Effect Of Kinetic Therapy on Pulmonary Complications

Critical Care Beds With Continuous Lateral Rotation Therapy to Prevent Ventilator-Associated Pneumonia and Hospital-Acquired Pressure Injury: A Cost-effectiveness Analysis

OBJECTIVES

Mechanical ventilation increases the risk of hospital-acquired conditions (HACs) such as ventilator-associated pneumonia (VAP) and pressure injury (PrI). Beds with continuous lateral rotation therapy (CLRT) are shown to reduce HAC incidence, but the value of switching to CLRT beds is presently unknown. We compared the cost-effectiveness of CLRT beds with standard care in intensive care units.

METHODS

A cost-effectiveness analysis from the healthcare sector and societal perspectives was conducted. A Markov model was constructed to predict health state transitions from time of ventilation through 28 days for the healthcare sector perspective and 1 year for the U.S. societal perspective. Value of information was calculated to determine whether parameter uncertainty warranted further research.

RESULTS

Our analysis suggested that CLRT beds dominate standard care from both perspectives. From the healthcare sector perspective, expected cost for CLRT was U.S. $47,165/patient compared with a higher cost of U.S. $49,258/patient for standard care. The expected effectiveness of CLRT is 0.0418 quality-adjusted life years/patient compared with 0.0416 quality-adjusted life years/patient for standard care. Continuous lateral rotation therapy dominated standard care in approximately 93% of Monte Carlo simulations from both perspectives. Value of information analysis suggests that additional research is potentially cost-effective.

CONCLUSIONS

Continuous lateral rotation therapy is highly cost-effective compared with standard care by preventing HACs that seriously harm patients in the intensive care unit.

Continuous lateral rotational therapy in thoracic trauma--A matched pair analysis

INTRODUCTION

Given the lack of reliable evidence on the utility of continuous lateral rotational therapy (CLRT) in chest trauma, we performed a single-centre retrospective matched-pair analysis of patients treated either with CLRT or non-continuous manual turning after blunt thoracic trauma.

METHODS

We included adult patients that were admitted to our level 1 trauma centre from 2010-2014 and presented with severe thoracic injuries (AISThorax ≥3) within 24 h after the injury and required at least 72 h of mechanical ventilation. Patients were either treated with manual turning every 2-4 h or CLRT. To ensure comparable injury severity and a similar risk for posttraumatic respiratory complications, we matched for thoracic injury severity, age, additional injuries (head, abdomen, extremities) and need for massive transfusion.

RESULTS

A total of 22 pairs (n = 44 patients) were successfully matched and analysed. The use of CLRT did not have a statistically significant impact on respiratory function, gas exchange, duration of mechanical ventilation, ICU or hospital length of stay, or overall patient outcomes (e.g. pneumonia, sepsis, ARDS, mortality). During active rotation the level of sedation was lower compared to manual turning (Richmond Agitation Sedation Scale; manual turning: -3.6; CLRT: -4.0; p = 0.01). Patient agitation was noticed more frequently in the CLRT group (manual turning: n = 2 (9%); CLRT: n = 9 (41%); p = 0.02).

DISCUSSION

In this well-matched sample, the use of CLRT did not seem to translate into relevant clinical benefits in patients with thoracic trauma in the setting of modern ICU care with the widespread implementation of lung protective ventilation. However, statistical power and generalisability were limited by the small sample size and single centre design. A large RCT is required to provide conclusive results.

[Continuous lateral rotational bed therapy in patients with traumatic lung injury: an analysis from the TraumaRegister DGU®]

BACKGROUND

Patients with severe thoracic trauma often receive continuous lateral rotational bed therapy (CLRT) for the treatment of lung contusions. In this study, the effects of CLRT on mortality, morbidity and length of stay (LOS) in the intensive care unit (ICU) and in the hospital were evaluated.

METHODS

Retrospective data from the TraumaRegister DGU® were analysed, focusing on patients with severe thoracic trauma. Patients treated with CLRT were compared to a control group with comparable trauma severity who had received conventional therapy.

RESULTS

A total of 1476 patients (239 with CLRT, 1237 without CLRT) were included in this study. Both groups were similar for demographic characteristics. The median CLRT duration was 6 (4-10) days. Patients receiving CLRT were ventilated for 17 (10-26) days compared to 14 (8-22) days (p = 0.001) in the control group. The ICU length of stay differed significantly (CLRT: 23 [14-32] days; control: 19 [13-28] days; p = 0.002). Also, organ failure occurred more frequently in patients treated with CLRT (CLRT: 76.6%, control: 67.6%; p = 0.006). No differences could be detected regarding mortality rates, multiple organ failure and hospital LOS.

CONCLUSIONS

The results of this retrospective analysis fail to detect a benefit for CLRT therapy in trauma patients. Considering inherent limitations of retrospective studies, caution should be exerted when interpreting these results. Further research is warranted to confirm these findings in a prospective trial.

Acute Lobar Atelectasis

Lobar atelectasis (or collapse) is an exceedingly common, rather predictable, and potentially pathogenic companion to many forms of acute illness, postoperative care, and chronic debility. Readily diagnosed by using routine chest imaging and bedside ultrasound, the consequences from lobar collapse may be minor or serious, depending on extent, mechanism, patient vulnerability, abruptness of onset, effectiveness of hypoxic vasoconstriction, and compensatory reserves. Measures taken to reduce secretion burden, assure adequate secretion clearance, maintain upright positioning, reverse lung compression, and sustain lung expansion accord with a logical physiologic rationale. Both classification and logical approaches to prophylaxis and treatment of lobar atelectasis derive from a sound mechanistic knowledge of its causation.

Rotational therapy in thoracic injuries: what is the evidence?

PURPOSE OF REVIEW

To review the current use of continuous lateral rotational therapy (CLRT) in patients with thoracic injuries and its impact on clinical course, complications and outcome.

