Implementation of a nurse-driven ventilation weaning protocol in critically ill children: Can it improve patient outcome?

BackgroundCritically ill children treated with invasive mechanical ventilation in a paediatric intensive care unit (PICU) may suffer from complications leading to prolonged duration of ventilation and PICU stay.ObjectiveThe objective of this study is to find out if the use of a nurse-driven ventilation weaning protocol in a PICU can shorten the duration of mechanical ventilation.MethodsIn a prospective, pretest–posttest implementation study, we implemented a nurse-driven ventilation weaning protocol and compared its outcomes with those of the usual physician-driven weaning. In the posttest period, nurses weaned the patients until extubation as per this protocol. The primary outcome was duration of ventilation. The secondary outcomes were length of PICU stay, reintubation rate, and compliance with the protocol (measured by use of the prescribed support mode).ResultsIn total, 424 patients aged from 0 to 18 years (212 pretest and 212 posttest) were included; in both groups, the median age was 3 months. The median duration of ventilation did not differ significantly between the pretest and posttest periods: 42.5 h. (interquartile range, IQR 14.3–121.3) vs. 44.5 h (IQR 12.3–107.0), respectively; p = 0.589. In the posttest period, the PICU stay was nonsignificantly shorter: 5.5 days (IQR 2–11) vs. 7 days (IQR 3–14) in the pretest period; p = 0.432. Compliance with the prescribed support mode was significantly higher in the posttest period: 69.9% vs. 55.7% in the pretest period; p = 0.005. The reintubation rate was not significantly different between the pretest and posttest periods (5% vs. 7%, respectively; p = 0.418). The extubation rate during nights was higher in the posttest period but not significantly different (p = 0.097).ConclusionsImplementation of a nurse-driven weaning protocol did not result in a significantly shorter duration of invasive mechanical ventilation but was safe and successful. The reintubation rate did not significantly increase compared with usual care.     

The burden of viral infections in pediatric intensive care unit between endemic and pandemic coronavirus infections: A tertiary care center experience

ObjectivesTo measure the prevalence of viral infections, length of stay (LOS), and outcome in children admitted to the pediatric intensive care unit (PICU) during the period preceding the COVID-19 pandemic in a MERS-CoV endemic country.MethodsA retrospective chart review of children 0–14 years old admitted to PICU with a viral infection.ResultsOf 1736 patients, 164 patients (9.45%) had a positive viral infection. The annual prevalence trended downward over a three-year period, from 11.7% to 7.3%. The median PICU LOS was 11.6 days. Viral infections were responsible for 1904.4 (21.94%) PICU patient-days. Mechanical ventilation was used in 91.5% of patients, including noninvasive and invasive modes. Comorbidities were significantly associated with intubation (P-value = 0.025). Patients infected with multiple viruses had median pediatric index of mortality 2 (PIM 2) scores of 4, as compared to 1 for patients with single virus infections (p < 0.001), and a median PICU LOS of 12 days, compared to 4 in the single-virus group (p < 0.001). Overall, mortality associated with viral infections in PICU was 7 (4.3%). Patients with viral infections having multiple organ failure were significantly more likely to die in the PICU (p = 0.001).ConclusionViral infections are responsible for one-fifth of PICU patient-days, with a high demand for mechanical ventilation. Patients with multiple viral infections had longer LOS, and higher PIM 2 scores. The downward trend in the yearly rate of PICU admissions for viral infections between the end of the MERS-CoV outbreak and the start of the COVID-19 pandemic may suggest viral interference that warrants further investigations.     

A clinical trial of silver-coated and tapered cuff plus supraglottic suctioning endotracheal tubes in preventing ventilator-associated pneumonia

PurposeNovel designs of the endotracheal tube (ETT) are emerged to reduce the risk of ventilator-associated pneumonia (VAP). We evaluated the effect of two different types, namely silver-coated (Bactiguard) and subglottic suctioning (Taperguard) ETTs, on the incidence of VAP in critically-ill patients.MethodsA total of 90 patients, mechanically ventilated for >72 h, were randomly assigned to Bactiguard and Taperguard groups. They otherwise received routine care, including VAP prevention measures during their intensive care unit (ICU) stay. Subglottic suctioning was performed in Taperguard group. Statistical analyses were performed using SPSS 25 for iMacs.ResultsBoth groups had similar demographics and did not differ in the prevalence of comorbidities and the severity of underlying illness. There was no difference in the frequency of reintubation (P = .565), the duration of ventilation, ICU and total hospital length of stay. VAP developed in 31% of the Bactiguard group and 20% of the Taperguard group (P = .227). Nearly twice the number of patients died in the Bactiguard group compared to the Taperguard group. This difference was not significant either (P = .352).ConclusionsThe use of Bactiguard or Taperguard ETTs was not associated with any difference in the incidence of VAP or ICU mortality.     

