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Patterson H, Eady J, Sommerfield A, Sommerfield D, Hauser N, von Ungern-Sternberg BS. Patient positioning and its impact on perioperative outcomes in children: A narrative review. Paediatr Anaesth 2024; 34:507-518. [PMID: 38546348 DOI: 10.1111/pan.14883] [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: 10/30/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 05/12/2024]
Abstract
Patient positioning interacts with a number of body systems and can impact clinically important perioperative outcomes. In this educational review, we present the available evidence on the impact that patient positioning can have in the pediatric perioperative setting. A literature search was conducted using search terms that focused on pediatric perioperative outcomes prioritized by contemporary research in this area. Several key themes were identified: the effects of positioning on respiratory outcomes, cardiovascular outcomes, enteral function, patient and carer-centered outcomes, and soft issue injuries. We encountered considerable heterogeneity in research in this area. There may be a role for lateral positioning to reduce respiratory adverse outcomes, head elevation for intubation and improved oxygenation, and upright positioning to reduce peri-procedural anxiety.
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Affiliation(s)
- Heather Patterson
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Jonathan Eady
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Department of Anaesthesia, Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, UK
| | - Aine Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Neil Hauser
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
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Wang D, Zhao P, Liu YX, Wang P, Gong ML, Qu GP, Fang XQ, Qian YP. Predicting ventilator-associated pneumonia in elderly patients requiring mechanical ventilation through the detection in tracheal aspirates. Postgrad Med 2023; 135:831-841. [PMID: 38032178 DOI: 10.1080/00325481.2023.2288559] [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: 02/28/2023] [Accepted: 11/23/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE In this study, we evaluated the clinical utility of tracheal aspirates α-amylase (AM), pepsin, and lipid-laden macrophage index (LLMI) in the early diagnosis of ventilator-associated pneumonia (VAP) in elderly patients on mechanical ventilation. METHODS Within 96 hours of tracheal intubation, tracheal aspirate specimens were collected from elderly patients on mechanical ventilation; AM, pepsin, and LLMI were detected, and we analyzed the potential of each index individually and in combination in diagnosing VAP. RESULTS Patients with VAP had significantly higher levels of AM, pepsin, and LLMI compared to those without VAP (P < 0.001), and there was a positive correlation between the number of pre-intubation risk factors of aspiration and the detection value of each index in patients with VAP (P < 0.001). The area under a receiver operating characteristic (ROC) curve (AUC) of AM, pepsin, and LLMI in diagnosis of VAP were 0.821 (95% CI:0.713-0.904), 0.802 (95% CI:0.693-0.892), and 0.621 (95% CI:0.583-0.824), the sensitivities were 0.8815, 0.7632, and 0.6973, the specificities were 0.8495, 0.8602, and 0.6291, and the cutoff values were 4,321.5 U/L, 126.61 ng/ml, and 173.5, respectively. The AUC for the combination of indexes in diagnosing VAP was 0.905 (95% CI:0.812-0.934), and the sensitivity and specificity were 0.9211 and 0.9332, respectively. In the tracheal aspirate specimens, the detection rate of AM ≥ cutoff was the highest, while it was the lowest for LLMI (P < 0.001). The detection rates of AM ≥ cutoff and pepsin ≥ cutoff were higher within 48 hours after intubation than within 48-96 hours after intubation (P < 0.001). In contrast, the detection rate of LLMI ≥ cutoff was higher within 48-96 hours after intubation than within 48 hours after intubation (P < 0.001). The risk factors for VAP identified using logistic multivariate analysis included pre-intubation aspiration risk factors (≥3), MDR bacteria growth in tracheal aspirates, and tracheal aspirate AM ≥ 4,321.5 U/L, pepsin ≥ 126.61 ng/ml, and LLMI ≥ 173.5. CONCLUSION The detection of AM, pepsin, and LLMI in tracheal aspirates has promising clinical utility as an early warning biomarker of VAP in elderly patients undergoing mechanical ventilation.
