Mary Jo Grap

Chlorhexidine, Toothbrushing, and Preventing Ventilator-Associated Pneumonia in Critically Ill Adults

BACKGROUND Ventilator-associated pneumonia is associated with increased morbidity and mortality. OBJECTIVE To examine the effects of mechanical (toothbrushing), pharmacological (topical oral chlorhexidine), and combination (toothbrushing plus chlorhexidine) oral care on the development of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation. METHODS Critically ill adults in 3 intensive care units were enrolled within 24 hours of intubation in a randomized controlled clinical trial with a 2 x 2 factorial design. Patients with a clinical diagnosis of pneumonia at the time of intubation and edentulous patients were excluded. Patients (n = 547) were randomly assigned to 1 of 4 treatments: 0.12% solution chlorhexidine oral swab twice daily, toothbrushing thrice daily, both toothbrushing and chlorhexidine, or control (usual care). Ventilator-associated pneumonia was determined by using the Clinical Pulmonary Infection Score (CPIS). RESULTS The 4 groups did not differ significantly in clinical characteristics. At day 3 analysis, 249 patients remained in the study. Among patients without pneumonia at baseline, pneumonia developed in 24% (CPIS >or=6) by day 3 in those treated with chlorhexidine. When data on all patients were analyzed together, mixed models analysis indicated no effect of either chlorhexidine (P = .29) or toothbrushing (P = .95). However, chlorhexidine significantly reduced the incidence of pneumonia on day 3 (CPIS >or=6) among patients who had CPIS <6 at baseline (P = .006). Toothbrushing had no effect on CPIS and did not enhance the effect of chlorhexidine. CONCLUSIONS Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline.

Evaluating and monitoring analgesia and sedation in the intensive care unit

Management of analgesia and sedation in the intensive care unit requires evaluation and monitoring of key parameters in order to detect and quantify pain and agitation, and to quantify sedation. The routine use of subjective scales for pain, agitation, and sedation promotes more effective management, including patient-focused titration of medications to specific end-points. The need for frequent measurement reflects the dynamic nature of pain, agitation, and sedation, which change constantly in critically ill patients. Further, close monitoring promotes repeated evaluation of response to therapy, thus helping to avoid over-sedation and to eliminate pain and agitation. Pain assessment tools include self-report (often using a numeric pain scale) for communicative patients and pain scales that incorporate observed behaviors and physiologic measures for noncommunicative patients. Some of these tools have undergone validity testing but more work is needed. Sedation-agitation scales can be used to identify and quantify agitation, and to grade the depth of sedation. Some scales incorporate a step-wise assessment of response to increasingly noxious stimuli and a brief assessment of cognition to define levels of consciousness; these tools can often be quickly performed and easily recalled. Many of the sedation-agitation scales have been extensively tested for inter-rater reliability and validated against a variety of parameters. Objective measurement of indicators of consciousness and brain function, such as with processed electroencephalography signals, holds considerable promise, but has not achieved widespread implementation. Further clarification of the roles of these tools, particularly within the context of patient safety, is needed, as is further technology development to eliminate artifacts and investigation to demonstrate added value.

Pain Management Principles in the Critically Ill

This article addresses conventional pharmacologic and nonpharmacologic treatment of pain in patients in ICUs. For the critically ill patient, opioids have been the mainstay of pain control. The optimal choice of opioid and dosing regimen for a specific patient varies depending on factors such as the pharmacokinetics and physicochemical characteristics of an opioid and the bodys handling of the opioid, concomitant sedative regimen, potential or actual adverse drug events, and development of tolerance. The clinician must appreciate that favorable pharmacokinetic properties such as a short-elimination half-life do not necessarily translate into clinical advantages in the ICU setting. A variety of medications have been proposed as alternatives or adjuncts to the opioids for pain control that have unique considerations when contemplated for use in the critically ill patient. Most have been relatively unstudied in the ICU setting, and many have limitations with respect to availability of the GI route of administration in patients with questionable GI absorptive function. Nonpharmacologic, complementary therapies are low cost, easy to provide, and safe, and many clinicians can implement them with little difficulty or resources. However, the evidence base for their effectiveness is limited. At present, insufficient research evidence is available to support a broad implementation of nonpharmacologic therapies in ICUs.

