The effect of adhesive tape versus endotracheal tube fastener in critically ill adults: the endotracheal tube securement (ETTS) randomized controlled trial

Lessons Learned From Ventilated and Proned Patients With COVID-19: A Multisite Retrospective Study to Identify Predictive Factors for Facial Pressure Injuries

BACKGROUND

Many patients critically ill with COVID-19 develop acute respiratory distress syndrome (ARDS) necessitating mechanical ventilation and proning. Although proning is lifesaving, it has been linked to the occurrence of facial pressure injuries (PIs).

OBJECTIVES

To evaluate the incidence and use of prevention strategies and identify predictors of facial PIs in patients who received ventilator and proning treatments in COVID-designated intensive care units at 2 large quaternary medical centers in the Midwest.

METHOD

This was a retrospective cohort study using data extracted from an electronic health record between October 2020 and February 2022. Demographics, clinical and care variables, and PI outcomes were analyzed to identify predictors of PI using logistic and Cox regression.

RESULTS

The cohort (N = 150) included patients from 2 units, unit a (n = 97) and unit b (n = 53) with a mean age of 60 years, with 68% identifying as male. Patients were vented for an average of 18 (SD, 16.2) days and proned for an average of 3 (SD, 2.5) days. Many (71%) died. Over half (56%) developed facial PI with a proning-exposure-adjusted incidence rate of 18.5%. Patients with PI were significantly different in several factors. Logistic regression showed predictors of PIs were duration of mechanical ventilation (in days; P = .02) and head turned (P = .01). Cox regression also identified head turn as predictive (P < .01), with Black/African American race as protective (P = .03).

DISCUSSION

Critically ill patients with COVID-19 receiving ventilator and proning therapy developed facial PIs despite the use of recommended prevention practices. Further research on effective PI prevention strategies is needed.

Analytical Review of Unplanned Extubation in Intensive Care Units and Recommendation on Multidisciplinary Preventive Approaches

Unplanned extubations (UE) frequently occur in critical care units. These events are precipitated by many risk factors and are associated with adverse outcomes for patients. We reviewed the current literature to examine factors related to UE and presented the analysis of 41 articles critical to the topic. Our review has identified specific risk factors that we discuss in this review, such as sedation strategies, physical restraints, endotracheal tube position, and specific nursing care aspects associated with an increased incidence of UE. We recommend interventions to reduce the risk of UE. However, we recommend that bundled rather than a single intervention is likely to yield higher success, given the heterogeneity of factors contributing to increasing the risk of UE.

Impact of two endotracheal tube fixation on the incidence of peri-oral lesions: Elastic adhesive strips versus cord in a protective sheath. Study protocol for a cluster cross-over randomized trial

BACKGROUND

Endotracheal tube fixation in ventilated patients must be appropriate to ensure security during mechanical ventilation and prevent skin lesions. The incidence of endotracheal tube-caused pressure ulcers ranges from 7% to 45%. Various endotracheal tube fixations are used in intensive care units (ICUs) worldwide. By pressure exercised on the skin, these systems could lead to mucosal and skin peri-oral lesions. The main objective of this study is to evaluate the impact of the two fixation systems most commonly used in French ICUs (adhesive elastic band versus fixation cord with PolyVinyl Chloride (PVC) sheath) on the incidence of these peri-oral skin lesions.

METHODS

This studyis a multicenter, open-label, controlled, superiority, cluster cross-over randomized trial. 768 patients will be recruited in the 16 ICUs involved. The inclusion of patients will be carried out over two 12-month periods. Each site begins with one of the evaluated fixation systems: elastic adhesive tape or cord associated with a protective sheath. After a 4-month break, each site switches to the other fixation system. The primary outcome is the development of at least one peri-oral lesion during the first ten days of maintaining an orally inserted endotracheal tube. The presence of lesions is assessed by a blinded adjudication committee using photographs taken daily.

DISCUSSION

This study is the first multicenter, randomized trial designed to evaluate the impact of elastic adhesive tape versus fixation cord with PVC sheath on the incidence of peri-oral lesions. The results will provide data which could change and standardize care practices.

TRIAL REGISTRATION

https://www.clinicaltrials.gov. Reference number: NCT04819425.