The incidence and characteristics of ventilator-associated pneumonia in a regional nontertiary Australian intensive care unit: A retrospective clinical audit study

BackgroundVentilator-associated pneumonia (VAP) is a common complication of mechanical ventilation in the intensive care unit. The incidence, patient characteristics, and outcomes have not been described in a regional Australian setting.ObjectivesΤhe primary objective was to establish the incidence of VAP in a regional intensive care unit using predetermined diagnostic criteria. The secondary objective was to compare the agreement between criteria-based and physician-based diagnostic processes. The tertiary objectives were to compare patient characteristics and clinical outcomes of cases with and without VAP.MethodsA retrospective clinical audit was performed of adult patients admitted to Rockhampton Intensive Care Unit, Australia, between 2013 and 2016. We included all patients ventilated for ≥72 h and not diagnosed with a pneumonia before or during the first 72 h of ventilation.ResultsA total of 170 cases met the inclusion criteria. The incidence of VAP as per the criteria-based diagnosis was 27.3 cases per 1000 ventilator days (95% confidence interval [CI]: 18.4–36.2) and as per the physician-based diagnosis was 25.8 cases per 1000 ventilator days (95% CI: 17.1–34.4). There was a moderate chance-corrected agreement between the criteria- and physician-based diagnosis. Very obese cases (body mass index [BMI] ≥40) were nearly four times more likely to develop VAP than cases with normal BMI (BMI <30) (odds ratio: 3.664; 95% CI: 1.394–9.634; p = 0.008). After controlling for sex, BMI category, comorbidities, and Acute Physiology and Chronic Health Evaluation II scores, there was a trend (p = 0.283) for higher adjusted mortality rate for cases with VAP (10.1%, 95% CI: 4.8–21.5) than for those without VAP (6.1%, 95% CI: 3.0–12.4). Cases with VAP had a higher total hospital cost ($123,223 AUD vs $66,425 AUD, p < 0.001), than cases without VAP.ConclusionsThis is the first study reporting incidence of VAP in an Australian regional intensive care unit setting. An increased length of stay and significantly higher hospital costs warrant research investigating reliable and valid clinical prediction rules to forecast those at risk of VAP.     

Effect of two different feeding methods on preventing ventilator associated pneumonia in the paediatric intensive care unit (PICU): A randomised controlled study

BackgroundFor infants and children who require intubation in the paediatric intensive care unit (PICU), ventilator-associated pneumonia (VAP) is a significant cause of secondary morbidity and mortality linked with extended use of intubation. Nurses are primarily responsible for the prevention of VAP and there are a number of procedures that contribute towards this end. Although enteral nutrition has been reported to be effective in the prevention of VAP, this remains controversial.ObjectiveTo compare and evaluate the effects of intermittent feeding through a nasogastric catheter with those of continuous feeding through a nasoduodenal catheter in preventing VAP in the PICU.DesignThe research design was a randomised, controlled experimental study.MethodsForty paediatric patients were randomised and divided into two groups of 20: one group for nasoduodenal (ND) feeding and the other for nasogastric (NG) feeding. Patients were assessed for the development of VAP using the clinical pulmonary infection score and Centers for Disease Control and Prevention criteria while working in accordance with the VAP prevention bundles introduced within the unit.ResultsThe incidence of paediatric VAP was 15%. The rate of VAP in patients who were ND fed was 10%, whereas the rate of VAP in patients who had NG feeding was 20%. No statistically significant difference was observed between the ND- and NG-fed patients (p = 0.661).ConclusionAlthough the results of our study were not statistically significant, nasoduodenal feeding helped to reduce the incidence of VAP.     

