIONS Compliance with the standards for the prevention of VAP in the intensive care units was relatively acceptable; however, it still requires serious attention by the officials with training and sensitization of nurses in implementing preventive measures, especially through the provision of clinical guidelines and related protocols.
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Affiliation(s)
- Saiede Masomeh Tabaeian
- Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmadreza Yazdannik
- Department of Critical Care Nursing, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Abbasi
- Department of Anesthesiology and Intensive Care, Isfahan University of Medical Sciences, Isfahan, Iran
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Hassan ZM, Wahsheh MA. Knowledge level of nurses in Jordan on ventilator-associated pneumonia and preventive measures. Nurs Crit Care 2016; 22:125-132. [PMID: 28008700 DOI: 10.1111/nicc.12273] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 10/07/2016] [Accepted: 11/01/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia is the most prevalent infection in Intensive Care Units, with the highest mortality rate; crude mortality rates may be as high as 20-75%. Many practices such as prevention measures (e.g. hand washing, wearing gloves, suctioning, elevated head of bed between 30° and 45°) have demonstrated an effect of reducing the incidence of this infection. AIMS To identify the level of nurses' knowledge of ventilator-associated pneumonia and prevention measures before an educational programme, identify the level of nurses' knowledge on ventilator-associated pneumonia and prevention post an educational programme and identify the reasons for not applying ventilator-associated pneumonia prevention measures among nurses in Jordan. DESIGN Pre- and post-intervention observational study. METHOD Data based on a self-reported questionnaire from 428 nurses who worked in intensive care units were analysed. PowerPoint lectures, videos, printed materials and electronic materials were used in the intervention. Paired t-tests were used to test research questions. RESULTS More than three-quarters of nurses had a low knowledge level regarding pathophysiology, risk factors and ventilator-associated pneumonia preventative measures. Nurses showed significant improvements in mean scores on the knowledge level of ventilator-associated pneumonia and prevention measures after an educational programme (p < 0.05). The main reasons for not applying prevention measures were the lack of time and no followed protocols in the units. CONCLUSION Health education programmes about ventilator-associated pneumonia must be conducted among nurses in Jordan through continuous education. RELEVANCE TO CLINICAL PRACTICE Hospital and nursing administrators should be actively involved in educational programmes and in assuring support for continuing education. Protocol for ventilator-associated pneumonia prevention should be developed based on current evidence-based guidelines.
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Affiliation(s)
| | - Moayad A Wahsheh
- Faculty of Physical Education and Sport Sciences, Hashemite University, Zarqa, Jordan
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Hua F, Xie H, Worthington HV, Furness S, Zhang Q, Li C. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev 2016; 10:CD008367. [PMID: 27778318 PMCID: PMC6460950 DOI: 10.1002/14651858.cd008367.pub3] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in people who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, toothbrush, or combination, together with aspiration of secretions, may reduce the risk of VAP in these patients. OBJECTIVES To assess the effects of oral hygiene care on incidence of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation in hospital intensive care units (ICUs). SEARCH METHODS We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 17 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 11), MEDLINE Ovid (1946 to 17 December 2015), Embase Ovid (1980 to 17 December 2015), LILACS BIREME Virtual Health Library (1982 to 17 December 2015), CINAHL EBSCO (1937 to 17 December 2016), Chinese Biomedical Literature Database (1978 to 14 January 2013), China National Knowledge Infrastructure (1994 to 14 January 2013), Wan Fang Database (January 1984 to 14 January 2013) and VIP Database (January 2012 to 4 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials to 17 December 2015. We placed no restrictions on the language or date of publication when searching the electronic databases. