Use of sedation and neuromuscular paralysis during mechanical ventilation.

Pharmacologic therapy can be a necessary adjunct with mechanical ventilation. The treatment of pain and anxiety and the suppression of the patient's respiratory drive may be necessary to facilitate effective ventilation and oxygenation. The critical care nurse must be clear as to the expected outcomes of this therapy. In addition to the traditional drugs for sedation and analgesia, neuromuscular blocking agents may be required to improve ventilatory assistance. The patient must be continually evaluated for the appropriateness and method of dosing, adequate sedation and analgesia, and adverse effects. Patient safety is one of the primary concerns of the critical care nurse during this time.     

Eye care for patients receiving neuromuscular blocking agents or propofol during mechanical ventilation.

BACKGROUND: The presence of a corneal reflex and the ability to maintain eye closure are instrumental in protecting the cornea. Use of neuromuscular blocking agents or propofol can result in impaired eyelid closure and loss of corneal reflex, leading to corneal exposure. The cornea is then at risk for drying, infection, and scarring, which may lead to permanent visual loss. OBJECTIVES: To determine whether applying artificial tear ointment to the eyes of paralyzed or heavily sedated patients receiving mechanical ventilation decreases the prevalence of exposure keratitis more than does passive closure of the eyelid. METHODS: A prospective, randomized control trial was done. The sample was 50 patients in the intensive care unit receiving either neuromuscular blocking agents or propofol during mechanical ventilation. In each patient, artificial tear ointment was applied to one eye; passive closure of the eyelid was used for the other eye (control eye). RESULTS: Nine patients had evidence of exposure keratitis in the untreated eye, and 2 had corneal abrasions in both the treated and the control eyes. The remaining 39 patients did not have corneal abrasions in either eye. Use of the artificial tear ointment was more effective in preventing corneal exposure than was passive eyelid closure (P = .004). CONCLUSIONS: Eye care with a lubricating ointment on a regular, set schedule can effectively reduce the prevalence of corneal abrasions in patients who are either paralyzed or heavily sedated and thus can help prevent serious complications such as corneal ulceration, infection, and visual loss.     

Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care

OBJECTIVE: To determine the cost-effectiveness and safety of a set of rational use guidelines for analgesia, sedation, and neuromuscular blockade in critically ill ventilated patients when compared with similar factors in standard prescribing. DESIGN: Prospective cost-benefit analysis. SETTING: Medical and surgical intensive care units (ICU) of a 350-bed tertiary care university hospital. PATIENTS: Patients admitted to our ICUs who required mechanical ventilation and continuous analgesics, sedatives, and/or neuromuscular junction blockers (NMJBs). There were 72 patients in the baseline and 84 patients in the follow-up groups. INTERVENTIONS: Prospective tracking of eligible baseline patients was followed by the development and introduction of guidelines and an academic detailing process to promote the use of guidelines. Several months after the introduction of guidelines, a second group of eligible follow-up patients was tracked. The use and effectiveness of analgesics, sedatives, and NMJBs, as well as cost and outcomes, were followed in both groups. Data were subsequently reviewed and analyzed. MEASUREMENTS AND MAIN RESULTS: We recorded data by means of Paradox and Excel databases and included demographics, costs, outcomes (including adverse drug reactions, functional status, ventilator time in hours, lengths of stay), and mortality rates. Data were subsequently analyzed via the Winks statistical data analysis program. Both groups were similar with regard to demographics. There was a statistically significant increase in severity of illness in the follow-up group without a statistically significant increase in mortality. Direct drug costs, ventilator time, and lengths of stay were reduced in the follow-up group. In addition, the use of NMJBs was reduced from 30% in the baseline group to 5% in the follow-up group. CONCLUSIONS: Rational use guidelines resulted in safe, cost-effective improvements in the provision of continuous analgesia, sedation, and neuromuscular blockade to critically ill patients requiring ventilator management when compared with similar factors in baseline prescribing strategies.     

Bedside adherence to clinical practice guidelines for enteral nutrition in critically ill patients receiving mechanical ventilation: a prospective,multi-centre,observational study

Introduction  

The primary aim was to measure the amount of nutrients required, prescribed and actually administered in critically ill patients. Secondary aims were to assess adherence to clinical practice guidelines, and investigate factors leading to non-adherence.     

Improving oral care in patients receiving mechanical ventilation.

BACKGROUND: Comprehensive oral care is an evidence-based prevention strategy to reduce the risk of ventilator-associated pneumonia in patients receiving mechanical ventilation. Until recently, no comprehensive guidelines or standards existed to define necessary tasks, methods, and frequency of oral care to provide patients with optimal results. OBJECTIVES: To observe current practice of, define best practice for, and measure compliance with standardized comprehensive oral care. METHODS: This observational study was part of a larger research study performed at 5 acute care hospitals. Time blocks of 4 hours were randomized over 8 intensive care units and the 7 days of the week. Baseline data were collected before implementation of multifaceted education on an oral-cleansing protocol; interventional data were collected afterward. RESULTS: Oral care practices were observed for 253 patients. During the baseline period, oral cleansing was primarily via suction swabs. Toothbrushing and moisturizing of the oral tissues were not observed. Only 32% of the patients had suctioning to manage oral secretions. During the interventional period, 33% of patients had their teeth brushed, 65% had swab cleansing, and 63% had a moisturizer applied to the oral mucosal tissues. A total of 61% had management of oral secretions; 38% had oropharyngeal suctioning via a special catheter. CONCLUSIONS: Implementation of an evidence-based oral cleansing protocol improved the care of patients receiving mechanical ventilation. Multifaceted education and implementation strategies motivated staff to increase oral care practices.     