Clinical impact of lung ultrasound monitoring for diagnosis of ventilator associated pneumonia: A diagnostic randomized controlled trial

PurposeStudies have shown that lung-ultrasound may be superior to chest x-ray (CXR) in diagnosing ventilator-associated pneumonia (VAP). This study investigated whether the use of lung-ultrasound monitoring could detect VAP earlier and improve patient outcome.MethodsThis was a single-center diagnostic randomized controlled trial. In the control group, VAP was diagnosed using a combination of CXR and clinical findings. In the intervention group, VAP was diagnosed using a combination of lung-ultrasound and clinical findings. The primary outcome measured was ventilator free days (VFD). Secondary outcomes were ICU mortality, length of stay in ICU, change in Sequential Organ Failure Score at day 4 compared to day 0 (delta SOFA), antibiotic duration and ventilator days.ResultsWe randomized intubated patients until 44 VAP diagnosis was made in each group. VFD was higher in the intervention group than in the control group (7.80+/− 9.7 days versus 3.7+/− 6.4 days, p = .044). There were no differences between the groups in terms of ICU mortality (p=.104), ICU length of stay, (p = .058), ventilator days, (p = .081), delta SOFA (p = .10) and antibiotic duration (p = .70).ConclusionThe use of lung-ultrasound monitoring for diagnosis of VAP improves patient outcome when compared to the standard diagnostic strategy that relies on CXR.     

Effects of neuromuscular electrical stimulation in critically ill patients: A systematic review and meta-analysis of randomised controlled trials

ObjectivesWe performed a systematic review and meta-analysis to examine the effect of neuromuscular electrical stimulation (NES) on prevention of critical care myopathy and its effect on various clinical outcomes in the intensive care unit (ICU).Review methods usedThis study involved systematic review and meta-analysis of randomised controlled trials (RCTs) comparing NES (applied to different muscle groups combined with usual care) and usual care (passive and active exercises along with early mobilisation and rehabilitation). Included studies enrolled adult patients managed in the ICU for medical or surgical diseases who were or were not mechanically ventilated. The primary outcome was global muscle strength measured by the Medical Research Council grading system. Secondary outcomes included ICU mortality, duration of mechanical ventilation (MV), and ICU length of stay. Risk ratio for dichotomous data and mean difference (MD) for continuous data with their corresponding 95% confidence interval (CI) were calculated.Data sourceA search in major electronic databases, including PubMed, Cochrane Library, and Embase, from inception to November 2018 was carried out.ResultsSix RCTs were included, representing 718 patients. The mean age 60 ± 15.3 years, and 60.6% were male. There was no significant difference between NES and usual care on global muscle strength measured by Medical Research Council grading system (MD: 0.45; 95% CI: −2.89 to 3.80; p = 0.79), ICU mortality (risk ratio: 1.30; 95% CI: 0.95–1.78; p = 0.10), duration of MV (days) (MD: -2.07; 95% CI: −5.06 to 0.92; p = 0.18), or ICU length of stay (days) (MD: -3.06; 95% CI: -9.79 to 3.68; p = 0.37) in comparison with the usual therapy alone in critically ill patients.ConclusionNES combined with usual care was not associated with significant differences in global muscle strength, ICU mortality, duration of MV, or ICU length of stay in comparison with usual care alone in critically ill patients. Further RCTs are needed to determine patients with maximum benefit and to examine NES safety and efficacy.     

Risk factors and outcomes of extubation failure in a South African tertiary paediatric intensive care unit