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Affiliation(s)
- Dan Wang
- Department of Respiratory and Critical Care Medicine, Second Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Peng Zhao
- Department of Health Management, Chinese PLA Air Force Healthcare Center for Special Services, Hangzhou, China
| | - Yan-Xin Liu
- Department of Respiratory and Critical Care Medicine, Second Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Peng Wang
- Department of Medical Oncology, Second Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Mei-Liang Gong
- Department of Laboratory Diagnosis, Second Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Ge-Ping Qu
- Department of Respiratory and Critical Care Medicine, Second Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiang-Qun Fang
- Department of Respiratory and Critical Care Medicine, Second Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Ya-Ping Qian
- Department of Hematology and Oncology, 903 hospital of ChinesePLA, Hangzhou, China
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Patel N, Lin P, Stack M, Conrad JM, Fakioglu H, Abomoelak B, Horvath K, Mehta DI. Oral Care Associated With Less Microaspiration in Ventilated Cardiac Patients. JPGN REPORTS 2023; 4:e290. [PMID: 37181916 PMCID: PMC10174743 DOI: 10.1097/pg9.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/08/2022] [Indexed: 05/16/2023]
Abstract
Aspiration is common in mechanically ventilated patients and may predispose patients to aspiration pneumonia, chemical pneumonitis, and chronic lung damage. Pepsin A is a specific marker of gastric fluid aspiration and is often detected in ventilated pediatric patients. We investigated the effect of oral care and throat suctioning in the detection of pepsin A in tracheal aspirates (TAs) up to 4 hours after these procedures. Methods Twelve pediatric patients between age 2 weeks to 14 years who underwent intubation for cardiac surgery were enrolled in this study. Six of the 12 patients were consented before their surgery with initial specimen collected at the time of intubation and last one shortly before extubation (intubation duration < 24 hours). The remaining 6 patients were consented after cardiac surgery. All specimens were collected per routine care per respiratory therapy protocol and shortly before extubation (intubation duration > 24 hours). Tracheal fluid aspirates were collected every 4 to 12 hours in the ventilated patients. Enzymatic assay for gastric pepsin A and protein determination were performed. The time of oral care and throat suctioning within 4 hours prior was recorded prospectively. Results A total of 342 TA specimens were obtained from the 12 intubated pediatric patients during their course of hospitalization; 287 (83.9%) showed detectable total pepsin (pepsin A and C) enzyme activity (> 6 ng/mL) and 176 (51.5%) samples had detectable pepsin A enzyme levels (>6 ng/mL of pepsin A). Only 29 samples of 76 samples (38.2%) had evidence of microaspiration after receiving oral care, while 147 of 266 (55.3%) samples were pepsin A positive when no oral care was provided. Odds ratio is 0.50 (Cl 0.30-0.84), and the number needed to treat is 5.8 (Confidence interval 3.4-22.3). Testing air filters for pepsin was not beneficial. Conclusion Oral care is a highly effective measure to prevent microaspiration of gastric fluid in ventilated pediatric patients. The number needed to treat (5.8) suggests this is a very effective prevention strategy. Our study suggests that pepsin A is a useful and sensitive biomarker that allows identification of gastric aspiration.
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Affiliation(s)
- Nishant Patel
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
| | - Philip Lin
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
| | - Michael Stack
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Janet M. Conrad
- Pediatric Gastroenterology and Translational Research Laboratory, Cardiology Arnold Palmer Hospital for Children, Orlando, FL
| | - Harun Fakioglu
- Department of Pediatric Cardiology Arnold Palmer Hospital for Children, Orlando, FL
| | - Bassam Abomoelak
- Pediatric Gastroenterology and Translational Research Laboratory, Cardiology Arnold Palmer Hospital for Children, Orlando, FL
| | - Karoly Horvath
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
| | - Devendra I. Mehta
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
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Abstract
OBJECTIVES Gastroesophageal reflux and aspiration can occur in premature infants who are supported with mechanical ventilation. The relation between physical positioning and gastric aspiration in ventilated infants has not been studied. Pepsin measured in tracheal aspirate (TA) emerged as a specific marker for aspiration. The objective of our study was to assess pepsin in TA of ventilated infants at 2 different positions: supine and right lateral. METHODS We conducted a randomized controlled trial on premature infants who were enterally fed and supported with mechanical ventilation. Patients were randomized into intervention and control groups. In the intervention group, infants were placed supine for 6 hours before a sample of TA was obtained. A second sample was collected 6 hours later while lying in the right lateral position. In the control group, the 2 samples of TA were obtained while infants remained in the supine position during the entire study time. Pepsin in TA was measured while blinded to the group assignment. RESULTS A total of 34 patients were enrolled and randomized to intervention (n = 17) and control (n = 17) groups. Gestational age was 32.7 ± 2.7 weeks, and birth weight was 1617 ± 526 g; both groups had similar demographic and clinical characteristics. Pepsin concentration did not differ between groups at baseline. In the intervention group, pepsin concentration significantly declined from 13 ng/mL (interquartile range [IQR] 11.9-38.7) to 10 ng/mL (IQR 7-12; P < 0.001), whereas it did not change in the control group (P = 0.42). CONCLUSIONS The right lateral positioning is associated with decreased TA pepsin. The implications of the present study on hospital practice and clinical outcomes need further investigations.
