Category Archives: Critical Care

What is the latest evidence and nursing implications on the use of high frequency ocsillatory ventilation?

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Mechanical Ventilation.  In:  DynaMed. 
See a summary of current evidence in the “Ventilator Settings (Evidence)” section>High Frequency Oscillatory Ventilation (HFOV).

A systematic review ( Cochrane Database Syst Rev 2013 Feb 28;(2):CD004085) of studies (N=419) with methodological limitations concluded that may reduce mortality and treatment failure.  However it did not include results of two recent RCTs:

1.  HFOV does not reduce mortality compared to conventional ventilation (N Engl J Med 2013 Feb 28;368(9):806)  RCT (N=795 adults with ARDS).  RESULTS:  All-cause mortality rate 41.7% for HFOV group v. 41.1% for conventional ventilation group (not significant).

2. HFOV may increase risk of mortality compared to conventional ventilation protocol.  RCT (N=548 adults with moderate to severe ARDS).  RESULTS:   12% of patients in control group received HFOV for refractory hypoxemia.  In-hospital mortality 47% for HFOV group vs. 35% for control group.

What evidence is published on timing and appropriateness of education for patients in the intensive care unit?

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Results below are from a search of PubMed and CINAHL for these concepts:

  • patient education
  • intensive care
  • English language limit
  • time/timing

PubMed:  “Patient Education as Topic”[MAJR] AND “intensive care”[mesh] AND english[lang]

CINAHL:  (MH “Intensive Care Units”) AND (MM “Patient Education+”) AND ( (time OR timing) )   This search focuses on papers that discuss some aspect of timing as it relates to patient education.  Removing the (time OR timing) part of the search will retrieve some additional papers discussing aspects, such as education for transition from ICU to general unit.

The PubMed search results are more general.  The references below discuss general aspects of patient education in the ICU.  Other references in the search results discuss patient education in specific situations, such as with patients on ventilators:

Häggström M, Asplund K, Kristiansen L.  How can nurses facilitate patient’s transitions from intensive care?: a grounded theory of nursing.  Intensive Crit Care Nurs. 2012 Aug;28(4):224-33

Scott A.  Managing anxiety in ICU patients: the role of pre-operative information provision.   Nursing in Critical Care (NURS CRIT CARE), 2004 Mar-Apr; 9 (2): 72-9.

Clark BJ, Moss M. Secondary prevention in the intensive care unit: does intensive care unit admission represent a “teachable moment?”. Crit Care Med. 2011 Jun;39(6):1500-6.

What evidence supports the use of mild hypothermia after cardiac arrest?

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A  search of PubMed retrieved these references using the search strategy:((“Heart Arrest”[Mesh])) AND (“Hypothermia, Induced”[Mesh]) AND (systematic[sb] AND hasabstract[text] AND “last 5 years”[PDat] AND English[lang])   TO SEE MORE

Arrich J, Holzer M, Havel C, Müllner M, Herkner H.
Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation
Cochrane Database Syst Rev. 2012 Sep 12;9:CD004128. doi: 10.1002/14651858.CD004128.pub3.

Delhaye C, Mahmoudi M, Waksman R. Hypothermia therapy: neurological and
cardiac benefits. J Am Coll Cardiol. 2012 Jan 17;59(3):197-210. doi: 10.1016/j.jacc.2011.06.077. Review. PubMed PMID: 22240124.

Cullen D, Augenstine D, Kaper L, Tinkham S, Utz D.
Therapeutic hypothermia initiated in the pre-hospital setting: a meta-analysis.
Adv Emerg Nurs J. 2011 Oct-Dec;33(4):314-21. doi: 10.1097/TME.0b013e3182343cb6.

 

Is capnography or end tidal CO2 assessment effective for monitoring adult patients in emergency departments or intensive care units who are undergoing moderate sedation or mechanical ventilation?

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Bottom line:  There is evidence that associates capnography with improved detection of respiratory depression during procedural sedation and in management of mechanical ventilation.