Background Extubation failure contributes to poor outcome of mechanically ventilated children, yet the prevalence and risk factors have been poorly studied in South African (SA) children. Objectives To determine the prevalence, risk factors and outcomes of extubation failure in an SA paediatric intensive care unit (PICU). Methods This was a prospective, observational study of all mechanically ventilated children admitted to a tertiary PICU in Cape Town, SA. Extubation failure was defined as requiring re-intubation within 48 hours of planned extubation. Results There were 219 episodes of mechanical ventilation in 204 children (median (interquartile range (IQR)) age 8 (1.6 - 44.4) months). Twenty-one of 184 (11.4%) planned extubations (95% confidence interval (CI) 7.2% - 16.9%) failed. Emergency cardiac admissions (adjusted odds ratio (aOR) 7.58 (95% CI 1.90 - 30.29), dysmorphology (aOR 4.90; 95% CI 1.49 - 16.14), prematurity (aOR 4.39; 95% CI 1.24 - 15.57), and ventilation ≥48 hours (aOR 6.42 (95% CI 1.57 - 26.22) were associated with extubation failure. Children who failed extubation had longer durations of ventilation (231 hours (146.0 - 341.0) v. 53 hours (21.7 - 123.0); p<0.0001); longer duration of PICU (15 (9 - 20) days v. 5 (2 - 9) days; p<0.0001) and hospital length of stay (32 (21 - 53) days v. 15 (8 - 27) days; p=0.009); and higher 30-day mortality (28.6% v. 6.7%; p=0.001) than successfully extubated children. Conclusion Extubation failure was associated with significant morbidity and mortality in our setting. Risk factors for extubation failure identified in our context were similar to those reported in other settings. Contributions of the study This study provides novel data on the prevalence, risk factors and outcomes associated with extubation failure in a single-centre South African PICU. The results of this study may help identify high-risk groups for extubation failure within our local context, and forms a basis for practice improvement initiatives aimed at decreasing extubation failure rates and improving outcomes.     

Early mobilisation in critically ill children: Does routine patient screening reduce time to commencing mobilisation?

ObjectiveThe objective of this study was to investigate the impact of daily screening for medical readiness to participate in early mobilisation in the paediatric intensive care unit (PICU), on reducing time to mobilisation and to explore the safety-, feasibility-, and patient-level barriers to the practice.MethodsAn interventional study with a historical control group was conducted in a PICU in a tertiary teaching hospital in Australia. The Early Mobilisation Screening Checklist was applied at 24–48 h of PICU stay with the aim to reduce time to commencing mobilisation. All patients aged term to 18 years admitted to the PICU for >48 h were included in this study. Data on time to mobilisation and patient characteristics were collected by an unblinded case note audit of children admitted to the PICU over 5 months in 2018 for the baseline group and over a corresponding period in 2019 for the intervention group.Measurements and main resultsA total of 71 children were enrolled. Survival analysis was used to compare time to mobilisation between groups, and a cox regression model found that children in the intervention group were 1.26 times more likely to participate in mobility, but this was not statistically significant (P = 0.391, log rank test for equality of survival functions). Early mobilisation was safe, with no adverse events reported in 177 participant mobilisation days. Feasibility was demonstrated by 62% of participants mobilising within 72 h of admission. Mechanical ventilation during stay (P = 0.043) and days receiving sedation infusion (% of days) (P = 0.042) were associated with a decreased likelihood of participating in mobility.ConclusionsImplementation of routine screening alone does not significantly reduce time to commencing mobility in the PICU. Early mobilisation in the PICU is safe and feasible and resulted in no adverse events during mobilisation. Patient characteristics influencing participation in mobility warrant further exploration.     

A pilot study of Biotene OralBalance® gel for oral care in mechanically ventilated preterm neonates

BackgroundNeonatal ventilator-associated pneumonia (VAP) is associated with increased morbidity and mortality. In adults on mechanical ventilation, timed oral care decreases the frequency of VAP, but this approach has not been studied in neonates.ObjectivesTo evaluate the feasibility of a randomized trial of timed oral care with Biotene OralBalance® gel and estimate the required sample size for such a trial.MethodsInfants were eligible for enrollment if they were born before 28 weeks of gestation, and were mechanically ventilated between 7 and 10 postnatal days. Infants were randomized to receive timed oral care with Biotene OralBalance® gel or sterile water. All subjects were treated with a standard bundle of procedures to reduce the risk of VAP.ResultsWe enrolled 41 of 46 eligible infants (89%). Compliance with timed oral care protocol was 97%. No local oral side effects of Biotene OralBalance® gel were observed. There were no significant group differences in mortality or short-term outcomes, except length of hospital stay which was significantly shorter in the Sterile water group (p = 0.02). A lower rate of VAP was found in the Biotene group, although the difference was not statistically significant (9/1000 ventilator-days versus 17/1000 ventilator-days in the Sterile water group, respectively; p = 0.16).ConclusionsThe results of this pilot study support the feasibility of a randomized trial of timed oral care with Biotene OralBalance® gel for prevention of VAP in mechanically ventilated neonates.     