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation for at least 48 hours. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed search results, extracted data and assessed risk of bias in included studies. We contacted study authors for additional information. We pooled data from trials with similar interventions and outcomes. We reported risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, using random-effects models unless there were fewer than four studies. MAIN RESULTS We included 38 RCTs (6016 participants). There were four main comparisons: chlorhexidine (CHX) mouthrinse or gel versus placebo/usual care; toothbrushing versus no toothbrushing; powered versus manual toothbrushing; and comparisons of oral care solutions. We assessed the overall risk of bias as low in five trials (13%), high in 26 trials (68%), and unclear in seven trials (18%). We did not consider the risk of bias to be serious when assessing the quality of evidence (GRADE) for VAP incidence, but we downgraded other outcomes for risk of bias.High quality evidence from 18 RCTs (2451 participants, 86% adults) shows that CHX mouthrinse or gel, as part of OHC, reduces the risk of VAP compared to placebo or usual care from 25% to about 19% (RR 0.74, 95% confidence intervals (CI) 0.61 to 0.89, P = 0.002, I2 = 31%). This is equivalent to a number needed to treat for an additional beneficial outcome (NNTB) of 17 (95% CI 10 to 33), which indicates that for every 17 ventilated patients in intensive care receiving OHC including chlorhexidine, one outcome of VAP would be prevented. There is no evidence of a difference between CHX and placebo/usual care for the outcomes of mortality (RR 1.09, 95% CI 0.96 to 1.23, P = 0.18, I2 = 0%, 15 RCTs, 2163 participants, moderate quality evidence), duration of mechanical ventilation (MD -0.09 days, 95% CI -1.73 to 1.55 days, P = 0.91, I2 = 36%, five RCTs, 800 participants, low quality evidence), or duration of intensive care unit (ICU) stay (MD 0.21 days, 95% CI -1.48 to 1.89 days, P = 0.81, I2 = 9%, six RCTs, 833 participants, moderate quality evidence). There is insufficient evidence to determine the effect of CHX on duration of systemic antibiotics, oral health indices, caregivers' preferences or cost. Only two studies reported any adverse effects, and these were mild with similar frequency in CHX and control groups.We are uncertain as to the effects of toothbrushing (± antiseptics) on the outcomes of VAP (RR 0.69, 95% CI 0.44 to 1.09, P = 0.11, I2 = 64%, five RCTs, 889 participants, very low quality evidence) and mortality (RR 0.87, 95% CI 0.70 to 1.09, P = 0.24, I2 = 0%, five RCTs, 889 participants, low quality evidence) compared to OHC without toothbrushing (± antiseptics). There is insufficient evidence to determine whether toothbrushing affects duration of mechanical ventilation, duration of ICU stay, use of systemic antibiotics, oral health indices, adverse effects, caregivers' preferences or cost.Only one trial (78 participants) compared use of a powered toothbrush with a manual toothbrush, providing insufficient evidence to determine the effect on any of the outcomes of this review.Fifteen trials compared various other oral care solutions. There is very weak evidence that povidone iodine mouthrinse is more effective than saline/placebo (RR 0.69, 95% CI 0.50 to 0.95, P = 0.02, I2 = 74%, three studies, 356 participants, high risk of bias), and that saline rinse is more effective than saline swab (RR 0.47, 95% CI 0.37 to 0.62, P < 0.001, I2 = 84%, four studies, 488 participants, high risk of bias) in reducing VAP. Due to variation in comparisons and outcomes among trials, there is insufficient evidence concerning the effects of other oral care solutions. AUTHORS' CONCLUSIONS OHC including chlorhexidine mouthwash or gel reduces the risk of developing ventilator-associated pneumonia in critically ill patients from 25% to about 19%. However, there is no evidence of a difference in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay. There is no evidence that OHC including both antiseptics and toothbrushing is different from OHC with antiseptics alone, and some weak evidence to suggest that povidone iodine mouthrinse is more effective than saline/placebo, and saline rinse is more effective than saline swab in reducing VAP. There is insufficient evidence to determine whether powered toothbrushing or other oral care solutions are effective in reducing VAP. There is also insufficient evidence to determine whether any of the interventions evaluated in the studies are associated with adverse effects.