RECENT FINDINGS

Patient positioning is a key factor in the treatment of severe thoracic injuries and CLRT, and intermittent supine and prone position are basic options. There is a lack of randomized controlled studies for trauma patients with chest injury undergoing kinetic therapy as standard of care. A positive effect of kinetic therapy for prevention of secondary respiratory complications has been reported; nevertheless, no positive effect on mortality or length of hospital stay could be affirmed so far. In general, standardized therapeutic regimes for treatment of chest trauma have been implemented, including ventilator settings and positioning therapy. However, the available data do not allow a clear recommendation for rotational/kinetic therapy or prone positioning as superior or inferior.

SUMMARY

The benefit of changing the patients' position for secret mobilization and recruitment of atelectasis after chest trauma and therefore preventing secondary complications seems to be self-evident. Since only few studies report about the utility of CLRT in critically ill chest trauma patients, randomized controlled multicenter trials are necessary to analyze the overall benefit of such means.

Lateral positioning for critically ill adult patients

BACKGROUND

Critically ill patients require regular body position changes to minimize the adverse effects of bed rest, inactivity and immobilization. However, uncertainty surrounds the effectiveness of lateral positioning for improving pulmonary gas exchange, aiding drainage of tracheobronchial secretions and preventing morbidity. In addition, it is unclear whether the perceived risk levied by respiratory and haemodynamic instability upon turning critically ill patients outweighs the respiratory benefits of side-to-side rotation. Thus, lack of certainty may contribute to variation in positioning practice and equivocal patient outcomes.

OBJECTIVES

To evaluate effects of the lateral position compared with other body positions on patient outcomes (mortality, morbidity and clinical adverse events) in critically ill adult patients. (Clinical adverse events include hypoxaemia, hypotension, low oxygen delivery and global indicators of impaired tissue oxygenation.) We examined single use of the lateral position (i.e. on the right or left side) and repeat use of the lateral position (i.e. lateral positioning) within a positioning schedule.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1950 to 23 May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to 23 May 2015), the Allied and Complementary Medicine Database (AMED) (1984 to 23 May 2015), Latin American Caribbean Health Sciences Literature (LILACS) (1901 to 23 May 2015), Web of Science (1945 to 23 May 2015), Index to Theses in Great Britain and Ireland (1950 to 23 May 2015), Trove (2009 to 23 May 2015; previously Australasian Digital Theses Program (1997 to December 2008)) and Proquest Dissertations and Theses (2009 to 23 May 2015; previously Proquest Digital Dissertations (1980 to 23 May 2015)). We handsearched the reference lists of potentially relevant reports and two nursing journals.

SELECTION CRITERIA

We included randomized and quasi-randomized trials examining effects of lateral positioning in critically ill adults. We included manual or automated turns but limited eligibility to studies that included duration of body position of 10 minutes or longer. We examined each lateral position versus at least one comparator (opposite lateral position and/or another body position) for single therapy effects, and the lateral positioning schedule (repeated lateral turning) versus other positioning schedules for repetitive therapy effects.

DATA COLLECTION AND ANALYSIS

We pre-specified methods to be used for data collection, risk of bias assessment and analysis. Two independent review authors carried out each stage of selection and data extraction and settled differences in opinion by consensus, or by third party adjudication when disagreements remained unresolved. We planned analysis of pair-wise comparisons under composite time intervals with the aim of considering recommendations based on meta-analyses of studies with low risk of bias.

MAIN RESULTS

We included 24 studies of critically ill adults. No study reported mortality as an outcome of interest. Two randomized controlled trials (RCTs) examined lateral positioning for pulmonary morbidity outcomes but provided insufficient information for meta-analysis. A total of 22 randomized trials examined effects of lateral positioning (four parallel-group and 18 cross-over designs) by measuring various continuous data outcomes commonly used to detect adverse cardiopulmonary events within critical care areas. However, parallel-group studies were not comparable, and cross-over studies provided limited data as the result of unit of analysis errors. Eight studies provided some data; most of these were single studies with small effects that were imprecise. We pooled partial pressure of arterial oxygen (PaO2) as a measure to detect hypoxaemia from two small studies of participants with unilateral lung disease (n = 19). The mean difference (MD) between lateral positions (bad lung down versus good lung down) was approximately 50 mmHg (MD -49.26 mmHg, 95% confidence interval (CI) -67.33 to -31.18; P value < 0.00001). Despite a lower mean PaO2 for bad lung down, hypoxaemia (mean PaO2 < 60 mmHg) was not consistently reported. Furthermore, pooled data had methodological shortcomings with unclear risk of bias. We had similar doubts regarding internal validity for other studies included in the review.

AUTHORS' CONCLUSIONS

Review authors could provide no clinical practice recommendations based on the findings of included studies. Available research could not eliminate the uncertainty surrounding benefits and/or risks associated with lateral positioning of critically ill adult patients. Research gaps include the effectiveness of lateral positioning compared with semi recumbent positioning for mechanically ventilated patients, lateral positioning compared with prone positioning for acute respiratory distress syndrome (ARDS) and less frequent changes in body position. We recommend that future research be undertaken to address whether the routine practice of repositioning patients on their side benefits all, some or few critically ill patients.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

Is it safe to use a kinetic therapy bed for care of patients with cervical spine injuries?

INTRODUCTION

Bedrest is often used for temporary management, as well as definitive treatment, for many spinal injuries. Under such circumstances patients cannot remain flat for extended periods due to possible skin breakdown, blood clots, or pulmonary complications. Kinetic therapy beds are often used in the critical care setting, although this is felt to be unsafe for turning patients with spine fractures. We sought to evaluate whether a kinetic therapy bed would cause as much spinal motion at an unstable cervical injury as occurs during manual log-rolling on a standard intensive care unit bed.

