Category Archives: Critical Care

Does the use of a thoracic impedance device during resuscitation improve patient outcomes compared to resuscitations without use of such a device?

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There is some evidence that use of an impedance threshold device added to active compression-decompression device  may result in small improvement in survival but impedance device added to standard cardiopulmonary resuscitation (CPR) does not improve survival.

Aufderheide TP, et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial. Lancet. 2011 Jan 22;377(9762):301-11. RESQ Trial
1,653 adult patients with out-of-hospital cardiac arrest randomized to resuscitation with compression-decompression device plus impedance threshold device compared to standard CPR. RESULTS:  Survival to discharge without neurologic impairment was similar for both groups.

Aufderheide TP, et al. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med. 2011 Sep 1;365(9):798-806. ROC PRIMED Trial
9,220 patients with out-of-hospital cardiac arrest randomized to standard CPR with active impedance threshold device (ITD) compared to standard CPR with sham ITD. RESULTS:  Survival to hospital discharge with normal Rankin score was 6% for the sham ITD group compared to 5.8% for the active ITD group.  Rates for return of spontaneous circulation and survival to hospital admission were also similar for both groups.

Also see Cardiac Arrest (Treatment>Other Management>Prehospital care>Improving chest compressions).  In:  DynaMed

Cabrini L, et al. Impact of impedance threshold devices on cardiopulmonary resuscitation: a systematic review and meta-analysis of randomized controlled studies. Crit Care Med. 2008 May;36(5):1625-32.
Systematic review of older, RCTs

Reviewed JKN 4/14

Are there studies demonstrating it to be safe for children visiting adults in the ICU in terms of spreading infections?

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Searches were conducted in PubMed & CINAHL on the concepts of children, infection, and ICU. The following guidelines, surveys, policies, and other articles all discuss children visiting and the spread of infection

Vint, Pauline, Children visiting adults in ITU-what support is available? A descriptive survey. Nursing in critical care 2005 vol:10 iss:2 pg:64 -71

Knutsson, Susanne E M, Visits of children to patients being cared for in adult ICUs: policies, guidelines and recommendations. Intensive and critical care nursing 2004 vol:20 iss:5 pg:264 -274

Johnstone, M Children visiting members of their family receiving treatment in ICUs: a literature review. Intensive and critical care nursing 1994 vol:10 iss:4 pg:289 -292

Ward, D, Practical tips from clinical nurses: opinions about children visiting. Dimensions of critical care nursing 1994 vol:13 iss:3 pg:155 -156

Spreen, Afien, Visiting policies in the adult intensive care units: a complete survey of Dutch ICUs. Intensive and critical care nursing 2011 vol:27 iss:1 pg:27 -30

Anzoletti, Antonio. Access to intensive care units: a survey in North-East Italy. Intensive and critical care nursing 2008 vol:24 iss:6 pg:366 -374

Falk, Jane, Using an evidence-based practice process to change child visitation guidelines. Clinical journal of oncology nursing 2012 vol:16 iss:1 pg:21 -23

Malacarne, Paolo Health care-associated infections and visiting policy in an intensive care unit. American journal of infection control 2011 vol:39 iss:10 pg:898 -900

Reviewed JKN 4/14

Do any ICUs in the United States use arteriovenous fistulae in implementing continous renal replacement therapy (CRRT)?

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The AACN Procedure Manual for Critical Care, 6th ed., 2011, states that although surgically created AV fistulas had been used in the past for CRRT, they are not recommended for CRRT access because of increased rates of injury, bleeding and infection (p. 1023), and the manual references National Kidney Foundation: KDOQI clinical practice guidelines for vascular access: update 2006, Am J Kidney Dis. 2006; 48:S176-S307.

The manual also references Uchino S, et al. Continuous renal replacement therapy: a worldwide practice survey. Intensive Care Med. 2007;33:1563-70.
Of a cohort of 1006 ICU patients treated with CRRT at 54 ICUs in 23 countries, Table 2 (p. 1566) shows that only 1 patient (0.1%) had continuous arteriovenous hemodialysis as the mode for RCCT.

A search of PubMed for continuous renal replacement therapy and access did not identify any studies published in the United States that specifically described using AVF for the access.

What is the recent evidence for intentional rounds in the intensive care unit?

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Searched CINAHL and PubMed for patient rounds AND (“intensive care” OR “critical care”)  with a limit of English.

Six quasi-experimental studies in CINAHL measuring nurse satisfaction, ventilator-associated pneumonia, cental-line associated bloodstream infection, nosocomial infections, healthcare outcomes, family presence, and facilitators and barriers to patient care rounds
Adding intensive care or critical care eliminates many studies that may also be relevant.