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Affiliation(s)
- Fang Hua
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthOxford RoadManchesterUKM13 9PL
| | - Huixu Xie
- West China College of Stomatology, Sichuan UniversityDepartment of Oral and Maxillofacial Surgery, State Key Laboratory of Oral DiseasesNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthOxford RoadManchesterUKM13 9PL
| | - Susan Furness
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthOxford RoadManchesterUKM13 9PL
| | - Qi Zhang
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan UniversityDepartment of Oral ImplantologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
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Muscedere J, Maslove D, Boyd JG, O'Callaghan N, Lamontagne F, Reynolds S, Albert M, Hall R, McGolrick D, Jiang X, Day AG. Prevention of nosocomial infections in critically ill patients with lactoferrin (PREVAIL study): study protocol for a randomized controlled trial. Trials 2016; 17:474. [PMID: 27681799 PMCID: PMC5041570 DOI: 10.1186/s13063-016-1590-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/02/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Nosocomial infections remain an important source of morbidity, mortality, and increased health care costs in hospitalized patients. This is particularly problematic in intensive care units (ICUs) because of increased patient vulnerability due to the underlying severity of illness and increased susceptibility from utilization of invasive therapeutic and monitoring devices. Lactoferrin (LF) and the products of its breakdown have multiple biological effects, which make its utilization of interest for the prevention of nosocomial infections in the critically ill. METHODS/DESIGN This is a phase II randomized, multicenter, double-blinded trial to determine the effect of LF on antibiotic-free days in mechanically ventilated, critically ill, adult patients in the ICU. Eligible, consenting patients will be randomized to receive either LF or placebo. The treating clinician will remain blinded to allocation during the study; blinding will be maintained by using opaque syringes and containers. The primary outcome will be antibiotic-free days, defined as the number of days alive and free of antibiotics 28 days after randomization. Secondary outcomes will include: antibiotic utilization, adjudicated diagnosis of nosocomial infection (longer than 72 h of admission to ICU), hospital and ICU length of stay, change in organ function after randomization, hospital and 90-day mortality, incidence of tracheal colonization, changes in gastrointestinal permeability, and immune function. Outcomes to inform the conduct of a larger definitive trial will also be evaluated, including feasibility as determined by recruitment rates and protocol adherence. DISCUSSION The results from this study are expected to provide insight into a potential novel therapeutic use for LF in critically ill adult patients. Further, analysis of study outcomes will inform a future, large-scale phase III randomized controlled trial powered on clinically important outcomes related to the use of LF. TRIAL REGISTRATION The trial was registered at www.ClinicalTrials.gov on 18 November 2013. TRIAL REGISTRATION NUMBER NCT01996579 .
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Affiliation(s)
- John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada. .,Kingston General Hospital, Room 5-411, Angada 4, 76 Stuart Street, Kingston, ON, K7L 2 V3, Canada.
| | - David Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - John Gordon Boyd
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Nicole O'Callaghan
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Francois Lamontagne
- Centre de recherché du CHU de Sherbrooke, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Steven Reynolds
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Martin Albert
- Centre de Recherche de l'Hôpital du Sacré-Coeur de Montréal, Division of Critical Care Medicine, Critical Care and Medicine Departments, Université de Montréal, Montréal, QC, Canada
| | - Rick Hall
- Department of Critical Care Medicine, Dalhousie University and the Nova Scotia Health Authority, Halifax, NS, Canada
| | - Danielle McGolrick
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Xuran Jiang
- Kingston General Hospital, Room 5-411, Angada 4, 76 Stuart Street, Kingston, ON, K7L 2 V3, Canada
| | - Andrew G Day
- Kingston General Hospital, Room 5-411, Angada 4, 76 Stuart Street, Kingston, ON, K7L 2 V3, Canada
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Karatas M, Saylan S, Kostakoglu U, Yilmaz G. An assessment of ventilator-associated pneumonias and risk factors identified in the Intensive Care Unit. Pak J Med Sci 2016; 32:817-22. [PMID: 27648020 PMCID: PMC5017083 DOI: 10.12669/pjms.324.10381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objectives: Ventilator-associated pneumonia (VAP) is a significant cause of hospital-related infections, one that must be prevented due to its high morbidity and mortality. The purpose of this study was to evaluate the incidence and risk factors in patients developing VAP in our intensive care units (ICUs). Methods: This retrospective cohort study involved in mechanically ventilated patients hospitalized for more than 48 hours. VAP diagnosed patients were divided into two groups, those developing pneumonia (VAP(+)) and those not (VAP(-)).\ Results: We researched 1560 patients in adult ICUs, 1152 (73.8%) of whom were mechanically ventilated. The MV use rate was 52%. VAP developed in 15.4% of patients. The VAP rate was calculated as 15.7/1000 ventilator days. Mean length of stay in the ICU for VAP(+) and VAP(-) patients were (26.7±16.3 and 18.1±12.7 days (p<0.001)) and mean length of MV use was (23.5±10.3 and 12.6±7.4 days (p<0.001)). High APACHE II and Charlson co-morbidity index scores, extended length of hospitalization and MV time, previous history of hospitalization and antibiotherapy, reintubation, enteral nutrition, chronic obstructive pulmonary disease, cerebrovascular disease, diabetes mellitus and organ failure were determined as significant risk factors for VAP. The mortality rate in the VAP(+) was 65.2%, with 23.6% being attributed to VAP. Conclusion: VAPs are prominent nosocomial infections that can cause considerable morbidity and mortality in ICUs. Patient care procedures for the early diagnosis of patients with a high risk of VAP and for the reduction of risk factors must be implemented by providing training concerning risk factors related to VAP for ICU personnel, and preventable risk factors must be reduced to a minimum.
