Gavin Lavery

Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis

Objective To investigate the effects of weaning protocols on the total duration of mechanical ventilation, mortality, adverse events, quality of life, weaning duration, and length of stay in the intensive care unit and hospital. Design Systematic review. Data sources Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL, LILACS, ISI Web of Science, ISI Conference Proceedings, Cambridge Scientific Abstracts, and reference lists of articles. We did not apply language restrictions. Review methods We included randomised and quasi-randomised controlled trials of weaning from mechanical ventilation with and without protocols in critically ill adults. Data selection Three authors independently assessed trial quality and extracted data. A priori subgroup and sensitivity analyses were performed. We contacted study authors for additional information. Results Eleven trials that included 1971 patients met the inclusion criteria. Compared with usual care, the geometric mean duration of mechanical ventilation in the weaning protocol group was reduced by 25% (95% confidence interval 9% to 39%, P=0.006; 10 trials); the duration of weaning was reduced by 78% (31% to 93%, P=0.009; six trials); and stay in the intensive care unit length by 10% (2% to 19%, P=0.02; eight trials). There was significant heterogeneity among studies for total duration of mechanical ventilation (I2=76%, P<0.01) and duration of weaning (I2=97%, P<0.01), which could not be explained by subgroup analyses based on type of unit or type of approach. Conclusion There is evidence of a reduction in the duration of mechanical ventilation, weaning, and stay in the intensive care unit when standardised weaning protocols are used, but there is significant heterogeneity among studies and an insufficient number of studies to investigate the source of this heterogeneity. Some studies suggest that organisational context could influence outcomes, but this could not be evaluated as it was outside the scope of this review.

Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. (Protocol)

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effectiveness of anti-adhesion therapy versus placebo, no therapy or an alternative anti-adhesion therapy following operative hysteroscopy for the treatment of female subfertility.To determine the efficacy and safety of metformin in treating women with endometrial hyperplasia

An evaluation of protocolised weaning on the duration of mechanical ventilation

Using a before and after study design, we compared protocolised weaning from mechanical ventilation with usual non‐protocolised practice in intensive care. Outcomes (duration of mechanical ventilation, duration of intubation, intensive care stay) and complications (re‐intubations, tracheostomy, mortality) were compared between baseline (Phase I) and following implementation of protocolised weaning (Phase II). Over the same period, we collected data in a second (reference) unit to monitor practice changes over time. In the intervention unit, outcomes were longer in Phase II compared with Phase I (all p < 0.005). When adjusted for admission APACHE II score and diagnostic category, only intensive care stay remained significantly longer (p = 0.002). There were significantly more tracheostomies in Phase II (p = 0.004). The reference unit demonstrated no statistically significant differences in study outcomes or complications between Phases. Protocolised weaning did not reduce the duration of mechanical ventilation and was not associated with an increased rate of re‐intubation or intensive care unit mortality.

A randomized controlled trial of tea tree oil (5%) body wash versus standard body wash to prevent colonization with methicillin-resistant Staphylococcus aureus (MRSA) in critically ill adults: research protocol

BackgroundOver the past ten years MRSA has become endemic in hospitals and is associated with increased healthcare costs. Critically ill patients are most at risk, in part because of the number of invasive therapies that they require in the intensive care unit (ICU). Washing with 5% tea tree oil (TTO) has been shown to be effective in removing MRSA on the skin. However, to date, no trials have evaluated the potential of TTO body wash to prevent MRSA colonization or infection. In addition, detecting MRSA by usual culture methods is slow. A faster method using a PCR assay has been developed in the laboratory, but requires evaluation in a large number of patients.Methods/DesignThis study protocol describes the design of a multicentre, phase II/III prospective open-label randomized controlled clinical trial to evaluate whether a concentration of 5% TTO is effective in preventing MRSA colonization in comparison with a standard body wash (Johnsons Baby Softwash) in the ICU. In addition we will evaluate the cost-effectiveness of TTO body wash and assess the effectiveness of the PCR assay in detecting MRSA in critically ill patients. On admission to intensive care, swabs from the nose and groin will be taken to screen for MRSA as per current practice. Patients will be randomly assigned to be washed with the standard body wash or TTO body wash. On discharge from the unit, swabs will be taken again to identify whether there is a difference in MRSA colonization between the two groups.DiscussionIf TTO body wash is found to be effective, widespread implementation of such a simple colonization prevention tool has the potential to impact on patient outcomes, healthcare resource use and patient confidence both nationally and internationally.Trial Registration[ISRCTN65190967]

