Impact of tapered-cuff tracheal tube on microaspiration of gastric contents in intubated critically ill patients: a multicenter cluster-randomized cross-over controlled trial

Purpose

Studies on the impact of tapered-cuff tracheal tubes on rates of microaspiration and ventilator-associated pneumonia (VAP) in intubated patients have reported conflicting results. The aim of this study was to determine the influence of this shape of tracheal cuff on abundant microaspiration of gastric contents in critically ill patients.

Methods

All patients intubated in the intensive care unit (ICU) and requiring mechanical ventilation for at least 48 h were eligible for this multicenter cluster-randomized controlled cross-over open-label study. The primary outcome was abundant microaspiration of gastric contents, defined by the presence of pepsin at significant level in >30% of tracheal aspirates. Quantitative measurement of pepsin and salivary amylase was performed in all tracheal aspirates during the 48 h following enrollment.

Results

A total of 326 patients were enrolled in the ten participating ICUs (162 in the PVC tapered-cuff group and 164 in the standard-cuff group). Patient characteristics were similar in the two study groups. The proportion of patients with abundant microaspiration of gastric contents was 53.5% in the tapered-cuff and 51.0% in the standard-cuff group (odds ratio 1.14, 95% CI 0.72–1.82). While abundant microaspiration of oropharyngeal secretions was not significantly different (77.4 vs 68.6%, p = 0.095), the proportion of patients with tracheobronchial colonization was significantly lower (29.6 vs 43.3%, p = 0.01) in the tapered-cuff than in the standard-cuff group. No significant difference between the two groups was found for other secondary outcomes, including ventilator-associated events and VAP.

Conclusions

This trial showed no significant impact of tapered-cuff tracheal tubes on abundant microaspiration of gastric contents.

Trial registration

ClinicalTrials.gov, number NCT01948635.

     

A survey of antenatal and peripartum provision of information on analgesia and anaesthesia

Pregnant women should receive information about what they might expect to experience during their delivery. Despite this, research shows many women are inadequately prepared for anaesthetic interventions during labour. We surveyed 903 postnatal women across 28 Greater London hospitals about: the analgesic and anaesthetic information that they recalled receiving during pregnancy and delivery; their confidence to make decisions on analgesia; and their satisfaction with the analgesia used. Wide variation was observed between hospitals. Overall, 67 of 749 (9.0%) women recalled receiving antenatal information covering all aspects of labour analgesia, and 108 of 889 (12.1%) covering anaesthesia for caesarean section. Regarding intrapartum information, 256 of 415 (61.7%) respondents recalled receiving thorough information before epidural insertion for labour analgesia, and 102 of 370 (27.6%) before anaesthesia for caesarean section. We found that 620 of 903 (68.7%) women felt well enough informed to be confident in their analgesic choices, and 675 of 903 (74.8%) stated that their analgesia was as expected or better. Receiving information verbally, regardless of provider, was the factor most strongly associated with respondents recalling receiving full information: odds ratio (95%CI) for labour analgesia 20.66 (8.98–47.53; p < 0.0001); epidural top-up for caesarean section 5.93 (1.57–22.35; p = 0.01); and general anaesthesia for caesarean section 12.39 (2.18–70.42; p = 0.01). A large proportion of respondents did not recall being fully informed before an anaesthetic intervention. Collaboration with current antenatal service providers, both in promoting information delivery and providing resources to assist with delivery, could improve the quality of information offered and women's retention of that information.     

Impact of pregnancy on psychoactive substance use among women with substance use disorders recruited in addiction specialized care centers in France

Pregnancy can be a motivation for decrease in drug abusing but may also represent a period of high vulnerability for relapse. We aimed to assess psychoactive substance use among women with substance use disorders followed in addiction care centers in France. We analyzed data from women aged 15–44 years included in the ‘Observation of illegal drugs and misuse of psychotropic medication (OPPIDUM) survey’, an annual cross‐sectional survey collecting details on psychoactive substances used. Characteristics of women included in 2005–2012 yearly surveys were compared depending on their pregnant or not pregnant status. Factors, including pregnancy, associated with illicit substance use and medication misuse were investigated through logistic regression. The study included 518 pregnant and 6345 nonpregnant women; 85.3% pregnant women were on opioid maintenance therapy (OMT) (vs. 77.1% of nonpregnant). Pregnancy was associated with lower illicit substance use (adjusted OR 0.71 [0.58–0.88]) and with lower medication misuse (0.66 [0.49–0.89]), whereas financial insecurity and living as a couple were associated with increased risk. Raising children was significantly associated with less risk of substance use. Each substance taken separately, the part of women using illicit substance or misusing medication did not differ depending on whether they were pregnant or not, except for heroin (24.5% in pregnant vs. 17.9% nonpregnant; <0.001). This nationwide study provides new insights into psychoactive substance use in a large mixed population of women with drug use disorders. Results outline the challenge of preventing drug use and initiating care strategies with a specific approach on socio‐economic environment.     

Treatment of umbilical cords: a randomised trial to assess the effect of treatment methods on the work of midwives

The national code of practice for midwives practising in England and Wales defines duties during the postnatal period for the care of mothers and their babies. This period is a minimum of 10 days, and up to 28 days. Visits after the 10th day are at midwives' discretion, but a survey of heads of midwifery services suggests that most midwives would extend postnatal care beyond the 10th day if the baby's umbilicus was not healed. Methods used for routine treatment of the umbilical cord in the newborn babies vary widely. Previous studies suggest that the rate of healing depends on the treatment method used. This, in turn, can affect the workload of midwives responsible for the care of newborn babies. Babies born in the Royal Berkshire Hospital in the summer of 1984 were allocated at random to have their cords treated by one of four dusting powders, one of three cleansing methods and one of two frequencies of treatment, in a trial with a factorial design. The effect of treatment on the time to separation of the cord and the number of midwives' visits was estimated. It was found that the treatment method used could significantly affect the healing process and therefore the number of visits made by midwives after the 10th day, and that the choice of cord powder could significantly affect the midwifery workload in the district. The difference would be enough to account for the work of one whole-time equivalent community midwife for every 3000–5000 births.