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Affiliation(s)
- Mevlut Karatas
- Mevlut Karatas, Assistant Professor, Department of Pulmonology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Sedat Saylan
- Sedat Saylan, Assistant Professor, Department of Anesthesiology and Reanimation, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Ugur Kostakoglu
- Ugur Kostakoglu, Assistant Professor, Department of Infection Diseases and Clinic Microbiology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Gurdal Yilmaz
- Gurdal Yilmaz, Associate Professor, Department of Infection Diseases and Clinic Microbiology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
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Chang I, Schibler A. Ventilator Associated Pneumonia in Children. Paediatr Respir Rev 2016; 20:10-16. [PMID: 26527358 DOI: 10.1016/j.prrv.2015.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/16/2015] [Indexed: 12/26/2022]
Abstract
Ventilator associated pneumonia (VAP) is a common complication in mechanically ventilated children and adults. There remains much controversy in the literature over the definition, treatment and prevention of VAP. The incidence of VAP is variable, depending on the definition used and can effect up to 12% of ventilated children. For the prevention and reduction of the incidence of VAP, ventilation care bundles are suggested, which include vigorous hand hygiene, head elevation and use of non-invasive ventilation strategies. Diagnosis is mainly based on the clinical presentation with a lung infection occurring after 48hours of mechanical ventilation requiring a change in ventilator settings (mainly increased oxygen requirement, a positive culture of a specimen taken preferentially using a sterile sampling technique either using a bronchoscope or a blind lavage of the airways). A new infiltrate on a chest X ray supports the diagnosis of VAP. For the treatment of VAP, initial broad-spectrum antibiotics should be used followed by a specific antibiotic therapy with a narrow target once the bacterium is confirmed.
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Affiliation(s)
- Ivy Chang
- Paediatric Critical Care Research Group, Lady Cilento Children's Hospital, South Brisbane QLD
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Lady Cilento Children's Hospital, South Brisbane QLD.
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Speck K, Rawat N, Weiner NC, Tujuba HG, Farley D, Berenholtz S. A systematic approach for developing a ventilator-associated pneumonia prevention bundle. Am J Infect Control 2016; 44:652-6. [PMID: 26874407 DOI: 10.1016/j.ajic.2015.12.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 12/07/2015] [Accepted: 12/09/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is among the most common type of health care-associated infection in the intensive care unit and is associated with significant morbidity and mortality. Existing VAP prevention intervention bundles vary widely on the interventions included and in the approaches used to develop these bundles. The objective of this study was to develop a new VAP prevention bundle using a systematic approach that elicits clinician perceptions on which interventions are most important and feasible to implement. METHODS We identified potential interventions to include through a review of current guidelines and literature. We implemented a 2-step modified Delphi method to gain consensus on the final list of interventions. An interdisciplinary group of clinical experts participated in the Delphi process, which was guided by a technical expert panel. RESULTS We identified 65 possible interventions. Through the Delphi method, we narrowed that list to 19 interventions that included 5 process and 14 structural measures. CONCLUSIONS We described a structured approach for developing a new VAP prevention bundle. Obtaining clinician input on what interventions to include increases the likelihood that providers will adhere to the bundle.
