A Turn for the Better: ‘Prone Positioning’ of Patients with ARDS

Cuidados de enfermagem e posição prona: revisão integrativa

Objetivo: explorar, na literatura científica, práticas atuais de cuidado de enfermagem ou intervenções para pacientes com síndrome respiratório agudo grave (SRAG) submetidos à posição prona.     Síntese do conteúdo: revisão integrativa, na qual foram realizadas buscas nas bases de dados PubMed, CINAHL, Scopus, Web of Science e LILACS em setembro de 2020 e janeiro de 2022, sem recorte temporal, por meio da questão deste estudo: “Quais são os cuidados de enfermagem para pacientes com SRAG submetidos à posição prona?”. Foram selecionados 15 artigos, a partir da busca nas bases de dados. Após a leitura, os cuidados encontrados foram categorizados em alinhamento do corpo para a prevenção de lesões neuromusculares, cuidados com equipamentos diversos, cuidados tegumentares e recomendações neurológicas. Conclusões: o enfermeiro deve ter conhecimento sobre as implicações e as complicações de se manter um paciente na posição prona. Tal conhecimento permitirá tomadas de decisões na construção ou no seguimento de protocolos institucionais que contribuam com a prevenção de riscos e resultem em melhores desfechos para o paciente.

Safe prone checklist: construction and implementation of a tool for performing the prone maneuver

OBJECTIVE

To construct and implement an instrument (checklist) to improve safety when performing the prone maneuver.

METHODS

This was an applied, qualitative and descriptive study. The instrument was developed based on a broad review of the literature pertaining to the construction of a care protocol using the main electronic databases (MEDLINE, LILACS and Cochrane).

RESULTS

We describe the construction of a patient safety tool with numerous modifications and adaptations based on the observations of the multidisciplinary team regarding its use in daily practice.

CONCLUSION

The use of the checklist when performing the prone maneuver increased the safety and reliability of the procedure. The team's understanding of the tool's importance to patient safety and training in its use are necessary for its success.

Good practices for prone positioning at the bedside: Construction of a care protocol

Last year, interest in prone positioning to treat acute respiratory distress syndrome (ARDS) resurfaced with the demonstration of a reduction in mortality by a large randomized clinical trial. Reports in the literature suggest that the incidence of adverse events is significantly reduced with a team trained and experienced in the process. The objective of this review is to revisit the current evidence in the literature, discuss and propose the construction of a protocol of care for these patients. A search was performed on the main electronic databases: Medline, Lilacs and Cochrane Library. Prone positioning is increasingly used in daily practice, with properly trained staff and a well established care protocol are essencial.

Using pressure-volume curves to set proper PEEP in acute lung injury

The evolution of respiratory care on patients with acute respiratory distress syndrome (ARDS) has been focused on preventing the deleterious effects of mechanical ventilation, termed ventilator-induced lung injury (VILI). Currently, reduced tidal volume is the standard of ventilatory care for patients with ARDS. The current focus, however, has shifted to the proper setting of positive end-expiratory pressure (PEEP). The whole lung pressure-volume (P/V) curve has been used to individualize setting proper PEEP in patients with ARDS, although the physiologic interpretation of the curve remains under debate. The purpose of this review is to present the pros and cons of using P/V curves to set PEEP in patients with ARDS. A systematic analysis of recent and relevant literature was conducted. It has been hypothesized that proper PEEP can be determined by identifying P/V curve inflection points. Acquiring a dynamic curve presents the key to the curve's bedside application. The lower inflection point of the inflation limb has been shown to be the point of massive alveolar recruitment and therefore an option for setting PEEP. However, it is becoming widely accepted that the upper inflection point (UIP) of the deflation limb of the P/V curve represents the point of optimal PEEP. New methods used to identify optimal PEEP, including tomography and active compliance measurements, are currently being investigated. In conclusion, we believe that the most promising method for determining proper PEEP settings is use of the UIP of the deflation limb. However, tomography and dynamic compliance may offer superior bedside availability.

Increased Prevalence of Post-traumatic Stress Disorder Symptoms in Critical Care Nurses

RATIONALE

Intensive care unit (ICU) nurses work in a demanding environment where they are repetitively exposed to traumatic situations and stressful events. The psychological effects on nurses as a result of working in the ICU are relatively unknown.

OBJECTIVE

To determine whether there is an increased prevalence of psychological symptoms in ICU nurses when compared with general nurses.

METHODS

We surveyed ICU and general nurses from three different hospitals (n=351) and then surveyed ICU nurses throughout the metropolitan area (n=140).

MEASUREMENTS AND MAIN RESULTS

In both cohorts of nurses, we determined the prevalence of symptoms of post-traumatic stress disorder (PTSD), anxiety, and depression using validated survey instruments. Within our hospital system, 24% (54/230) of the ICU nurses tested positive for symptoms of PTSD related to their work environment, compared with 14% (17/121) of the general nurses (p=0.03). ICU nurses did not report a greater amount of stress in their life outside of the hospital than general nurses. There was no difference in symptoms of depression or anxiety between ICU and general nurses. In the second survey of ICU nurses from our metropolitan area, 29% (41/140) of the respondents reported symptoms of PTSD, similar to our first cohort of ICU nurses.

CONCLUSIONS

ICU nurses have an increased prevalence of PTSD symptoms when compared with other general nurses. These results may increase awareness of these symptoms in nurses and lead to future interventions that improve their mental health and job satisfaction and help retain ICU nurses in their profession.

Body positioning and its effect on oxygenation--a literature review

Evidence-based health care has become a priority in the National Health Service (NHS), with increased emphasis on clinical practices that are grounded in quality evidence rather than those that persist because of tradition. Turning and positioning of patients are well-accepted nursing activities. Appropriate positioning of the critically ill patient can dramatically improve gas exchange, resulting in a shorter stay in the critical care unit and an improved outcome. This study reviews the current published literature on the subject of positioning and gas exchange, with emphasis on oxygenation. Conclusions made from this study are that nurses need to be aware of how different positions can affect patients' oxygenation. Further research on exploring patients' experience of positioning within the critical care environment and nurses' understanding of positioning and oxygenation is needed.