Monitoring during moderate sedation:

PubMed search: (capnography OR end tidal carbon dioxide) AND sedation AND (emergency department OR intensive care OR critical care) AND humans[mesh]
Includes prospective studies, a systematic review and some lower quality comparative studies.

Higher quality study (Randomized controlled trial and prospective studies)
Proehl J, et al. J Emerg Nurs. 2011 Nov;37(6):533-6. Emergency Nursing Resource: the use of capnography during procedural sedation/analgesia in the emergency department.
Systematic review describes evidence from research studies, meta-analyses, systematic
reviews, and existing guidelines. Rates evidence using Appraisal of Guidelines Research & Evaluation methodology.

Deitch K, et al. Ann Emerg Med. 2010 Mar;55(3):258-64. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial.
Patients (n=132) in the ED who received propofol sedation received standard monitoring plus capnography and were randomized so that physicians administering care either had access to capnography readings or were blinded to capnography readings.  RESULTS:  Hypoxia was observed in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography (P=.035; difference 17%; 95% confidence interval 1.3% to 33%).  Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds (range 5 to 240 seconds)

Burton JH, et al. Acad Emerg Med. 2006 May;13(5):500-4. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?
60 patients (enrollment stopped after review of 20 acute respiratory events) underwent capnographic monitoring while under procedural sedation. Abnormal end tidal CO2 findings were documented in 36 patients (60%). Abnormal ETCO2 findings were documented before changes in SpO2 or clinically observed hypoventilation in 14 patients (70%) with acute respiratory events.

Monitoring during mechanical ventilation

PubMed:  (capnography OR end tidal carbon dioxide) AND mechanical ventilation AND (emergency department OR intensive care OR critical care) AND humans[mesh]
Filters:  Systematic reviews

Walsh BK, Crotwell DN, Restrepo RD. Capnography/Capnometry during mechanical ventilation: 2011.  Respir Care. 2011 Apr;56(4):503-9.
Applied GRADE criteria to 200+ identified studies and guidelines. Includes several recommendations for use of capnography in monitoring patients on mechanical ventilation.

Should sedation medications be turned off daily in patients on mechanical ventilation?

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Recent study of deeply sedated patients compares protocol of hourly assessment alone versus the protocol plus daily sedation interruption.  There was nodifference in time to extubation, ICU length of stay, hospital LOS, rate of delirium, or accidental extubation.  Daily interruption may not be beneficial over hourly monitoring alone.

Mehta S et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: A randomized controlled trial. JAMA 2012 Oct 17

RCT of  430 critically ill, mechanically ventilated adults in 16 tertiary care medical and surgical ICUs.  All patients received continuous opioid and/or benzodiazepine infusions and were randomized to protocolized sedation (n = 209) (control) or to protocolized sedation plus daily sedation interruption.  Protocolized sedation involved nurses using standardized scales to assess sedation needs hourly and titrate infusions.

RESULTS:  For interruption group v. control group:

  • NO DIFFERENCE IN THESE VARIABLES
  • Median time to successful extubation:  interruption was 7 days (IQR 4-13) v control was 7 days (IQR 3-12)
  • Duration of ICU stay:  median [IQR]     10 [5-17] vs 10 [6-20]
  • Length of  stay:  median [IQR]   20 [10-36] vs 20 [10-48]
  • Rates of delirium:  53.3% in the interruption group vs 54.1% in the control group; relative risk, 0.98; 95% CI, 0.82-1.17; P = .83
  • Unintentional endotracheal tube removal:  10 of 214 (4.7%) in interruption group vs 12 of 207 patients (5.8%) in the control group, RR 0.82, p=0.64

DIFFERENCES BETWEEN THE GROUPS FOR THESE VARIABLES

  • Mean daily doses of midazolam was higher for the interruption group:  102 mg/d vs 82 mg/d; P = .04  and  for fentanyl:  median [IQR], 550 [50-1850] vs 260 [0-1400]; P < .001
  • Number of daily boluses of benzodiazepines was also higher in the interruption group:  mean, 0.253 vs 0.177; P = .007,   and for opiates:  mean, 2.18 vs 1.79; P < .001
  • Nurse workload was greater in the interruption group (VAS score, 4.22 vs 3.80; mean difference, 0.41; 95% CI, 0.17-0.66; P = .001).