Interventions and strategies to prevent medical device-related pressure injury in adult patients: A systematic review

BACKGROUND

Current evidence shows that medical device-related pressure injury (MDRPI) has a high prevalence (10%) and incidence (12%), and much research has been done to prevent MDRPI in recent years. However, to our knowledge, there is limited systematic review available on interventions and strategies to prevent MDRPI.

AIM

To synthesise research evidence on interventions and strategies used to prevent MDRPI.

METHODS

This systematic review adhered to the PRISMA Guidelines. We searched six databases including Medline, CINAHL, EMBASE, Cochrane library, Web of Science and ProQuest with no restriction to year of publication. Data were extracted and checked by two authors independently. A narrative summary technique was used to describe the findings. Implementation strategies were grouped into six classifications: dissemination/implementation process/integration/capacity building/sustainability/scale-up strategies.

RESULTS

Twenty-four peer-reviewed papers met the inclusion criteria, which comprised of 11 quality improvement projects and 13 original research. Types of devices included respiratory devices (non-invasive ventilation mask, CPAP/BiPAP mask, endotracheal tube), gastrointestinal/urinary devices and other devices. Interventions used included the use of dressing, hyperoxygenated fatty acids, full-face mask, training, and/or multidisciplinary education, use of special securement devices or tube holder, repositioning, application of stockinette, early removal and foam ring use. Common implementation strategies included ongoing staff education, audit and standardising documentation or guideline development.

CONCLUSION

Much work on MDRPI prevention strategies has been undertaken. There were a variety of devices reported, however, it is evident that higher quality research is needed.

RELEVANCE TO CLINICAL PRACTICE

Current evidence shows that interventions including use of dressing or special securement device, repositioning, and training/multidisciplinary education can be beneficial for MDRPI prevention. High-quality research, such as randomised controlled trials are needed to test the effectiveness of the interventions and their implementation strategies. No patient or public contribution.

High preoperative serum strontium levels increase the risk of acute kidney injury after cardiopulmonary bypass

BACKGROUND

Acute kidney injury (AKI) is a common complication of cardiac surgeries. The incidence of AKI after cardiac surgeries using cardiopulmonary bypass (CPB-AKI) is high, emphasizing the need to determine strategies to prevent CPB-AKI. This study investigates the correlation between CPB-AKI and trace metal levels in clinical and animal studies.

METHODS

Samples and clinical data were obtained from 74 patients from the Nagoya City University Hospital and Okazaki City Hospital. Blood samples were collected before, immediately after, and 2 h after CPB withdrawal. Trace metal levels were measured using inductively coupled plasma mass spectrometry. Sr or vehicle treatment was orally administered to the rats to determine if Sr was associated with CPB-AKI. After the treatment, ischemia-reperfusion (IR) injury was induced, and serum creatinine (SCr) and blood urea nitrogen (BUN) levels were measured.

RESULTS

In this clinical study, the incidence of CPB-AKI was found to be 28% (21/74). The body mass index and estimated glomerular filtration rate were significantly different in patients with AKI. The intensive care unit and hospital stay were longer in AKI patients than in non-AKI patients. The Na, Fe, and Sr levels were significantly higher in AKI patients before CPB. Also, Fe and Sr were higher immediately after CPB withdrawal, and Sr was higher 2 h after CPB withdrawal in AKI patients. Animal studies showed that Sr-treated rats had significantly increased SCr and BUN levels than vehicle-treated rats at 24 h post-IR injury.

CONCLUSIONS

High preoperative serum Sr levels may be associated with CPB-AKI.

Prevention of medical adhesive-related skin injury during patient care: A scoping review

Background

: Medical adhesive-related skin injury can occur during health care. Professionals must adopt preventive measures to maintain the integrity of the skin and patient comfort and safety.

Objective

: To map the existing scientific evidence on preventing medical adhesive-related skin injury in adults.

Design

: Scoping Review.

Methods

: Searches were conducted in PubMed/Medline, Cochrane Library, Embase®, Latin American and Caribbean Literature in Health Sciences, Cumulative Index for Nursing and Allied Health Literature, and Google Scholar, without period delimitation. Duplicate studies and those that didn´t answer the research question were excluded.