Risk factors of multidrug-resistant bacteria infection in patients with ventilator-associated pneumonia: A systematic review and meta-analysis

BackgroundMultidrug-resistant (MDR) bacteria-induced VAP often has high lethality. We present this systematic review and meta-analysis to assess the risk factors for MDR bacterial infection in patients with VAP.MethodsPubMed, EMBASE, Web of Science, and Cochrane Library were searched for studies regarding MDR bacterial infection in VAP patients, from Jan 1996 to Aug 2022. Study selection, data extraction, and quality assessment of included studies were conducted by two reviewers independently, and potential risk factors for MDR bacterial infection were identified.ResultsMeta-analysis showed that the score of the Acute Physiology and Chronic Health Evaluation II (APACHE-II) [OR = 1.009, 95% (CI 0.732, 1.287)], Simplified Acute Physiology Score II (SAPS-II) [OR = 2.805, 95%CI (0.854, 4.755)], length of hospital-stay before VAP onset (days) [OR = 2.639, 95%CI (0.387, 4.892)], in-ICU duration [OR = 3.958, 95%CI (0.894, 7.021)], Charlson index [OR = 1.000, 95%CI (0.889, 1.111)], overall hospital-stay [OR = 20.742, 95%CI (18.894, 22.591)], Medication of Quinolones [OR = 2.017, 95%CI (1.339, 3.038)], medication of carbapenems [OR = 3.527, 95%CI (2.476, 5.024)], combination of more than 2 prior antibiotics [OR = 3.181, 95%CI (2.102, 4.812)], and prior use of antibiotics [OR 2.971, 95%CI (2.001, 4.412)] were independent risk factors of MDR bacterial infection in VAP patients. Diabetes and mechanical ventilation duration before VAP onset showed no association with risk for MDR bacterial infection.ConclusionsThis study has identified 10 risk factors associated with MDR bacterial infection in VAP patients. Identification of these factors would be able to facilitate the treatment and prevention of MDR bacterial infection in clinical practice.     

Cuidados de enfermería en la prevención de la neumonía asociada a ventilación mecánica. Revisión sistemática

ObjectiveTo assess the efficacy of eight nursing care interventions in the prevention of ventilator-associated pneumonia (VAP).MethodWe performed a search of the MEDLINE, CINAHL, Cochrane and Cuiden databases for articles published from 1990 to 2005. We included randomized clinical trials in adults undergoing mechanical ventilation in intensive care units that provided data on the incidence of VAP when the following nursing interventions were applied: oral rinse with chlorhexidine 0.12%; subglottic secretion aspiration; semirecumbent patient positioning; ventilator circuit changes; heat and moisture filter changes; body position changes (rotational therapy); closed aspiration system; and percussion and vibration.Results and conclusionsTwenty articles meeting all the inclusion criteria were analyzed. The VAP-preventive interventions supported by the strongest evidence were: oral rinse with chlorhexidine 0.12%, subglottic secretion aspiration, semirecumbent patient positioning, avoidance of routine circuit ventilation changes, and changing the heat and moisture filter every 48 hours. Body position changes (rotational therapy) may be useful in patients who tolerate it. There is no evidence to support the closed aspiration system, percussion and vibration as preventive measures against VAP.The results show the importance of nursing care in the prevention of VAP.     

How do we reduce acyclovir overuse? Impact of FilmArray meningitis/encephalitis panel tests for pediatric patients

BackgroundFew Japanese hospitals can perform in-house cerebrospinal fluid (CSF) polymerase chain reaction (PCR) to screen for herpes simplex virus, leading to patients being administered acyclovir (ACV) for several days. The FilmArray Meningitis/Encephalitis Panel (ME Panel) is a multiplex PCR test that can identify 14 major pathogens within 1 h. We aimed to investigate the efficacy of the ME Panel in children admitted with central nervous system infections in Japan.MethodsWe conducted a single-center, quasi-experimental study. The ME panel was introduced in April 2020. We outsourced the CSF samples to a laboratory during the pre-intervention period (April 2016 to March 2020) and performed the ME panel at our hospital during the post-intervention period (April 2020 to December 2021). Duration and dose of ACV and antibiotic use, length of stay (LOS) in the pediatric intensive care unit (PICU), and total LOS after testing were compared using the Mann-Whitney U test.ResultsThe number of cases in the pre- and post-intervention periods was 67 and 22 cases, respectively. The median duration of ACV decreased significantly from 6 days to 0 day (p < 0.001), and the median dose of ACV use decreased significantly from 14 vials to 0 vial (p < 0.001). No significant differences were noted in the total duration and dose of antibiotic use, LOS in PICU, and the total LOS after testing.ConclusionThe introduction of ME panel may contribute to appropriate ACV use; however, there was no significant change in the duration and dose of antibiotic use or LOS.     