METHODS

Unstable C5-C6 ligamentous injuries were surgically created in 15 fresh, whole cadavers. Sensors were affixed to C5 and C6 posteriorly and electromagnetic motion tracking analysis performed. In all cases a cervical collar was applied by an orthotist after creation of the injury. The amount of angular motion and linear displacement that occurred at this injured level was measured during manual log-rolling and patient turning using a kinetic therapy bed. For statistical analysis, the range of motion for angles about each axis and displacement in each direction was analyzed by multivariate analysis of variance with repeated measures.

RESULTS

When comparing manual log-rolling and kinetic bed therapy, significantly more angular motion was created by the log-roll manoeuvre in flexion-extension (p=0.03) and lateral bending (p=0.01). There was no significant difference in axial rotation between the two methods (p=0.80). There were no significant differences demonstrated in medial-lateral and anterior-posterior translation. There was almost two times the axial displacement between manual log-rolling and the kinetic therapy bed and this reached statistical significance (p=0.05).

CONCLUSION

There is less motion at an unstable cervical injury in flexion-extension, lateral bending, and axial displacement when turning a patient using a kinetic therapy bed as opposed to traditional manual log-rolling. It may be preferable to use a kinetic therapy bed rather than manual log-rolling for patients with cervical spine injuries to decrease unwanted spinal motion. In addition, it may be easier and less physically demanding on nursing staff that must regularly turn the patient if manual log-rolling is implemented.

Building a protocol to guide mobility in the ICU

Professional experience and wisdom have taught us that immobility is a risk factor for various adverse outcomes, such as deep vein thrombosis, joint contractures, pulmonary dysfunction, and bone demineralization to name a few. Balancing bed rest and mobility may improve both short- and long-term outcomes for our patients. Moreover, early, routine mobilization of critically ill patients is safe and reduces hospital length of stay, shortens the duration of mechanical ventilation, improves muscle strength, and functional independence. At the University of Michigan, we have turned the tides by creating a structured process to get our patients moving through the use of a standardized mobility protocol. Our protocol is simple and can easily be adapted for all patient populations by simply modifying some of the inclusion and exclusion criteria. The activities are grounded in the evidence and well thought out to prevent complications and promote mobilization. The purpose of this article was to present the science behind the development of a multidisciplinary protocol for early mobilization of critically ill patients that can be adapted to any intensive care unit patient with minor modifications.

Lung Organ Failure Score (LOFS): probability of severe pulmonary organ failure after multiple injuries including chest trauma

BACKGROUND

Pulmonary complications are common in multiple trauma patients with chest injury. Factors predisposing these critically ill patients to respiratory organ failure are not fully understood.

METHODS

Univariate and multivariate logistic regression analyses were used to assess the prognostic value of clinical and laboratory variables (2002-2008; n = 30,616) from the Trauma Registry of the German Trauma Society (DGU). Data from patients admitted to the ICU with lung contusion/lacerations, an Injury Severity Score ≥ 16 and age ≥ 18 were included in the study. Severe pulmonary organ failure was defined as PaO(2)/FiO(2)<200 for ≥ 3 days and based on the odds ratios (ORs) a simplified Lung Organ Failure Score (LOFS) was developed using integer values.

RESULTS

21.3% (1254) of the 5892 patients analysed developed severe pulmonary organ failure. We identified seven independent predictors with significant correlation: age, gender, head injury, fluid therapy, injury severity, degree of chest trauma and surgical interventions. The highest ORs were observed in cases of Abbreviated Injury Scale (AIS)(Thorax) = 5 (1.58), surgical intervention (1.71) and multiple surgeries (2.41). We found that patients with simplified score values ≥ 21 points were at a maximum risk (>30%) for developing severe pulmonary complications.

CONCLUSION

This scoring method could help trauma surgeons determine which multiple trauma patients are at risk for pulmonary complications after trauma. Efficacy analyses of prophylactic PEEP ventilation or rotational bed therapy in subgroups with comparable risks for respiratory complication could be based on the LOFS.

A prospective, randomized trial of continuous lateral rotation ("kinetic therapy") in patients with cardiogenic shock

BACKGROUND

Continuous lateral rotation ["Kinetic therapy" (KT)] has been shown to reduce complications and to shorten hospital stay in trauma patients. Data in non-surgical patients is inconclusive. Retrospective data suggest a beneficial effect of KT in patients with cardiogenic shock (CS) requiring ventilator therapy. KT, however, has not been tested prospectively in those patients.

METHODS

A prospective, randomized, open-label trial was performed to compare KT using oscillating beds (TryaDyne Proventa, KCI) with standard care (SC). Patients with cardiogenic shock requiring ventilator therapy for more than 24 h were included. Primary endpoint was the occurrence of hospital-acquired pneumonia. Secondary endpoints were the occurrence of pressure ulcers during the hospital stay and 1-year all-cause mortality.

RESULTS

Forty-five patients were randomized to KT, and 44 to SC. All patients required at least one inotropic agent and one vasopressor for circulatory assistance. The groups were comparable in the etiology of heart disease, in the use of revascularization procedures, the use of balloon counterpulsation, and APACHE-II score (33 ± 5 vs. 33 ± 4) and SOFA score (11 ± 1 vs. 11 ± 1) at inclusion; however, more patients in SC were subject to resuscitation before inclusion. Hospital-acquired pneumonia occurred in 10 patients in KT and 28 patients in SC (p < 0.001); pressure ulcers were seen in 10 versus 2 patients (p < 0.001). Hospital mortality tended to be lower in KT, and 1-year all-cause mortality was 41 % in KT and 66 % in SC (p = 0.028).

CONCLUSION

The use of KT reduces rates of pneumonia and pressure ulcers as compared to SC. Moreover, in this study, patients with KT had a better outcome. The study suggests that KT should be used in patients with cardiogenic shock requiring ventilator therapy for a prolonged time.

Mobilisation in critical care: a concept analysis

OBJECTIVES

The aim of this paper is to analyse the concept of mobilisation within the context of the critical care setting. Mobilisation is a widely used term that belies the complexity of its use in practice. Whilst facilitating movement is a significant nursing concern, mobilisation practices vary widely amongst nurses, perhaps due to conceptual incongruence.