Results

: Of the 209 studies identified in the search process, 30 made up the final sample. The prevention of injury by adhesives mainly involves identifying risk factors, proper adhesive selection, and correct application and removal. Health education and medical records about injuries related to medical adhesives are essential.

Conclusions

: The prevention of medical adhesive-related skin injury should be done by adopting multifactorial measures, which range from identifying risk factors and correct handling of adhesives to the process of educating professionals, patients and communities about these injuries.

Registration

: The research was registered on the Open Science Framework DOI 10.17605/OSF.IO/NSWP8.

Prevention of Endotracheal Tube-Related Pressure Injury: A Systematic Review and Meta-analysis

BACKGROUND

Hospital-acquired pressure injuries, including those related to airway devices, are a significant source of morbidity in critically ill patients.

OBJECTIVE

To determine the incidence of endotracheal tube-related pressure injuries in critically ill patients and to evaluate the effectiveness of interventions designed to prevent injury.

METHODS

MEDLINE, Embase, CINAHL, and the Cochrane Library were searched for studies of pediatric or adult patients in intensive care units that evaluated interventions to reduce endotracheal tube-related pressure injury. Reviewers extracted data on study and patient characteristics, incidence of pressure injury, type and duration of intervention, and outcomes. Risk of bias assessment followed the Cochrane Collaboration's criteria.

RESULTS

Twelve studies (5 randomized clinical trials, 3 quasi-experimental, 4 observational) representing 9611 adult and 152 pediatric patients met eligibility criteria. The incidence of pressure injury was 4.2% for orotracheal tubes and 21.1% for nasotracheal tubes. Interventions included anchor devices, serial endotracheal tube assessment or repositioning, and barrier dressings for nasotracheal tubes. Meta-analysis revealed that endotracheal tube stabilization was the most effective individual intervention for preventing pressure injury. Nasal alar barrier dressings decreased the incidence of skin or mucosal injury in patients undergoing nasotracheal intubation, and data on effectiveness of serial assessment and repositioning were inconclusive.

CONCLUSIONS

Airway device-related pressure injuries are common in critically ill patients, and patients with nasotracheal tubes are particularly susceptible to iatrogenic harm. Fastening devices and barrier dressings decrease the incidence of injury. Evidence regarding interventions is limited by lack of standardized assessments.

Optimizing Physiology During Prehospital Airway Management: An NAEMSP Position Statement and Resource Document

Airway management is a critical component of resuscitation but also carries the potential to disrupt perfusion, oxygenation, and ventilation as a consequence of airway insertion efforts, the use of medications, and the conversion to positive-pressure ventilation. NAEMSP recommends:Airway management should be approached as an organized system of care, incorporating principles of teamwork and operational awareness.EMS clinicians should prevent or correct hypoxemia and hypotension prior to advanced airway insertion attempts.Continuous physiological monitoring must be used during airway management to guide the timing of, limit the duration of, and inform decision making during advanced airway insertion attempts.Initial and ongoing confirmation of advanced airway placement must be performed using waveform capnography. Airway devices must be secured using a reliable method.Perfusion, oxygenation, and ventilation should be optimized before, during, and after advanced airway insertion.To mitigate aspiration after advanced airway insertion, EMS clinicians should consider placing a patient in a semi-upright position.When appropriate, patients undergoing advanced airway placement should receive suitable pharmacologic anxiolysis, amnesia, and analgesia. In select cases, the use of neuromuscular blocking agents may be appropriate.

Endotracheal Tube Fastening Device-Related Facial Pressure Ulcers

Acute respiratory distress syndrome (ARDS) can be present in a substantial number of hospitalized Coronavirus disease 2019 (COVID19) disease patients. Some of these patients progress to severe ARDS and require mechanical ventilation. Patients requiring mechanical ventilation and intensive care unit (ICU) admission are at an increased risk of developing pressure ulcers from multiple medical devices used in their care. In this report, we describe a case of facial pressure ulcers in a 59-year-old COVID19 positive female with ARDS requiring endotracheal intubation and mechanical ventilation.