Clinical outcomes of COVID-19 caused by the Alpha variant compared with one by wild type in Kobe,Japan. A multi-center nested case-control study

ObjectivesThe emergence of the Alpha variant of novel coronavirus 2019 (SARS-CoV-2) is a concerning issue but their clinical implications have not been investigated fully.MethodsWe conducted a nested case-control study to compare severity and mortality caused by the Alpha variant (B.1.1.7) with the one caused by the wild type as a control from December 2020 to March 2021, using whole-genome sequencing. 28-day mortality and other clinically important outcomes were evaluated.ResultsInfections caused by the Alpha variant were associated with an increase in the use of oxygen (43.4% vs 26.3%. p = 0.017), high flow nasal cannula (21.2% vs 4.0%, p = 0.0007), mechanical ventilation (16.2% vs 6.1%, p = 0.049), ICU care (30.3% vs 14.1%, p = 0.01) and the length of hospital stay (17 vs 10 days, p = 0.031). More patients with the Alpha variant received medications such as dexamethasone. However, the duration of each modality did not differ between the 2 groups. Likewise, there was no difference in 28-day mortality between the 2 groups (12% vs 8%, p = 0.48), even after multiple sensitivity analyses, including propensity score analysis.ConclusionThe Alpha variant was associated with a severe form of COVID-19, compared with the non-Alpha wild type, but might not be associated with higher mortality.     

Clinical profile and recovery pattern of dysphagia in the COVID-19 patient: A prospective observational cohort within NSW

BackgroundThe impact of COVID-19 on swallowing function is not well understood. Despite low hospital admission rates in Australia, the virus and subsequent treatment affects swallow function in those requiring intensive care unit (ICU) treatment. As such, the current pandemic provides a unique opportunity to describe swallowing function and outline dysphagia characteristics and trajectory of recovery for a series of cases across NSW.AimThe aims of this study were to describe (i) physiological characteristics of swallowing dysfunction and (ii) pattern of swallowing recovery and outcomes, in ICU patients with COVID-19.MethodsAll patients admitted to 17 participating NSW Health ICU sites over a 12-month period (March 2020–March 2021), diagnosed with COVID-19, treated with the aim for survival, and seen by a speech pathologist for clinical swallowing examination during hospital admission were considered for inclusion. Demographic, critical care airway management, speech pathology treatment, and swallowing outcome data were collected.ResultsTwenty-seven patients (22 male; 5 female) with a median age of 65 years (interquartile range [IQR] = 15.5) were recruited. All required mechanical ventilation. Almost 90% of the total cohort had pre-existing comorbidities, with the two most frequently observed being diabetes (63%, 95% confidence interval = 44%–78%) and cardiac disease (59%, 95% confidence interval = 40%–75%) in origin. Prevalence of dysphagia was 93%, with the majority (44%) exhibiting profound dysphagia at the initial assessment. Median duration to initiate oral feeding was 38.5 days (IQR = 31.25) from ICU admission, and 33% received dysphagia rehabilitation. Dysphagia recovery was observed in 81% with a median duration of 44 days (IQR = 29). Positive linear associations were identified between duration of intubation, mechanical ventilation, hospital and ICU length of stay, and the duration to speech pathology assessment (p < 0.005), dysphagia severity (p < 0.002), commencing oral intake (p < 0.02), dysphagia recovery (p < 0.004), and enteral feeding (p < 0.024).ConclusionCOVID-19 considerably impacted swallowing function in the current study. Although many patients recovered within an acceptable timeframe, some experienced persistent severe dysphagia and a protracted recovery with dependence on enteral nutrition.     