METHODS

Evolutionary methodology was used in this concept analysis. Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews and PsycInfo databases were searched from 1966 to present. Search terms included mobilisation, mobility and passive exercise, yielding 61 articles suitable for analysis.

FINDINGS

Findings indicate that mobilisation is an interdisciplinary, goal-directed therapy used to facilitate movement and improve outcomes. It involves energy expenditure and has both physical and psychological domains. Disciplines vary in applications of mobilisation and therapy parameters are essentially undefined. The energy expenditure attribute has been well-exemplified in physical therapy literature, but only to a minimal degree in nursing literature.

CONCLUSION

In spite of the wide use of mobilisation, the concept requires further development, particularly in the critical care setting. Barriers to mobilisation require further delineation as does the psychological domain. Ongoing concept analysis can be used to inform practice and guide research activities.

Circulating levels of Clara cell protein 16 but not surfactant protein D identify and quantify lung damage in patients with multiple injuries

BACKGROUND

Almost 60% of all patients with severe multiple injuries sustain severe chest trauma with aggravating effect on morbidity and mortality. Diagnosis of lung contusion is performed by early posttraumatic multislice computed tomography. Because this diagnostic procedure requires time, resources, and exposure to radiation, a noninvasive approach with easy follow-up measurements is warranted.

METHODS

Serum levels of Clara cell protein 16 (CC16) and surfactant protein D as lung-specific biomarkers were obtained on admission from 104 patients with multiple injuries using enzyme-linked immunosorbent assay technique. Patients were divided into those with severe lung injury ([LI]; n = 68) and without LI (NLI; n = 36). Nonsmoking healthy volunteers served as controls. In addition, volume of lung contusions were calculated planimetrically on serial multislice computed tomography scans obtained after admission. Factors influencing CC16 serum levels were determined in uni- and multivariate analyses, and Spearman rank coefficients were calculated for correlations.

RESULTS

Patients with LI showed a significant (p < 0.05) elevation of median CC16 levels (10.2 ng/mL) compared with NLI patients (5.4 ng/mL) and controls (5.2 ng/mL). Serum CC16 levels correlated with the volume of lung contusions (r = 0.78, p < 0.0001) and were not influenced by overall injury severity, age, gender, or preclinical ventilation. In contrast, circulating surfactant protein D levels were not associated with the presence of LI or the extent of lung contusions.

CONCLUSIONS

Our results advocate CC16 as a potential biomarker for LI in severely injured patients because of its high correlation with the volume of contused lung parenchyma. Therefore, this parameter may allow a specified initial treatment of patients with multiple injuries.

The validation of a clinical algorithm for the prevention and management of pulmonary dysfunction in intubated adults--a synthesis of evidence and expert opinion

BACKGROUND

Pulmonary dysfunction (PDF) in intubated patients remains a serious and costly complication of intensive care unit care. Optimal cardiopulmonary therapy strategies to prevent and manage PDF need clarification to reduce practice variability. The purpose of this paper is to report on the content validation of an evidence-based clinical management algorithm (EBCMA) aimed at the prevention, identification and management of PDF in critically ill patients.

METHODS

Forty-four draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by research clinicians (n = 7) in an electronic three-round Delphi process. Statements which reached a priori defined consensus [semi-interquartile range (SIQR) <0.5] were collated into the EBCMA.

RESULTS

One hundred per cent response rate. Forty-four statements were added after round one. Consensus was reached on rating of 83% (73/88) statements. Differences in interpretation of the existing evidence base, and variations in accepted clinical practice were identified. Four themes were identified where panel failed to reach consensus.

CONCLUSION

The internationally agreed hierarchical framework of current available evidence and clinical expertise developed through this Delphi process provides clinicians with a tool to inform clinical practice. This tool has the potential to reduce practice variability thereby maximizing safety and treatment outcome. The clinical utility of the EBCMA requires further evaluation.

Continuous lateral rotation therapy - a review

AIMS

This article reviews the current evidence, benefits and drawbacks for the use of continuous lateral replacement therapy in the treatment and prevention of nosocomial infections in the ventilated patient.

RELEVANT TO PRACTICE

The acquisition of nosocomial infections and the development of pressure sores continue to be major issues in the care of the critically ill, ventilated patient. The use of continuous lateral rotation therapy (CLRT) as an adjunct in the prevention and treatment of pneumonia has increased in popularity in recent years. A number of institutions routinely advocate the use of CLRT in critically ill patients.

CONCLUSION

While there is some data to suggest that CLRT may have an impact on prevention of and treatment for nosocomial infections acquired by ventilated patients, there still remains insufficient evidence to its inclusion as a fully validated treatment. Clearly, there is a requirement for more robust, in-depth research into the efficacy of this proposed treatment.

Continuous lateral rotation therapy to prevent ventilator-associated pneumonia

OBJECTIVE

To investigate the impact of prophylactic continuous lateral rotation therapy on the prevalence of ventilator-associated pneumonia, duration of mechanical ventilation, length of stay, and mortality in critically ill medical patients.

DESIGN

Prospective, randomized, clinical study.

SETTING

Three medical intensive care units of an university tertiary care hospital.

PATIENTS

Patients were randomized to continuous lateral rotation therapy or standard care if they were mechanically ventilated for <48 hrs and free from pneumonia. Primary study end point was development of ventilator-associated pneumonia. Ventilator-associated pneumonia was defined as infiltrate on the chest radiograph plus newly developed purulent tracheal secretion plus increasing signs of inflammation. The diagnosis had to be confirmed microbiologically and required the growth of a pathogen >10(4) colony-forming units/mL in bronchoalveolar lavage. Radiologists were blinded to randomization whereas clinical outcome assessors were not.