Symptoms, clinical and physiological findings motivating home mechanical ventilation in patients with neuromuscular diseases.

OBJECTIVE: To clarify the relationship between symptoms, clinical signs and physiological abnormalities that were motivating the initiation of home mechanical ventilation in patients suffering from neuromuscular diseases. METHODS: From The Swedish Home Mechanical Ventilation Register we identified 352 patients with neuromuscular diseases and we looked at circumstances (acute vs elective) and clinical motives for starting ventilatory support. RESULTS: Home mechanical ventilation was commenced electively in 268 patients (76%) and among these daytime sleepiness was the most common motive, being reported in 56% of the patients. In the 24 children with spinal muscular atrophy, however, 96% started ventilation electively and cough insufficiency was the most common motive. The patients were moderately hypercapnic (PaCO(2): 7.0 kPa, SD 1.3). None of the clinical motives were related to the PaCO(2) level. Average PaO(2) was above 8 kPa in all groups, but lowest in the patients with post-polio and dystrophia myotonica. Mean vital capacity was close to 40% of predicted, but significantly lower in the Duchenne patients (26% of predicted). CONCLUSION: Daytime sleepiness was the most common clinical symptom motivating home mechanical ventilation in this group of patients with chronic hypercapnic respiratory insufficiency secondary to neuro/myopathies. Respiratory function testing is therefore suggested to be included in the diagnostic work up of daytime sleepiness in these patients.     

机械通气患者镇静早期深镇静发生情况及危险因素分析

目的 分析ICU机械通气镇静患者早期深镇静的发生情况及危险因素,为降低深镇静的发生率提供参考依据.方法 采用回顾性研究方法选取ICU机械通气镇静患者77例,分析早期深镇静的发生情况及相关危险因素.结果 机械通气早期有57.14％ 的患者发生了深镇静;二元Logistic回归分析显示:使用苯二氮卓类药物(OR:6.685...     

Collaborative practice: development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation.

BACKGROUND: Use of protocols to reduce weaning time for patients receiving mechanical ventilation helps reduce cost and length of stay. However, implementation of this type of protocol is not easy and requires a consistent collaborative effort. OBJECTIVE: To provide a systematic approach to the weaning process by developing, implementing, and evaluating a protocol for weaning patients from mechanical ventilation in a medical respiratory intensive care unit. METHODS: The weaning protocol used was a modification of a protocol developed by Ely et al. Modifications included a more aggressive approach in proceeding to the spontaneous breathing trial, inclusion of the Richmond Agitation-Sedation Scale, and documentation of the production of secretions. RESULTS: Implementation of the protocol significantly reduced the duration of mechanical ventilation as measured by 8-hour shifts and ventilator days. Although length of stay in the intensive care unit was not significantly reduced (P = .29), a continuing downward trend occurred, from a mean of 8.6 days before the protocol was implemented to 7.9 days during the last 6 months of data collection (P = .07). CONCLUSIONS: The need to provide efficient care requires the collaboration of all disciplines involved in providing patients' care. The weaning protocol introduced in this study demonstrates the benefits of using a collaborative team to identify best practices and implement them in a practice setting.     

Providing palliative care for patients receiving mechanical ventilation. Part 1: Invasive and non-invasive ventilation

Abstract

Intensive care units (ICUs) provide care to many patients who ultimately die while receiving, or after withdrawal of, mechanical ventilation. During the transition from curative to palliative care, it is important to emphasise comfort and symptoms' relief. This includes management of the mechanical ventilator. This review outlines a framework for symptoms-based ventilation of the critically ill patient. A future paper will address withdrawal of mechanical ventilation.     

机械通气治疗后并发急性呼吸窘迫综合征的危险因素分析

目的:探索呼吸功能正常患者接受机械通气治疗发生急性呼吸窘迫综合征(ARDS)的危险因素。方法:回顾分析自2002年—2007年间接受通气治疗超过48h的患者资料,比较入住时呼吸功能正常患者是否发生ARDS之间的不同。结果:共有823例患者接受了超过48h的机械通气治疗。其中751例患者符合入选标准,接受机械通气治疗时临床上排除充血性心功能衰竭,明确无ARDS存在,但在随后的治疗期间139例最后发生ARDS。单因素回归分析表明高吸气峰压(相对危险度OR值1.70,可信区间CI1.41～2.07),PEEP(相对危险度OR值1.76,可信区间CI1.45～2.14)和潮气量(相对危险度OR值1.07,可信区间CI1.06～1.10)增加是显著危险因素。非机械通气相关的因素包括脓毒血症,低pH值,低白蛋白,血浆,高净液体输入和低呼吸顺应性。多元回归分析表明机械通气相关因素PEEP及潮气量影响ARDS。而峰气道压,平台压均与ARDS无关。结论:机械通气设置等因素潮气量及PEEP与ARDS密切相关。合理设置参数可以一定程度上预防部分患者发生ARDS。