Normal saline and lung recruitment with paediatric endotracheal suction (NARES): A pilot,factorial, randomised controlled trial

Background/objectiveEndotracheal suction is one of the most common and harmful procuedres performed on mechanically ventilated children. The aim of the study was to establish the feasibility of a randomised controlled trial (RCT) examining the effectiveness of normal saline instillation (NSI) and a positive end-expiratory pressure recruitment manoeuvre (RM) with endotracheal suction in the paediatric intensive care unit.MethodsPilot 2 × 2 factorial RCT.The study was conducted at a 36-bed tertiary paediatric intensive care unit in Australia.Fifty-eight children aged less than 16 years undergoing tracheal intubation and invasive mechanical ventilation.(i) NSI or no NSI and (ii) RM or no RM with endotracheal suction . The primary outcome was feasibility; secondary outcomes were ventilator-associated pneumonia (VAP), change in end-expiratory lung volume assessed by electrical impedance tomography, dynamic compliance, and oxygen saturation-to-fraction of inspired oxygen (SpO₂/FiO₂) ratio.Results/FindingsRecruitment, retention, and missing data feasibility criteria were achieved. Eligibility and protocol adherence criteria were not achieved, with 818 patients eligible and 58 enrolled; cardiac surgery was the primary reason for exclusion. Approximately 30% of patients had at least one episode of nonadherence. Children who received NSI had a reduced incidence of VAP; however, this did not reach statistical significance (incidence rate ratio = 0.12, 95% confidence interval = 0.01–1.10; p = 0.06). NSI was associated with a significantly reduced SpO₂/FiO₂ ratio up to 10 min after suction. RMs were not associated with a reduced VAP incidence (incidence rate ratio = 0.31, 95% confidence interval = 0.05–1.88), but did significantly improve end-expiratory lung volume at 2 and 5 min after suction, dynamic compliance, and SpO₂/FiO₂ ratio.ConclusionRMs provided short-term improvements in end-expiratory lung volume and oxygenation. NSI with suction led to a reduced incidence of VAP; however, a definitive RCT is needed to test statistical differences. A RCT of study interventions is worthwhile and may be feasible with protocol modifications including the widening of participant eligibility.     

The incidence and clinical outcomes of postextubation dysphagia in a regional critical care setting

BackgroundPostextubation dysphagia (PED) has been shown to occur in 41% of critically ill patients requiring endotracheal intubation. With one-third of patients with PED experiencing silent aspiration, it is reasonable to anticipate negative health outcomes are likely, although this has not yet been systematically explored in an Australian context.ObjectivesThe aim of the study was to determine the impact of PED, in a regional Australian intensive care unit (ICU), on rates of pneumonia, the length of stay in the ICU and hospital, and healthcare expenditure.MethodsThis study was conducted as a retrospective cohort analysis, which used administrative healthcare data of patients who received endotracheal intubation for invasive mechanical ventilation. Patients with a tracheostomy or known pre-existing dysphagia were excluded.ResultsA total of 822 patient episodes were identified, of which 7% (n = 58) presented with PED. Half of all patients within the PED cohort (53%) were intubated for fewer than 48 h. Patients with PED had a longer median length of stay in the ICU (5 days versus 3 days, p < 0.001) and were more likely to develop pneumonia (odds ratio = 2.51, 95% confidence interval = 1.28, 4.95) than extubated patients without dysphagia. Median cost per hospital admission for patients with PED was double that for extubated patients without dysphagia (AUD $42,685 versus AUD $20,840, p < 0.001).ConclusionsThis study highlights that even a short duration of intubation may carry a risk of PED. The presence of PED, regardless of duration of intubation, increased the rates of pneumonia, length of stay in the ICU and hospital, and healthcare expenditure.     

Evaluating the effect of Matricaria recutita and Mentha piperita herbal mouthwash on management of oral mucositis in patients undergoing hematopoietic stem cell transplantation: A randomized,double blind,placebo controlled clinical trial

ObjectivesTo investigate the effects of Matricaria recutita and Mentha piperita on oral mucositis (OM) in patients undergoing hematopoietic stem cell transplantation (HSCT).DesignRandomized double blind placebo controlled clinical trial.SettingFaculty of Pharmacy, Shahid Beheshti University of Medical Sciences, and Bone Marrow Transplantation Center at Taleghani Teaching Hospital, Tehran, Iran.ParticipantsSixty patients undergoing HSCT were randomly assigned to two groups: placebo (n = 33), and herbal mouthwash group (n = 27).InterventionsAll patients received the mouthwash one week before HSCT and were instructed to use it three times daily for at least 30 s.Main outcome measuresOM was graded using National Cancer Institute Common Toxicity Criteria (NCI-CTC) scale (grade 0–5). The Numerical Rating Scale (NRS: 0–10 scale) measured the severity of OM symptoms.ResultsThe duration, maximum and average daily grade of OM were significantly reduced in the treatment group (P < 0.05). The use of herbal mouthwash led to significant improvements in pain intensity (P = 0.009), dryness (P = 0.04) and dysphagia (P = 0.009). Other significant results included: reduced need for complementary medications (P = 0.03), narcotic analgesics (P = 0.047), total parenteral nutrition (TPN) (P = 0.02) and the duration of TPN (P = 0.03).ConclusionThis study shows that patients receiving the herbal mouthwash experienced less complications and symptoms associated with OM. In summary, it seems that the use of our prepared herbal mouthwash is beneficial for patients undergoing HSCT.     