Evaluation of facial tissue stresses under medical devices post application of a cyanoacrylate liquid skin protectant: An integrated experimental-computational study

Medical device‐related pressure ulcers (PUs) (injuries) are a subclass of PUs, associated with pressure and/or shear applied by a medical device onto the skin. Clinical application of a cyanoacrylate liquid skin protectant (CLSP) under the contours of skin‐contacting medical devices to shield an intact skin from the sustained mechanical loads that are applied by medical devices is a preventative option, but no computer modelling work has been reported to assess the biomechanical efficacy of such interventions. Here, we investigated the biomechanical protective effect of a polymerised cyanoacrylate coating using three‐dimensional, anatomically realistic finite element models of the ear with oxygen cannula and the mouth with endotracheal attachment device, informed by experimental studies. We have compared tissue stress exposures under the devices at these facial sites between conditions where the cyanoacrylate skin protectant has been applied or where the device was contacting the skin directly, without the shielding of the cyanoacrylate coating. The CLSP considerably reduced the skin stress concentration levels and overall tissue stress exposures under the aforementioned medical devices. This demonstrates strong biomechanical effectiveness of the studied cyanoacrylate‐based skin protectant in prevention of facial medical device‐related injuries at small, curved and thereby difficult to protect facial sites.

Comparing methods to secure a tracheal tube placed via a surgical cricothyroidotomy: a randomised controlled study in cadavers

Objective

In the ‘can’t intubate can’t oxygenate’ scenario, techniques to achieve front of neck access to the airway have been described in the literature but there is a lack of guidance on the optimal method for securing the tracheal tube (TT) placed during this procedure. The aim of this study was to compare three different methods of securing a TT to prevent extubation following a surgical cricothyroidotomy.

Methods

A randomised controlled trial was undertaken. The population studied were emergency physicians (EPs) attending a cadaveric airway course. The intervention was securing a TT placed via a surgical cricothyroidotomy by suture. The comparison was securing the TT using fabric tape with two different tying techniques. The primary outcome was the force required to extubate the trachea. The trial was registered with ANZCTR.org.au (ACTRN12621000320853).

Results

17 emergency physicians completed intubations using all three of the securing methods on 12 cadavers for a total of 51 experiments. The mean extubation force was 6.54 KG (95 % CI 5.54–7.55) in the suture group compared with 2.28 KG (95 % CI 1.91–2.64) in the ‘Wilko tie’ group and 2.12 KG (95 % CI 1.63–2.60) in the ‘Lark’s foot tie’ group; The mean difference between the suture and fabric tie techniques was significant (p < 0.001).

Conclusions

Following a surgical cricothyroidotomy in cadavers, EPs were able to effectively secure a TT using a suture technique, and this method was superior to tying the TT using fabric tape.

Incidence and risk factors of medical device-related pressure injuries among patients undergoing prone position spine surgery in the operating room

AIM

We aimed to investigate the incidence rate and risk factors of medical device-related pressure injuries (MDRPIs) among patients undergoing prone position spine surgery.

MATERIALS AND METHODS

This was a prospective observational study of 147 patients who underwent spine surgery in an orthopaedic hospital in Korea. The incidence of MDRPI according to intrinsic and extrinsic factors was assessed using the independent t-, χ² -, or Fisher's exact tests. A logistic regression analysis was performed exclusively for MDRPI areas with an incidence rate >5%.

RESULTS

The mean incidence rate of overall MDRPI was 27.4%, while that of MDRPI by Wilson frame, bi-spectral index, and endotracheal tube (ETT) was 56.5%, 52.4%, and 9.5%, respectively. The risk factors under Wilson frame were operation time and body mass index classification. Compared to their normal weight counterparts, those who were underweight, overweight, and obese had a 46.57(95% CI: 6.37-340.26), 3.96 (95% CI: 1.13-13.86), and 5.60 times (95% CI: 1.62-19.28) higher risk of developing MDRPI, respectively. The risk factors by bi-spectral index were sex, operation time, and the American Society of Anaesthesiologists classification. Compared to ETT intubation of <2 h, the risk of MDRPI increased by 7.16 times (95% CI: 1.35-38.00) and 7.93 times (95% CI: 1.45-43.27) for<3 and ≥3 h' duration, respectively.

CONCLUSION

The difficulty of device repositioning can increase the incidence of MDRPI, and prolonged surgery was a significant risk factor. Thus, appropriate planning and correct equipment utilization is needed during prone position spine surgeries.