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McGinnis CM, Worthington P, Lord LM. Nasogastric versus feeding tubes in critically ill patients. Crit Care Nurse 2011; 30:80-2. [PMID: 21123235 DOI: 10.4037/ccn2010402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Pneumonia. SURGICAL INTENSIVE CARE MEDICINE 2010. [PMCID: PMC7122224 DOI: 10.1007/978-0-387-77893-8_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hospital-acquired pneumonia (HAP) is usually caused by bacterial, viral, or fungal pathogens that occur ≥48 h after hospital admission.1,2 Overall, more than 80% of HAP episodes are related to invasive airway management (in patients with endotracheal intubation or tracheostomy) with mechanical ventilation, which is known as ventilator-associated pneumonia (VAP).3 VAP is defined as pneumonia developing more than 48 h after intubation and mechanical ventilation. Healthcare-associated pneumonia (HCAP) is part of the continuum of pneumonia, which includes patients who were hospitalized in an acute-care hospital for ≥2 days within 90 days of the infection; resided in a long-term care facility; received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection; or attended a hospital or hemodialysis clinic.1,2 Although this document focuses more on HAP and VAP, many of the principles are also relevant to the management of HCAP. HAP, VAP, and HCAP are the second most common nosocomial infections after urinary tract infection, but are the leading causes of mortality due to hospital-acquired infections.4,5
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Gopalareddy V, He Z, Soundar S, Bolling L, Shah M, Penfil S, McCloskey JJ, Mehta DI. Assessment of the prevalence of microaspiration by gastric pepsin in the airway of ventilated children. Acta Paediatr 2008; 97:55-60. [PMID: 18076720 DOI: 10.1111/j.1651-2227.2007.00578.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM Mechanically ventilated patients are at risk for aspiration of gastric contents. The aim of this observational study was to determine the prevalence of micro-aspiration in children with cuffed and uncuffed endotracheal (ET) tubes and with tracheostomies and to assess the effect of feeding status on aspiration. Micro-aspiration was determined by measuring gastric pepsin in tracheal aspirates. METHODS We studied 27 children on ventilators in paediatric intensive care unit (PICU) and 10 children undergoing elective surgeries for various indications. Tracheal aspirates were collected from children on ventilatory support in the intensive care unit during medically indicated suctioning and from the group of children undergoing elective surgery in the operation room. Pepsin was detected by enzymatic assay. RESULTS Overall 70% of cases in PICU were positive for pepsin in at least one of the aspirates. Pepsin positivity was significantly lower in the cuffed group than in the uncuffed and tracheostomy groups. Tube feedings did not significantly influence the prevalence of pepsin positivity. CONCLUSIONS Measurement of gastric pepsin in tracheobronchial fluid is a sensitive tool to detect aspirations in mechanically ventilated children and to assess the efficacy of preventive measures in PICU settings.