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Affiliation(s)
- Kathleen Speck
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Nishi Rawat
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Community Physicians, Baltimore, MD
| | - Noah C Weiner
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Haddis G Tujuba
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Donna Farley
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sean Berenholtz
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Abstract
OBJECTIVE Ventilator-associated pneumonia is considered the second most frequent infection in pediatric intensive care, and there is agreement on its association with higher morbidity and increased healthcare costs. The goal of this study was to apply a bundle for ventilator-associated pneumonia prevention as a process for quality improvement in the PICU of Hospital Italiano de Buenos Aires, Argentina, aiming to decrease baseline ventilator-associated pneumonia rate by 25% every 6 months over a period of 2 years. DESIGN Quasi-experimental uninterrupted time series. SETTING PICU of Hospital Italiano de Buenos Aires, Argentina. PATIENTS All mechanical ventilated patients admitted to the unit. INTERVENTION It consisted of the implementation of an evidence-based ventilator-associated pneumonia prevention bundle adapted to our unit and using the plan-do-study-act cycle as a strategy for quality improvement. The bundle consisted of four main components: head of the bed raised more than 30°, oral hygiene with chlorhexidine, a clean and dry ventilator circuit, and daily interruption of sedation. MEASUREMENTS AND MAIN RESULTS Ventilator-associated pneumonia prevention team meetings started in March 2012, and the ventilator-associated pneumonia bundle was implemented in November 2012 after it had been developed and made operational. Baseline ventilator-associated pneumonia rate for the 2 years before intervention was 6.3 episodes every 1,000 mechanical ventilation days. ventilator-associated pneumonia rate evolution by semester and during the 2 years was, respectively, 5.7, 3.2, 1.8, and 0.0 episodes every 1,000 mechanical ventilation days. Monthly ventilator-associated pneumonia rate time series summarized in a 51-point control chart showed the presence of special cause variability after intervention was implemented. CONCLUSIONS The implementation over 2 years of a ventilator-associated pneumonia prevention bundle specifically adapted to our unit using quality improvement tools was associated with a reduction in ventilator-associated pneumonia rate of 25% every 6 months and a nil rate in the last semester.
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Kho ME, Molloy AJ, Clarke F, Herridge MS, Koo KKY, Rudkowski J, Seely AJE, Pellizzari JR, Tarride JE, Mourtzakis M, Karachi T, Cook DJ. CYCLE pilot: a protocol for a pilot randomised study of early cycle ergometry versus routine physiotherapy in mechanically ventilated patients. BMJ Open 2016; 6:e011659. [PMID: 27059469 PMCID: PMC4838736 DOI: 10.1136/bmjopen-2016-011659] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Early exercise with in-bed cycling as part of an intensive care unit (ICU) rehabilitation programme has the potential to improve physical and functional outcomes following critical illness. The objective of this study is to determine the feasibility of enrolling adults in a multicentre pilot randomised clinical trial (RCT) of early in-bed cycling versus routine physiotherapy to inform a larger RCT. METHODS AND ANALYSIS 60-patient parallel group pilot RCT in 7 Canadian medical-surgical ICUs. We will include all previously ambulatory adult patients within the first 0-4 days of mechanical ventilation, without exclusion criteria. After informed consent, patients will be randomised using a web-based, centralised electronic system, to 30 min of in-bed leg cycling in addition to routine physiotherapy, 5 days per week, for the duration of their ICU stay (28 days maximum) or routine physiotherapy alone. We will measure patients' muscle strength (Medical Research Council Sum Score, quadriceps force) and function (Physical Function in ICU Test (scored), 30 s sit-to-stand, 2 min walk test) at ICU awakening, ICU discharge and hospital discharge. Our 4 feasibility outcomes are: (1) patient accrual of 1-2 patients per month per centre, (2) protocol violation rate <20%, (3) outcome measure ascertainment >80% at the 3 time points and (4) blinded outcomes ascertainment >80% at hospital discharge. Hospital outcome assessors are blinded to group assignment, whereas participants, ICU physiotherapists, ICU caregivers, research coordinators and ICU outcome assessors are not blinded to group assignment. We will analyse feasibility outcomes with descriptive statistics. ETHICS AND DISSEMINATION Each participating centre will obtain local ethics approval, and results of the study will be published to inform the design and conduct of a future multicentre RCT of in-bed cycling to improve physical outcomes in ICU survivors. TRIAL REGISTRATION NUMBER NCT02377830; Pre-results.