Risk factors for late-onset ventilator-associated pneumonia in trauma patients receiving selective digestive decontamination

Objective To determine the independent risk factors for late-onset ventilator-associated pneumonia (VAP) in trauma patients receiving selective digestive decontamination (SDD).Design A 4-year, prospective cohort study of trauma patients meeting the following criteria: injury severity score >15, and duration of mechanical ventilation >5 days. Predictors of late-onset VAP occurrence were assessed by logistic regression analysis.Population All patients received SDD consisting of polymixin E, gentamicin, and amphotericin B applied in nostrils, mouth, and gut with a 3-day course of parenteral cefazolin. VAP was suspected on clinical and radiological signs, and confirmed by the presence of at least one microorganism at a concentration of at least 10⁴ CFU/ml on the broncho-alveolar lavage.Measurement Independent risk factors for late-onset VAP.Results A late-onset VAP was diagnosed in 90 (56%) out of 159 patients. Predicting factors for late-onset VAP were: use of non-depolarizing muscle relaxant agents for intubation [3.4 (CI 1.08–10.73)], duration of intubation [1.06 (CI 1.01–1.17)], length of intensive care unit (ICU) stay [1.05 (CI 1.02–1.09)], and prior tracheal colonization [1.03 (CI 1.02–1.21)]. Exposure to prior antimicrobial treatment, except SDD, conferred protection [0.3 (0.12–0.74)].Conclusion This study confirms the role of duration of intubation, length of ICU stay, and prior tracheal colonization in the development of late-onset VAP. The results also highlight the importance of the initial management on the development of late-onset VAP. The type of neuromuscular blocking agents to intubate trauma patients should be evaluated in future studies.     

A reappraisal of childhood drowning in a pediatric emergency department

BackgroundIn the present study, we aimed to investigate the demographic and clinical features, laboratory and radiologic characteristics, management, and outcomes of pediatric drowning patients in order to identify predictors of hospital admission, and to evaluate the need for respiratory support, and prognosis.MethodsIn this retrospective chart review, children aged 0 to 18 years who presented to the pediatric emergency department due to drowning between July 2009 and September 2019 were included. Demographics, initial vital signs, clinical findings, laboratory and radiologic results, and the need for respiratory support or cardiopulmonary resuscitation in the emergency department were recorded. Subjects were divided into 6 groups using the Szpilman classification system.ResultsA total of 89 patients were enrolled. Among the children who were admitted to the hospital, initial Szpilman score, crepitations on lung auscultation, and pathologic chest X-ray (CXR) findings were higher and Glasgow Coma Score and oxygen saturation (SpO 2) levels were lower than those of children who were discharged from the emergency department. A Szpilman score of ≥4, a lactate level of >2 mmol/L, and pathologic CXR findings were identified as predictors of hospital admission. Of the 89 patients, 22 (24.7%) underwent non-invasive ventilation (NIV) treatment and were classified as grade 3 or 4 according to the Szpilman score. Length of stay in the pediatric intensive care unit (PICU) and in the hospital was lower in patients who underwent NIV. As the Szpilman score increased as of grade 3, a positive correlation was observed with lactate levels (p <0.001, r: 0.552) and the total length of stay in the hospital (p: 0.001, r : 0.491), both of which gradually increased.ConclusionThe Szpilman score was associated with the duration of hospital stay and the degree of hypoxia, so it could help the physician make rapid decisions on ventilation strategy. Application of NIV in the emergency department shortened the length of stay in the PICU and in the hospital, suggesting that it can be used more often in pediatric emergency settings.