INTERVENTIONS

Rotation therapy was performed continuously in a specially designed bed over an arc of 90 degrees. Additional measures to prevent ventilator-associated pneumonia were equally standardized in both groups including semirecumbent position.

MEASUREMENTS AND MAIN RESULTS

Ventilator-associated pneumonia frequency during the intensive care unit stay was 11% in the rotation group and 23% in the control group (p = .048), respectively. Duration of ventilation (8 +/- 5 vs. 14 +/- 23 days, p = .02) and length of stay (25 +/- 22 days vs. 39 +/- 45 days, p = .01) were significantly shorter in the rotation group. In a forward stepwise logistic regression model including the continuous lateral rotation therapy, gender, Lung Injury Score, and Simplified Acute Physiology Score II, continuous lateral rotation therapy just failed to reach statistical significance with respect to development of ventilator-associated pneumonia (p = .08). Intolerance to continuous lateral rotation therapy during the weaning phase was observed in 29 patients (39%). Mortality was comparable in both groups.

CONCLUSIONS

Ventilator-associated pneumonia prevalence was significantly reduced by continuous lateral rotation therapy. Continuous lateral rotation therapy led to shorter ventilation time and length of stay. Continuous lateral rotation therapy should be considered in ventilated patients at risk for ventilator-associated pneumonia as a feasible method exerting additive effects to other preventive measures.

Cardiovascular impact of manual and automated turns in ICU

Mechanically ventilated patients in the intensive care unit (ICU) are typically turned manually by nursing staff to reduce the risk of developing ventilator associated pneumonia and other problems in the lungs. However, turning can induce changes in the heart rate and blood pressure that can at times have a destabilizing effect. We report here on the early stage of a study that has been undertaken to measure the cardiovascular impact of manual turning, and compare it to changes induced when patients lie on automated beds that turn continuously. Heart rate and blood pressure data were analyzed over ensembles of turns with autoregressive models for comparing baseline level to the dynamic response. Manual turning stimulated a response in the heart rate that lasted for a median of 20 minutes and was of magnitude 5 to 13 bpm. The corresponding response in mean arterial pressure was 11 to 19 mm Hg, lasting for 8 to 21 minutes. There was no discernible response of either variable to automated turns.

Therapeutic positioning of the multiply-injured trauma patient in ICU

Critically-ill patients who have sustained multiple traumatic injuries have complex, and often conflicting, physiological needs. These have profound implications on the way in which nursing staff approach the physical positioning of these patients to minimize the risks of further physiological injury and damage, maintain homeostasis and promote optimum recovery. This article reviews and discusses the evidence base underpinning therapeutic positioning of the multiply-injured trauma patient within the intensive-care unit (ICU), focusing on patients with a known or suspected unstable spinal injury, pelvic injury, traumatic brain injury, chest injury, or multiple limb fractures. Included are guidelines on the therapeutic positioning of the multiply-injured trauma patient within the ICU, based on the current available evidence and also drawn from practical experience within the author's own place of work. There is also a brief discussion of how such guidelines may be introduced into clinical practice.

The impact of continuous lateral rotation therapy in overall clinical and financial outcomes of critically ill patients

BACKGROUND

Significant pulmonary complications are prevalent in intubated and mechanically ventilated patients.

OBJECTIVES

This study was conducted to determine the impact of continuous lateral rotation therapy (CLRT) on patients considered to be at high risk for pulmonary complications. Overall study objectives included hospital length of stay, critical care length of stay, ventilator days, and cost to treat.

METHODS

Patients at risk for pulmonary complications as defined by Pao2/Fio2 ratio < 300, Fio2 > 50% for more than 1 hour, positive end-expiratory pressure > or = 8, or a Predicus score of > or = 5 were compared with a historical comparison group that met the high-risk criteria given above and did not receive CLRT. Patients who received CLRT were separated into 2 groups, early CLRT group (began therapy within 48 hours, n = 49) or late CLRT group (n = 46).

RESULTS

The early CLRT group had a reduction in critical care LOS, (P = .04) as compared with the non-CLRT group. Total hospital costs were reduced (P = .01) in the early intervention group compared to the late intervention group, as well as ICU LOS (P = .02). Nonsignificant trends were seen in reduced ventilator days and hospital LOS. Reintubation rates and readmissions to critical care were also lower in the early intervention group.

CONCLUSIONS

Continuous lateral rotation therapy, when introduced early in course of treatment of high-risk patients, reduces critical care LOS and cost to treat.

Promoting research in clinical practice: strategies for implementing research initiatives

Promoting the use and conduct of research in clinical practice is an essential component in ensuring best practices and promoting positive outcomes for patients. Yet, it is often difficult for nurses in clinical practice to devote time to research activities because the daily demands of practice often take precedence. This article reviews key strategies for implementing research in clinical practice. Examples of ongoing initiatives being conducted at a variety of clinical settings are highlighted to showcase strategies for implementing clinically focused research projects.

A systematic approach to care: adult respiratory distress syndrome

Trauma patients present with and have the potential to develop an array of systemic and metabolic disturbances. Adult respiratory distress syndrome has been identified as a life-threatening development, especially in trauma patients. A systematic approach to care utilizing the acronyms FASTHUG and BANDAIDS, along with incorporating lung protective strategies, provides avenues to decrease mortality related to adult respiratory distress syndrome. A case study presentation, pathophysiology related to symptoms, interventions, and clinical outcomes are presented.

Adverse hemodynamic effects of lateral rotation during mechanical ventilation

Turning critically ill, mechanically ventilated patients every 2 hours is a fundamental nursing intervention to reduce the negative impact of prolonged immobility from preventable pulmonary complications such as ventilator-associated pneumonia and atelectasis. Unfortunately, when coupled with positive pressure ventilation, the benefits of turning may come at the expense of cardiovascular function. Clinicians should closely monitor the hemodynamic response to turning mechanically ventilated patients, and if compromise is observed, the degree and duration of compromise may provide guidance to the appropriate intervention.