Effectiveness of an exercise programme on physical function in patients discharged from hospital following critical illness: a randomised controlled trial (the REVIVE trial)

Objective To investigate the effectiveness of a 6-week exercise programme in patients discharged home following critical illness compared with standard care. Design Multicentre prospective phase II randomised controlled trial, with blinded outcome assessment after hospital discharge, following the 6-week intervention and at 6 months. Participants 60 patients (30 per group) aged ≥18 years, mechanically ventilated >96 hours, and not in other rehabilitation, that is, cardiac or pulmonary rehabilitation programmes. Participants in the intervention group completed an individually tailored (personalised) exercise programme. Outcome measures Primary outcome measure was SF-36 physical functioning following the intervention. Secondary outcomes included a range of performance-based and patient-reported measures. Results Improvements in the primary outcome did not differ significantly between groups (mean difference (95% CI) 3.0 (−2.2 to 8.2), p=0.26). The intervention group showed significant improvement compared with the control group (mean difference (95% CI)) in SF-36 role physical (6.6 (0.73 to 12.5), p=0.03); incremental shuttle walk test (83.1 m (8.3 to 157.9), p=0.03); functional limitations profile (−4.8 (−8.7 to −0.9), p=0.02); self-efficacy to exercise (2.2 (0.8 to 3.7), p=0.01) and readiness to exercise (1.3 (0.8 to 1.9), p<0.001). These improvements were not sustained at 6 months except readiness to exercise. Improvements in all other secondary outcome measures were not significant. Conclusions There was no statistically significant difference in the primary outcome measure of self-reported physical function following this 6-week exercise programme. Secondary outcome results will help inform future studies. Trial registration number NCT01463579. (results), https://clinicaltrials.gov/

Phagocyte priming as a prognostic indicator in the intensive care unit.

BACKGROUND The purpose of this study was to study the temporal changes in circulating phagocyte respiratory burst activity and its relationship to mortality in intensive care unit (ICU) patients. METHODS Thirty-seven consecutive patients over a 3-week period were studied on their first, third, and seventh day of admission to the regional ICU in Northern Ireland. Blood samples were assayed for respiratory burst activity using luminol-enhanced whole blood chemiluminescence. RESULTS Compared with survivors, nonsurvivors exhibited significantly higher Acute Physiology and Chronic Health Evaluation II scores, a base deficit, and reduced phagocyte activity (median [interquartile range]) (24.00% [18.00%, 56.00%] vs. 38.00% [30.00%, 63.50%], p = 0.047, Mann-Whitney U test) on day 3 of admission to the ICU. CONCLUSION Temporal changes in phagocyte activation dependent on the underlying insult were seen in ICU patients. Furthermore, the degree of phagocyte activation was able to distinguish between survivors and nonsurvivors on day 3 of admission to the ICU. Nonsurvivors exhibited reduced phagocyte activation, suggesting patients at risk of mortality exhibit systemic anergy.

The crossover study design and its clinical application

This paper describes the crossover design in research methodology and illustrates its use in a clinical study in an intensive care unit (ICU). The benefits and shortcomings of the design are described. Strategies to avoid or minimise the shortcomings are explained with reference to examples from a study carried out in clinical practice. By linking theory to practice in this way, we hope to help to increase the understanding of this methodology for the nurse researcher.