(MH “Patient Rounds”) AND (hourly OR intentional OR proactive OR comfort)
These results include several experimental and quasi-experimental studies. If you want to look at specific outcomes, see the following searches for particular topics:

Falls – (MH “Patient Rounds”) AND (hourly OR intentional OR proactive OR comfort) AND falls

Patient satisfaction – (MH “Patient Rounds”) AND (hourly OR intentional OR proactive OR comfort) AND patient satisfaction

Patient centered care – (MH “Patient Rounds”) AND (MH “Patient centered care”)

Papers in PubMed search: (rounds OR rounding) AND (intentional OR hourly OR time factors OR proactive) AND (nurses OR nursing) AND (safety OR quality improvement OR infection OR pneumonia OR pressure ulcers OR falls OR patient satisfaction OR patient outcome assessment OR outcomes assessments) AND (“intensive care” OR “critical care”)
This search retrieves papers examining common outcomes in the intensive care unit.  Other outcomes can be included in the search.

Reviewed and updated 5/1/2014 ldt

Is there evidence for optimal frequency for monitoring sedation level?

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Bottom line:  There is little published evidence evaluating frequency of monitoring level sof sedation.

Joanna Briggs did not have any information.

CINAHL and PubMed had guidelines and validation studies evaluating the various sedation assessment scales, but none of that literature addresses how frequently to perform assessments.

DynaMed references recommendations of American Hospital Formulary Service.

Most relevant results

Brook AD, et al.  Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.  Crit Care Med. 1999 Dec;27(12):2609-15.
Reassessment every 4 hours is part of the protocol; outcomes were reduced time on mechanical ventilator, length of stay in ICU, and rate of tracheostomy for the protocol group compared to the standard care group

DynaMed

Propofol drug information.
Recommends assessing level of sedation at least daily.  See Warning and Precautions>General Precautions>Critical Care Sedation

Guidelines and additional validation studies:

Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.  Crit Care Med. 2002 Jan;30(1):119-41
-recommends using a validated scale to monitor level of sedation, but cites a systematic review of scales to state that there was no gold-standard scale for assessing sedation level at time of these guidelines.  Does not recommend specific frequency for monitoring patients.  Objective Assessment of Sedation section reviews evidence of Motor Activity Assessment Scale, Riker Sedation-Agitation Scale, and Ramsay Scale and Vancouver Interaction and Calmness Scale.  Does not include the Richmond Agitation-Sedation Scale.

Ely EW, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).  JAMA. 2003 Jun 11;289(22):2983-91.
-Confirmed interrater reliability and validity of RASS in medical ICU patients.

Vender JS.  Sedation, analgesia, and neuromuscular blockade in sepsis: an evidence-based review.  Crit Care Med. 2004 Nov;32(11 Suppl):S554-61.
-Includes discussion of scales in context of patients with sepsis

What is the recent published evidence on risks and best practices for transporting critically ill patients within the hospital?

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Here are references from a PubMed search of the question concepts:  tranportation within the hospital and critically ill patients.  For a more specific search, add an outcome term to the search.

(“Transportation of Patients”[MeSH Terms] OR transport OR “Patient Transfer”[mesh terms]) AND intrahospital AND (critical care OR critically ill OR critical illness OR critical illnesses) Limit:  English

These references include reviews, prospective and retrospective studies, and guidelines.

Reviewed 4/15/2014 ldt

Can a MRSA bundle prevent healthcare-associated MRSA infections in the ICU?

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Bottom line:  Use of a bundle decreased infection rates of healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) at Veterans Affairs (VA) hospitals.

Summary: Jain R, et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.  N Engl J Med. 2011 Apr 14;364(15):1419-30.

The study compared rates of healthcare-acquired MRSA infections at VA units before (October 2005 – March 2007) and after (October 2007 – June 2010) implementation of a care bundle that included universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, promotion of hand hygiene, and a change in the workplace culture that made infection control the responsibility of every staff member who had contact with patients. During the period there was a total of  8,318,675 patient days. Rates of MRSA infections in ICU units were reduced by 62% while the rates at units other than ICUs were reduced by 45% during the same period.

Huskins WC, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med. 2011 Apr 14;364(15):1407-18.

This study of 18 ICU units looked at infection rates of MRSA and vancomycin-resistant enterococcus (VRE) in adult ICUs. Units were randomized to receive an intervention (n=10)  of increased surveillance and expanded barriers or to remain the same as a control (n=8). Intervention group patients were assigned to contact precautions based on history of MRSA or VRE in the past 12 months or results of nasal and perianal swabs. Patients in control units had swabs, but contact precautions were instituted based on hospital procedures and were blinded to the swab results. As Figure 3 summarizes, there was no significant difference in change of infection rates between the two groups. Authors concluded that the intervention was unable to reduce the transmission of MRSA and VRE. The surveillance cultures identified a significant subgroup of colonized patients who would not have been recognized otherwise, but the healthcare providers who participated in the study failed to use clean gowns and gloves and perform hand hygiene as often as was required by the intervention.

Two studies of antibiotic care bundles for MRSA in ICUs can be found here.

Reviewed and updated 4/11/2014 ldt