Removal of oral secretion prior to position change can reduce the incidence of ventilator-associated pneumonia for adult ICU patients: a clinical controlled trial study

AIM

The purpose of this study was to explore the effect of oral secretion on aspiration and reducing ventilator-associated pneumonia.

BACKGROUND

Ventilator-associated pneumonia is a serious hospital-acquired infection with reported incidence rate of 12.2% and mortality rate of 29.3%. Oral secretion is purported as a media which brings the oropharyngeal pathogens down to the respiratory track.

METHODS

Two-group comparison study design was adopted. Subjects were recruited from an adult general intensive care unit of a medical centre in Taipei city. Patients in the study group received suction of oral secretion before each positional care, in contrast with patients in the control group who received routine care.

RESULTS

Ventilator-associated pneumonia was found in 24 of 159 (15.1%) patients in the control group and in five of 102 (4.9%) patients in the study group with a reduction of risk ratio of 0.32 (95% CI 0.11-0.92). Eight of the 24 ventilator-associated pneumonia patients died in the control group; however, none of those ventilator-associated pneumonia patients died in the study group. The increased chance of survival was 1.50 (95% CI 1.13-1.99). The length of stay in ICU and duration of mechanical ventilation were reduced in the study group. In consideration of cost, the cost of tubes used to remove oral secretion is much less than the one used to do continuous subglottal suction.

CONCLUSION

Removal of oral secretion is effective in reducing the incidence of ventilator-associated pneumonia with minimum cost intervention.

RELEVANCE TO CLINICAL PRACTICE

This study provides evidence that removal of oral secretion prior to position change is cost effective to reduce the incidence of ventilator-associated pneumonia. As such intervention is an easy task, routine removal of oral secretion is recommended as the standard of daily nursing care of patients on ventilator.

Impact of oral hygiene on prevention of ventilator-associated pneumonia in neuroscience patients

Ventilator-associated pneumonia is one of the most frequent complications among critically ill patients. Growth of pathogenic bacteria in dental plaque may serve as the source of these infections. This performance improvement initiative evaluated an aggressive oral care approach to prevent the accumulation of plaque containing bacteria. Our data support the use of these oral care measures and deep oral-pharyngeal suctioning for the prevention of aspiration of oral contents.

A mobility protocol for critically ill adults

Although the complications of immobility are well-described in the literature, critically ill patients are often subjected to prolonged periods of bed rest. Nurses, by virtue of their expertise in preventing iatrogenic complications, are in an ideal position to prevent the adverse outcomes associated with immobility. This article describes how nurses can use a mobility protocol to increase the activity of critically ill patients in a timely manner that may prevent the infirmity and suffering that is caused by unnecessarily long periods of bed rest.

Prevention of ventilator-associated pneumonia: analysis of studies published since 2004

As the most recent guidelines for the prevention of ventilator-associated pneumonia (VAP) were published four years ago, we have conducted a systematic review to discover whether the recently published articles should further influence existing guidelines. Articles published since 2004 dealing with infection control measures for prevention of VAP were gathered and evaluated in order to identify evidence for the possible modification of routine practice. Special emphasis was placed on randomized controlled trials (RCTs), meta-analyses or systematic reviews and studies applying multi-module interventions. A total of 15 RCTs and seven meta-analyses or systematic reviews were found. In addition to these, five cohort studies were identified where multi-module programmes were introduced for reducing VAP rates. The data lead to the conclusion that topical use of chlorhexidine for oral care is beneficial and subglottic secretion drainage may lead to delayed onset of VAP. The remaining studies had only a minor influence on existing guidelines for the prevention of VAP and confirmed the earlier recommendations in several points. However, the studies investigating multi-module programmes led to a substantial reduction of VAP of between 31 and 57%. The data show that many VAP cases are preventable and that there is room for improvement in many institutions. Often simple interventions are useful for the reduction of VAP rates, for which the best chances appeared to be the application of multi-module programmes. On average a reduction of more than 40% seems to be possible.

Impact of kinetic beds on the incidence of atelectasis in mechanically ventilated patients

We investigated the impact of kinetic beds on the incidence of atelectasis in mechanically ventilated patients in an intensive care unit (ICU). All bronchoscopies performed for atelectasis on mechanically ventilated patients between July 2000 and June 2001 and between July 2002 and June 2003 were reviewed. On July 26, 2001, 50 kinetic beds, 20 continuous lateral rotation therapy modules, and 20 percussion and vibration modules were introduced to our institution. Of the 3399 ICU admissions between July 2000 and June 2001, 71 patients developed atelectasis while being mechanically ventilated. Of the 3065 ICU admissions between July 2002 and June 2003, 83 patients developed atelectasis while being mechanically ventilated. Of these, 48 (58%) patients had left-sided atelectasis, 30 (36%) had right-sided atelectasis, and 5 (6%) had bilateral atelectasis. There was no decrease in the incidence of atelectasis in mechanically ventilated patients at our institution after the introduction of kinetic beds and vibration, percussion, and rotation modules despite their widespread availability.

Is there evidence to support the use of lateral positioning in intensive care? A systematic review

A systematic review of randomised clinical trials was conducted to investigate the efficacy and safety of use of the lateral position in the management of ventilated intensive care patients. One review article and 11 empiric studies, which were mostly of low methodological quality, met the eligibility criteria. Large individual variations in PaO2 response to lateral positioning were demonstrated. Greatest improvement in PaO2 occurred in patients with unilateralpulmonary infiltrates positioned with the bad lung up versus bad lung down (average difference = 33.6 mmHg (range 0-58), effect size 1.13 (95% CI: 0.44, 1.19, P = 0.001)) or supine (average difference=27 mmHg (range 5-42), effect size 0.58 (95% CI: 0.11, 1.06, P = 0.017)). This effect appeared to be most prominent in patients with widespread, unilateral infiltrates. Lung compliance was not affected by lateral positioning. Haemodynamic compromise was evident with lateral positioning of greater than 60 degrees to the right side in patients requiring vasopressors and/or with right ventricular dysfunction; or with lateral positioning in postoperative coronary artery bypass graft patients. No studies were found that had investigated the effect of routine applications of the lateral positioning to improve, prevent or treat pneumonia, decrease mortality or influence other long-term outcomes. The results of this review demonstrate the limited evidence available to support the use of lateral positioning in the intensive care environment. More data reporting the long-term effects of lateral position on long-term outcomes would aid clinical decision making and may improve the application of patient positioning in critical care environments.