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Affiliation(s)
- Michelle E Kho
- McMaster University, School of Rehabilitation Science, Hamilton, Ontario, Canada
- Department of Physiotherapy, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander J Molloy
- Department of Physiotherapy, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - France Clarke
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Margaret S Herridge
- Department of Medicine, University of Toronto, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Karen K Y Koo
- Swedish Early Mobility Program in Critical Care, Swedish Medical Group, First Hill Campus, Seattle, Washington, USA
- Department of Medicine, Western University, London, Ontario, Canada
| | - Jill Rudkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J E Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Joseph R Pellizzari
- Consultation-Liaison Psychiatry Service, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Programs for the Assessment of Technology in Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Marina Mourtzakis
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Timothy Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Niederman MS. New Strategies to Prevent Ventilator-Associated Pneumonia: What to Do for Your Patients. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2016. [DOI: 10.1007/s40506-016-0067-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Palese A, Comisso I, Burra M, DiTaranto PP, Peressoni L, Mattiussi E, Lucchini A. Nursing Activity Score for estimating nursing care need in intensive care units: findings from a face and content validity study. J Nurs Manag 2016; 24:549-59. [PMID: 26806600 DOI: 10.1111/jonm.12357] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2015] [Indexed: 11/30/2022]
Abstract
AIM To re-evaluate the face and content validity of the Nursing Activity Score currently adopted in evaluating activities that best describe workloads in intensive care units and their weight in describing average nursing time consumption. BACKGROUND The Nursing Activity Score calculates the amount of nursing time that each patient will require over the next 24 hours. It has been widely used around the world since its first validation in 2003. However, no re-evaluation of its validity with regard to the advancements achieved in intensive care units nursing care has been documented to date. METHOD A research project was undertaken from 2012 to 2015, aimed at critically evaluating and validating this tool in the current context of Italian intensive care units nursing care. The 23 items were translated forward and backward into the Italian language, then a panel of 10 experts in critical care evaluated the face validity. Content validity was evaluated through focus groups involving seven critical care expert registered nurses. FINDINGS The Nursing Activity Score instrument has been considered as not fully adequate to measure current intensive care units nursing activities and their weightings have been considered not fully adequate to score average nursing time consumption. From the content validity process, lack of adequacy has emerged with respect to the concept of nursing care underpinning the tool, the interventions included, its capability to predict the nursing resources needed, advancements achieved in intensive care units nurses' roles and competences, and the contextual factors that may influence consumption of nursing time. CONCLUSIONS Development of the Nursing Activity Score tool both conceptually and in its structure, in view of the innovations that have occurred in the context of intensive care units, is necessary to continue to have a common tool to help clinicians and managers to capture accurately and compare nursing care required by patients in critical care settings. IMPLICATIONS FOR NURSING MANAGEMENT There is a need to revise the Nursing Activity Score tool, enabling its use in estimating nursing workloads in current Italian intensive care units practice. A taskforce of clinical nurses and nursing managers, capable of protecting the valuable original Nursing Activity Score project and to advance its further development is recommended.
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Affiliation(s)
| | - Irene Comisso
- Department of Anesthesia and Intensive Care, Academic Hospital of Udine, Italy
| | - Monica Burra
- Department of Anesthesia and Intensive Care, Academic Hospital of Udine, Italy
| | | | - Luca Peressoni
- Department of Anesthesia and Intensive Care, Academic Hospital of Udine, Italy
| | - Elisa Mattiussi
- Department of Anesthesia and Intensive Care, Academic Hospital of Udine, Italy
| | - Alberto Lucchini
- Intensive Care and Emergency Department, San Gerardo, Hospital, Monza, Italy