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Affiliation(s)
- Vani Gopalareddy
- Gastroenterology, Levine Children's Hospital, Charlotte, NC, USA
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Ipaktchi K, Mattar A, Niederbichler AD, Kim J, Hoesel LM, Hemmila MR, Su GL, Remick DG, Wang SC, Arbabi S. Attenuating burn wound inflammation improves pulmonary function and survival in a burn-pneumonia model. Crit Care Med 2007; 35:2139-44. [PMID: 17855827 DOI: 10.1097/01.ccm.0000280568.61217.26] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We previously showed that topical inhibition of inflammatory signaling in burn wounds reduced systemic inflammatory response and burn-induced pulmonary inflammation. We hypothesized that this topical intervention would attenuate burn-induced lung injury, improve pulmonary function, protect lungs from bacterial invasion, and reduce mortality. DESIGN Controlled, in vivo, laboratory study. SETTING University laboratory. SUBJECTS Female mice, 8-10 wks old. INTERVENTIONS Animals received 30% total body surface area burn followed by topical application of a specific inhibitor of p38 mitogen-activated protein kinase, a key inflammatory signaling pathway, or vehicle to the wound. Twenty-four hours after injury, pulmonary collagen deposition and pulmonary function were assessed. One day postburn, some of the animals received intratracheal instillation of Klebsiella pneumoniae and were subsequently monitored for 7 days. MEASUREMENTS AND MAIN RESULTS Topical inhibition of p38 mitogen-activated protein kinase significantly decreased pulmonary collagen deposition and prevented a decline in pulmonary function at 1 day after burn injury. Compared with sham controls, animals with burn injury had a significantly higher mortality in response to intratracheal bacterial challenge. Application of p38 mitogen-activated protein kinase inhibitor to the burn wound attenuated pulmonary neutrophil infiltration and reduced the mortality rate to a level experienced by sham controls. CONCLUSIONS Inflammatory source control in burn wounds with topical p38 mitogen-activated protein kinase inhibition attenuates acute lung injury, avoids pulmonary dysfunction, protects lungs from bacterial challenge, and improves survival.
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Affiliation(s)
- Kyros Ipaktchi
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Abstract
Ventilator-associated pneumonia (VAP) is a common nosocomial pneumonia that occurs in critically ill patients and results in mortality rates as high as 71%. Subglottic secretions (SSs) are a known risk factor. Several clinical trials have shown that continuous aspiration of subglottic secretions (CASS) reduces the risk of VAP by nearly half. Optimal suction pressure levels needed to efficiently evacuate viscous SSs are unknown. The purpose of this study was to describe SSs and the effective suction pressure (20 mmHg, 30 mmHg, 40 mmHg, and 50 mmHg) needed to maximize evacuation efficiency based on SS volume (2 ml, 4 ml, and 6 ml) and viscosity (watery, thick, and gel-like). A laboratory model was designed to replicate a human trachea. Thick secretions had the highest percentage of mean recovery representative of evacuation efficiency of SSs (mean recovery of 86%). The suction pressure of 30 mmHg had the highest overall mean of secretion recovery (83%) across all viscosity types and amounts. This study demonstrated that higher viscosity secretions were easier to evacuate than lower viscosity secretions when 30-mmHg suction pressure was applied. Management of secretion viscosity may assist in secretion removal and delay VAP development. With increased understanding of the molecular structure of SSs, there is the potential that clinicians will be able to manipulate secretion viscoelastic properties to maximize evacuation efficiency of the secretions. Further research is needed to identify safe suction pressures for optimal evacuation of SSs in human subjects.
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Affiliation(s)
- Pamela V O'Neal
- College of Nursing, University of Alabama, Huntsville, AL 35899, USA.
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Abstract
Several types of feeding tubes can be placed at a patient's bedside; examples include nasogastric, nasointestinal, gastrostomy, and jejunostomy tubes. Nasoenteral tubes can be placed blindly at bedside or with the assistance of placement devices. Nasoenteric tubes can also be placed via fluoroscopy and endoscopy. Gastrostomy and jejunostomy tubes can be placed using endoscopic techniques. This paper will describe the indications and contraindications for different types of tubes that can be placed at the bedside and complications associated with tube placement. Complications associated with nasoenteral tubes include inadvertent malpositioning of the tube, epistaxis, sinusitis, inadvertent tube removal, tube clogging, tube-feeding-associated diarrhea, and aspiration pneumonia. Complications from percutaneous gastrostomy and jejunostomy tube placements include procedure-related mishaps, site infection, leakage, buried bumper syndrome, tube malfunction, and inadvertent removal. These complications will be reviewed, along with a discussion of incidence, cause, treatment, and prevention approaches.
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Affiliation(s)
- William N Baskin
- University of Illinois College of Medicine at Rockford, 401 Roxbury Road, Rockford, IL 61107-5078, USA.
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Rice TW, Maloney JP. Nutrition and lung disease. Nutr Clin Pract 2005; 19:547-9. [PMID: 16215152 DOI: 10.1177/0115426504019006547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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