Quality measurement at intensive care units: which indicators should we use?

OBJECTIVE

This study was conducted to develop a set of indicators that measure the quality of care in intensive care units (ICU) in Dutch hospitals and to evaluate the feasibility of the registration of these indicators.

METHODS

To define potential indicators for measuring quality, 3 steps were made. First, a literature search was carried out to obtain peer-reviewed articles from 2000 to 2005, describing process or structure indicators in intensive care, which are associated with patient outcome. Additional indicators were suggested by a panel of experts. Second, a selection of indicators was made by a panel of experts using a questionnaire and ranking in a consensus procedure. Third, a study was done for 6 months in 18 ICUs to evaluate the feasibility of using the identified quality indicators. Site visits, interviews, and written questionnaires were used to evaluate the use of indicators.

RESULTS

Sixty-two indicators were initially found, either in the literature or suggested by the members of the expert panel. From these, 12 indicators were selected by the expert panel by consensus. After the feasibility study, 11 indicators were eventually selected. "Interclinical transport," referring to a change of hospital, was dropped because of lack of reliability and support for further implementation by the participating hospitals in the study. The following structure indicators were selected: availability of intensivist (hours per day), patient-to-nurse ratio, strategy to prevent medication errors, measurement of patient/family satisfaction. Four process indicators were selected: length of ICU stay, duration of mechanical ventilation, proportion of days with all ICU beds occupied, and proportion of glucose measurement exceeding 8.0 mmol/L or lower than 2.2 mmol/L. The selected outcome indicators were as follows: standardized mortality (APACHE II), incidence of decubitus, number of unplanned extubations. The time for registration varied from less than 30 minutes to more than 1 hour per day to collect the items. Among other factors, this variation in workload was related to the availability of computerized systems to collect the data.

CONCLUSION

In this study, a set of 11 quality indicators for intensive care was defined based on literature research, expert opinion, and testing. The set gives a quick view of the quality of care in individual ICUs. The availability of a computerized data collection system is important for an acceptable workload.

Kinetic therapy beds are associated with more complications in patients with thoracolumbar spinal column injuries

BACKGROUND AND PURPOSE

Traumatic spine injuries are an important cause of morbidity and mortality. Kinetic therapy (KT) beds were designed to minimize skin breakdown and enhance clearance of pulmonary secretions by rotating the patient from side to side. However, little evidence exists to suggest that fewer complications occur in patients with thoracolumbar spine injuries (TLSIs) treated preoperatively with a KT bed. We investigated the effect of KT bed use on infectious complications and respiratory failure in patients requiring surgery for TLSIs.

METHODS

We queried the trauma registry of a Level 1 trauma center for patients who had surgery for a TLSI from January 1, 1994, through June 30, 2001, and performed a retrospective medical record review. Patients were divided into two groups according to whether they were treated with a KT bed preoperatively. Patient data included age, injury severity score (ISS), admission Glasgow Coma Scale score (GCS), time to surgery, narcotics administered in total and during the first 24 h after injury, the lowest recorded systolic blood pressure, and acute resuscitation volume requirement. Outcome data included infectious complications, neurologic deficits, respiratory failure, hospital length of stay (LOS), and number of days of ventilator support. Infectious complications included pneumonia, urinary tract infections, and surgical site infections.

RESULTS

Patients treated with a KT bed and patients treated with a conventional bed were similar in age, ISS, admission GCS, time to surgery, total narcotics administered, lowest recorded systolic blood pressure, and resuscitation requirement during the first 24 h. However, patients with neurologic deficits were more frequently treated with a KT bed. Infectious complications were more common in patients receiving KT bed therapy than among those on conventional beds. The incidence of respiratory failure, the number of days of ventilator support, and hospital LOS also were significantly higher in patients treated with KT beds. The variables most predictive of infectious complications were the number of days of ventilator support, the amount of fluid administered during the first 24 h, and KT bed therapy (r2 = 0.459).

CONCLUSIONS

Patients with TLSIs treated with a KT bed had a higher incidence of infectious complications and respiratory failure and more days of ventilator support than patients treated with a conventional bed despite similar ISS and time to surgical repair. The longer hospital LOS in patients treated with a KT bed may be secondary to the higher incidence of infectious complications and respiratory failure and the greater number of days of ventilator support.

Ventilator-associated pneumonia and pressure ulcer prevention as targets for quality improvement in the ICU

The health care culture must change. Florence Nightingale wrote [8] "deep-rooted and universal is the conviction that to give a medicine is to be doing something, or rather everything and to give air, warmth, cleanliness etc. is to do nothing." Hygiene care practices and mobility activities are fundamental and independent care components in the nursing profession. When implemented using available evidence, they can significantly improve patient outcomes. It is time to claim and demonstrate the importance of consistent delivery of the fundamentals of basic nursing care. Interventional patient hygiene is an effective framework to ensure the the basics of nursing care are consistently applied to improve patient outcomes.

Rotational Bed Therapy to Prevent and Treat Respiratory Complications: A Review and Meta-Analysis

• Background Immobility is associated with complications involving many body systems.

• Objective To review the effect of rotational therapy (use of therapeutic surfaces that turn on their longitudinal axes) on prevention and/or treatment of respiratory complications in critically ill patients.