Care for unplanned extubation prevention: analysis of the validity of an instrument's content

OBJECTIVES

to analyze the validity of a nursing care instrument content for unplanned extubation prevention in Intensive Care Units.

METHODS

a methodological study carried out with 40 nurses, containing 26 interventions distributed in the components: agitation/delirium/pain management; respiratory device stability; weaning from sedation and spontaneous breathing assessment; human resource management. Content Validity Index, average and universal proportion, and Fleiss' Kappa coefficient were applied.

RESULTS

Brazilian female experts stood out, with an average age of 44.9 years and a standard deviation of 7.75 years. Two interventions did not reach a valid Content Validation Index (≥0.78), when considering the set of evaluated criteria. A universal agreement of 4.0% was identified among Brazilians and 26.6% among foreigners.

CONCLUSIONS

the instrument is relevant and represents "unplanned extubation prevention in Intensive Care Units", which can be implemented in Brazil and in Latin countries, in Brazilian and foreign versions.

A comparison of methods used to secure pediatric endotracheal tubes using a live human dermal model

BACKGROUND

Endotracheal intubation is a common lifesaving procedure. An in situ endotracheal tube (ETT) must be secured in position to avoid displacement and potentially life-threatening complications. Adhesive tapes form the most common intraoperative ETT stabilization methods. Limited published data are available to guide the clinical decision regarding ETT taping method. We performed an interventional study aiming to establish which of many commonly employed ETT tape/supplementary adhesive methods provides the most resistance to ETT distraction.

METHODS

An experiment was undertaken to measure the force required to distract an ETT secured to a live dermal model with 24 different ETT securing methods comprising six types of tape alone and in combination with one of three supplementary adhesives. The primary measurement was the peak force (Newtons) required to distract a secured ETT 3 cm.

RESULTS

A total of 1,164 measurements were made. The mean force required to distract the ETT ranged from 7.8 to 21.8 Newtons. The combination of Cloth Adhesive™ + Mastisol® had the greatest observed mean distraction force, as well as the greatest estimated lower and upper confidence limits.

CONCLUSIONS

There are significant differences in force required to distract an ETT based on taping methods.

Medical device related pressure ulcer of the lip in a patient with COVID-19: Case report and review of the literature

Pressure ulcers of the lip constitute a rare entity faced by plastic surgeons and there is a relatively paucity of data regarding optimal management. In this study we present one case of upper lip pressure ulcer related to prone intubation for respiratory distress due to SARS-CoV-2 infection, treated with surgical excision and reconstruction. We also performed a review of the literature to identify other studies on pressure lip ulcers. Six studies were considered relevant. Conservative management constitutes the most common method of treatment; however, little is known about the aesthetic, and functional morbidity related to either surgical or non-surgical treatments.

Comparison of the effectiveness of endotracheal tube holder with the conventional method in a manikin model

OBJECTIVES:

Endotracheal tube (ETT) displacement occurs by improper fixation. To fix an ETT, many types of fixation tools are employed. Thomas tube holder is one of the fixation tools widely used in many countries. This study aims to compare the ETT fixation using the Thomas tube holder with the conventional method (adhesive tape) in a mannequin model.

METHODS:

The fixation tools were random, using the box of six randomizes to Thomas tube holder and conventional method. After fixation, the mannequin model was being logged roll, chest compression by automated chest compression machine, and transported by the paramedic. The time to ETT fixation and displacements were recorded.

RESULTS:

The mean time (standard deviation) to fixate an ETT was shorter (33.0 s [7.3]) with a Thomas tube holder compared to adhesive tape (52.6 s [7.3], P < 0.001). The number and proportion of the ETT displacements were significantly less with Thomas tube holder compared to adhesive tape during log roll (16, 35.6% vs. 29, 64.4%, P = 0.011), chest compression with automated machine (23, 51.1% vs. 37, 82.2%, P = 0.003), and transport (26, 57.8% vs. 40, 88.9%, P = 0.002).

CONCLUSION:

The Thomas tube holder is more effective than adhesive tape in preventing ETT displacement in a mannequin subjected to log roll, chest compressions, and transportation.