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Wang L, Li X, Yang Z, Tang X, Yuan Q, Deng L, Sun X. Semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in adults requiring mechanical ventilation. Cochrane Database Syst Rev 2016; 2016:CD009946. [PMID: 26743945 PMCID: PMC7016937 DOI: 10.1002/14651858.cd009946.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is associated with increased mortality, prolonged length of hospital stay and increased healthcare costs in critically ill patients. Guidelines recommend a semi-recumbent position (30º to 45º) for preventing VAP among patients requiring mechanical ventilation. However, due to methodological limitations in existing systematic reviews, uncertainty remains regarding the benefits and harms of the semi-recumbent position for preventing VAP. OBJECTIVES To assess the effectiveness and safety of semi-recumbent positioning versus supine positioning to prevent ventilator-associated pneumonia (VAP) in adults requiring mechanical ventilation. SEARCH METHODS We searched CENTRAL (2015, Issue 10), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1946 to October 2015), EMBASE (2010 to October 2015), CINAHL (1981 to October 2015) and the Chinese Biomedical Literature Database (CBM) (1978 to October 2015). SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing semi-recumbent versus supine positioning (0º to 10º), or RCTs comparing alternative degrees of positioning in mechanically ventilated patients. Our outcomes included clinically suspected VAP, microbiologically confirmed VAP, intensive care unit (ICU) mortality, hospital mortality, length of ICU stay, length of hospital stay, duration of ventilation, antibiotic use and any adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently and in duplicate screened titles, abstracts and full texts, assessed risk of bias and extracted data using standardised forms. We calculated the mean difference (MD) and 95% confidence interval (95% CI) for continuous data and the risk ratio (RR) and 95% CI for binary data. We performed meta-analysis using the random-effects model. We used the grading of recommendations, assessment, development and evaluation (GRADE) approach to grade the quality of evidence. MAIN RESULTS We included 10 trials involving 878 participants, among which 28 participants in two trials did not provide complete data due to loss to follow-up. We judged all trials to be at high risk of bias. Semi-recumbent position (30º to 60º) versus supine position (0° to 10°) A semi-recumbent position (30º to 60º) significantly reduced the risk of clinically suspected VAP compared to a 0º to 10º supine position (eight trials, 759 participants, 14.3% versus 40.2%, RR 0.36; 95% CI 0.25 to 0.50; risk difference (RD) 25.7%; 95% CI 20.1% to 30.1%; GRADE: moderate quality evidence).There was no significant difference between the two positions in the following outcomes: microbiologically confirmed VAP (three trials, 419 participants, 12.6% versus 31.6%, RR 0.44; 95% CI 0.11 to 1.77; GRADE: very low quality evidence), ICU mortality (two trials, 307 participants, 29.8% versus 34.3%, RR 0.87; 95% CI 0.59 to 1.27; GRADE: low quality evidence), hospital mortality (three trials, 346 participants, 23.8% versus 27.6%, RR 0.84; 95% CI 0.59 to 1.20; GRADE: low quality evidence), length of ICU stay (three trials, 346 participants, MD -1.64 days; 95% CI -4.41 to 1.14 days; GRADE moderate quality evidence), length of hospital stay (two trials, 260 participants, MD -9.47 days; 95% CI -34.21 to 15.27 days; GRADE: very low quality evidence), duration of ventilation (four trials, 458 participants, MD -3.35 days; 95% CI -7.80 to 1.09 days), antibiotic use (three trials, 284 participants, 84.8% versus 84.2%, RR 1.00; 95% CI 0.97 to 1.03) and pressure ulcers (one trial, 221 participants, 28% versus 30%, RR 0.91; 95% CI 0.60 to 1.38; GRADE: low quality evidence). No other adverse events were reported. Semi-recumbent position (45°) versus 25° to 30° We found no statistically significant differences in the following prespecified outcomes: clinically suspected VAP (two trials, 91 participants, RR 0.74; 95% CI 0.35 to 1.56; GRADE: very low quality evidence), microbiologically confirmed VAP (one trial, 30 participants, RR 0.61; 95% CI 0.20 to 1.84: GRADE: very low quality evidence), ICU mortality (one trial, 30 participants, RR 0.57; 95% CI 0.15 to 2.13; GRADE: very low quality evidence), hospital mortality (two trials, 91 participants, RR 1.00; 95% CI 0.38 to 2.65; GRADE: very low quality evidence), length of ICU stay (one trial, 30 participants, MD 1.6 days; 95% CI -0.88 to 4.08 days; GRADE: very low quality evidence) and antibiotic use (two trials, 91 participants, RR 1.11; 95% CI 0.84 to 1.47). No adverse events were reported. AUTHORS' CONCLUSIONS A semi-recumbent position (≧ 30º) may reduce clinically suspected VAP compared to a 0° to 10° supine position. However, the evidence is seriously limited with a high risk of bias. No adequate evidence is available to draw any definitive conclusion on other outcomes and the comparison of alternative semi-recumbent positions. Adverse events, particularly venous thromboembolism, were under-reported.
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Affiliation(s)
- Li Wang
- West China Hospital, Sichuan UniversityChinese Cochrane CentreNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Xiao Li
- West China Hospital, Sichuan UniversityChinese Evidence‐Based Medicine CentreNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Zongxia Yang
- West China Hospital, Sichuan UniversityChinese Evidence‐Based Medicine CentreNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Xueli Tang
- West China Hospital, Sichuan UniversityChinese Evidence‐Based Medicine CentreNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Qiang Yuan
- West China Hospital, Sichuan UniversityChinese Evidence‐Based Medicine CentreNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Lijing Deng
- West China Hospital, Sichuan UniversityIntensive Care UnitNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Xin Sun
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1200 Main Street WestHamiltonONCanadaL8N 3Z5
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