• Methods Published articles evaluating prophylaxis and/or treatment were reviewed. Prospective randomized controlled trials were assessed for quality and included in meta-analyses.

• Results A literature search yielded 15 nonrandomized, uncontrolled, or retrospective studies. Twenty prospective randomized controlled trials on rotational therapy were published between 1987 and 2004. Various types of beds were studied, but few details on the rotational parameters were reported. The usual control was manual turning of patients by nurses every 2 hours. One animal investigation and 12 clinical trials addressed the effectiveness of rotational therapy in preventing respiratory complications. Significant benefits were reported in the animal study and 4 of the trials. Significant benefits to patients were reported in 2 of another 4 studies focused on treatment of established complications. Researchers have examined the effects of rotational therapy on mucus transport, intrapulmonary shunt, hemodynamic effects, urine output, and intracranial pressure. Little convincing evidence is available, however, on the most effective rotation parameters (eg, degree, pause time, and amount of time per day). Meta-analysis suggests that rotational therapy decreases the incidence of pneumonia but has no effect on duration of mechanical ventilation, number of days in intensive care, or hospital mortality.

• Conclusions Rotational therapy may be useful for preventing and treating respiratory complications in selected critically ill patients receiving mechanical ventilation.

Kinetic therapy reduces complications and shortens hospital stay in patients with cardiogenic shock - a retrospective analysis

BACKGROUND

Kinetic therapy (KT) has been shown to reduce complications and to shorten hospital stay in trauma patients. Data in non-surgical patients are inconclusive, and kinetic therapy has not been tested in patients with cardiogenic shock.

OBJECTIVE

The present analysis compares KT with standard care in patients with cardiogenic shock.

METHODS

A retrospective analysis of 133 patients with cardiogenic shock admitted to 1 academic heart center was performed. Patients with standard care (SC, turning every 2 h by the staff) were compared with kinetic therapy (KT, using oscillating air-flotation beds).

MEASUREMENTS AND MAIN RESULTS

68 patients with KT were compared with 65 patients with SC. Length of ventilator therapy was 11 days in KT and 18 days in SC (p=0.048). The mortality was comparable in both groups. Pneumonia occurred in 14 patients in KT and 39 patients in SC (p<0.001); pressure ulcers were reduced by 50% (p<0.001). Length of ICU stay (21 days in SC and 13 days in KT, p=0.009) and length of hospital stay were reduced in the patients treated with kinetic therapy.

CONCLUSION

The use of KT shortens hospital stay and reduces rates of pneumonia and pressure ulcers as compared to SC.

Nonoperative management and treatment of spinal injuries

STUDY DESIGN

Review of literature.

OBJECTIVE

To delineate and discuss nonoperative treatment and treatment of spinal injuries.

SUMMARY OF BACKGROUND DATA

Nonoperative methods have been a mainstay of care for spinal injuries since ancient Egypt. The vast majority of all spinal injuries should be treated in the nonoperative fashion. The indications and methods continue to evolve.

METHODS

A PubMed search of the literature returned more than 1000 articles related to spine trauma. A total of 270 were references to nonoperative treatment, and 100 were thought to be relevant and included in this review.

RESULTS

All spine injuries are treated in a nonoperative manner, at least initially. The vast majority of injuries are successfully and appropriately treated in a definitive manner with nonsurgical methods. Over the past 10-15 years, the advent of better rigid cervical fixation has decreased the use of halo vests as definitive treatment of many cervical injuries. In contrast, during the same time, more thoracolumbar injuries are being treated in a nonsurgical fashion because the outcomes have been shown to be similar or superior.

CONCLUSIONS

As with all of medicine, the treatment of spine trauma will continue to evolve with time. It is paramount that the physician selects the treatment that will provide the best short-term recovery with the least impact on long-term function.

Health-Care–Associated Infections and Prevention

Health-care-associated infections (HAIs) are an important cause of perioperative morbidity and mortality. Currently, one out of every 10 surgical patients develops an HAI. Causes of HAIs vary, but include the transient immunodeficiency associated with surgery,immobility, and the presence of indwelling devices. With rates of antimicrobial resistance increasing, prevention remains the best solution. The investigators review the most frequently encountered health-care-associated infections with an emphasis on preventative strategies. The article addresses issues related to the diagnosis,treatment, and prevention of health-care-related pneumonia,health-care-associated urinary tract infections, and intravascular-catheter-related infections. The article also discusses the utility of hand hygiene policies.

Ventilator-associated pneumonia

PURPOSE OF REVIEW

This review summarises some of the notable papers on ventilator-associated pneumonia (VAP) from January 2003 to October 2004.

RECENT FINDINGS

Ventilator-associated pneumonia remains an important drain on hospital resources. All population groups are affected, but patients with VAP are more likely to be older, sicker, and male, with invasive medical devices in situ. Early VAP diagnosis is desirable to reduce VAP mortality and to retard emergence of multidrug-resistant microbes. This may be possible using preliminary culture results or intracellular organism in polymorphonuclear cells. In most intensive care units, Staphylococcus aureus, Pseudomonas aeruginosa, and Acinetobacter baumannii are the commonest organisms isolated in VAP. However, causative organisms vary between and within hospitals. Consequently, individual intensive care units should develop empirical antibiotic policies to target the pathogenic bacteria prevalent in their patient populations. Preventative strategies aimed at reducing aerodigestive tract colonisation by pathogenic organisms, and also their subsequent aspiration, are becoming increasingly important. Educating medical staff about these simple measures is therefore pertinent. To reduce the occurrence of multidrug-resistant organisms, limiting the duration of antibiotic treatment to 8 days and antimicrobial rotation should be contemplated. Empirical therapy with antipseudomonal penicillins plus beta-lactamase inhibitors should be considered. If methicillin-resistant Staphylococcus aureus VAP is a possibility, linezolid may be better than vancomycin.

SUMMARY

Prevention remains the key to reducing VAP prevalence.