Reviewed JKN 4/14

What is postoperative systemic inflammatory response syndrome (SIRS) and what are the symptoms?

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Bottom line:  SIRS is a response by the body to some kind of infectious or noninfectious insult.  The response includes a profound systemic inflammation that can lead to septic shock and multiple organ failure.  Surgey can elicit this systemic inflammation by exposing patient to tissue damage and to possible infection.  Signs of SIRS include changes in heart rate, respiratory rate, blood pressure, temperature regulation, and immune cell activation.

Details:
Chapter 4. Fever and hypothermia.  In: Textbook of Critical Care, 6th ed., 2011.
Chapter 8. Inflammation, Infection, & Antimicrobial Therapy.  In:  Current Diagnosis & Treatment: Surgery [AccessSurgery]
These two chapters provide a brief explanation of SIRS.  Chapter 4 also includes algorithm for looking for source of infection.

Sepsis in adults.  In: DynaMed.  Summarizes diagnostic criteria and treatment options.  Patient is considered to have SIRS if he/she exhibits more than one of these criteria from the 2001 Society of Critical Care Medicine (SCCM)/The European Society of Intensive Care Medicine (ESICM)/American College of Chest Physicians (ACCP)/American Thoracic Society (ATS)/Surgical Infection Society (SIS) International Sepsis Definitions Conference:

  • Body temperature higher than 38°C or lower than 36°C
  • Heart rate higher than 90/min
  • Hyperventilation evidenced by respiratory rate higher than 20/min or PaCO2lower than 32 mmHg
  • White blood cell count higher than 12,000 cells/ μl or lower than 4,000/ μl

Intensive Care Med 2003 Apr;29(4):530

Chapter 68.  Multiple organ failure.  In:  Trauma [AccessSurgery] explains SIRS in the context of noninfectious causes.

Does trimming peripherally inserted central catheters (PICC) increase the incidence of thrombosis?

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Bottom line: There is not much published evidence addressing this question.

Summary:
Joanna Briggs: Peripherally Inserted Central Catheters: Occlusion
Reviews evidence associated with risk associated with misplacement or movement of the catheter tip and location of insertion site.  I checked the references cited, but did not find any discussion of modifying or trimming the catheter.

PubMed:
peripherally inserted catheter AND thrombosis AND (trimmed OR trimming OR modif* OR cutting)

Evidence that specifically discusses trimming includes
Parvez. Thrombosis Research (2004) 113, 175—177:  A comparison of changes in surface of catheter at site of trimming.  Authors hypothesize that roughness introduced by trimming line can contribute to thrombosis.

EMBASE:
To view search click on the EMBASE link and then copy this search statement into the search box:

‘peripherally inserted central catheter’ AND thrombosis  AND (trimming OR trimmed OR modif*)

Additional evidence that specifically discusses trimming includes:

Trimming of peripherally inserted central catheters: The end result
Pettit J.  JAVA – Journal of the Association for Vascular Access 2006 11:4 (209-214)
This paper references a study showing how trimming affects the catheter tip.  Possibly this reference is to the Parvez article from the PubMed results above.  We do not have access to this Pettit paper, but you can request through interlibrary loan link in the Find It @ Emory menu for this article

Other papers in both the PubMed and EMBASE searches seem to mention trimming or cutting the catheter, but only as part of the procedures and not as a risk factor.

SEARCH METHODS
Resources searched:
Evidence summary resources:  Joanna Briggs JBI+Connect
Large literature databases: PubMed, EMBASE

Search included combinations of these terms:
Peripherally inserted central catheter, catheter
trimming, trimmed, modif* (for modify, modified, modification, etc.)
thrombosis