Predictors of backrest elevation in critical care

Low backrest and supine positions are associated with increased mortality and ventilator associated pneumonia (VAP). Data are not available across ICU settings about the level of backrest position used and its relationship to enteral feeding and hemodynamic status. The purpose of this descriptive study was to document the level of backrest elevation and position and identify factors associated with and predict positioning in a medical, surgical and neuroscience intensive care unit. Data were collected randomly in each unit over a 6-week period, resulting in 506 observations for170 patients. Backrest elevation was determined by electronic bed read-out or bed frame elevation gauge. BP, HR and enteral feeding status were retrieved from the medical record. Results showed that mean backrest elevation was 19.2 degrees and 70% of subjects were supine. No difference in backrest elevation among units was found. Significant correlations between backrest elevation and systolic BP (r=0.15, P=0.006); and backrest and diastolic BP (r=0.13, P=0.02) were found. There was no difference in backrest elevation between patients being fed and not being fed. Differences in backrest elevation for intubated versus nonintubated patients approached significance (P=0.07) with intubated patients at lower backrest elevations. In summary, use of higher backrest elevations (>30 degrees ) is minimal, is not related to feeding and minimally related to hemodynamic status. Strategies to meet published recommendations for backrest elevation (30-45 degrees ) must include repeated feedback about nurses use of backrest elevation and estimates of elevation.

The Role of Biobehavioral, Environmental, and Social Forces on Oral Health Disparities in Frail and Functionally Dependent Nursing Home Elders

The purpose of this article is to review the literature on and discuss how interactions between bio-behavioral aging, nursing home environments, and social forces shaping current health care policies have contributed to oral health disparities in frail and functionally dependent elders who reside in nursing homes. Emerging empirical evidence suggests links between poor oral health with dental plaque deposition and systemic disease, such as nursing home-acquired pneumonia. The majority of nursing home residents lack either the functional ability or the mental capacity to perform their own mouth care and therefore must rely on others to perform mouth care for them. Certified nursing assistants (CNAs), who provide the majority of care activities, were unsure how to provide care to residents who engaged in care-resistive behaviors. The nurses who supervise the CNAs have limited knowledge regarding the provision of mouth care in general, and they specifically lack knowledge regarding the provision of mouth care to elders exhibiting care-resistant behavior. Elders in nursing homes have limited options when paying for dental care; Medicare does not generally cover routine dental care. Medicaid coverage varies widely between individual states; even when coverage exists, low Medicaid reimbursements discourage dentists from accepting Medicaid patients. The strategies needed to reduce these oral health disparities are complicated but not unrealistic. Investigators willing to embrace this cause will have no shortage of opportunities to test methods to improve the delivery of oral care as well as to monitor and reassess these methods.

Comparison of Biomarkers in Blood and Saliva in Healthy Adults

Researchers measure biomarkers as a reflection of patient health status or intervention outcomes. While blood is generally regarded as the best body fluid for evaluation of systemic processes, substitution of saliva samples for blood would be less invasive and more convenient. The concentration of specific biomarkers may differ between blood and saliva. The objective of this study was to compare multiple biomarkers (27 cytokines) in plasma samples, passive drool saliva samples, and filter paper saliva samples in 50 healthy adults. Demographic data and three samples were obtained from each subject: saliva collected on filter paper over 1 minute, saliva collected by passive drool over 30 seconds, and venous blood (3 mL) collected by venipuncture. Cytokines were assayed using Bio-Rad multiplex suspension array technology. Descriptive statistics and pairwise correlations were used for data analysis. The sample was 52% male and 74% white. Mean age was 26 (range = 19–63 years, sd = 9.7). The most consistent and highest correlations were between the passive drool and filter paper saliva samples, although relationships were dependent on the specific biomarker. Correlations were not robust enough to support substitution of one collection method for another. There was little correlation between the plasma and passive drool saliva samples. Caution should be used in substituting saliva for blood, and relationships differ by biomarker.

Structured Approaches to Pain Management in the ICU

Pain in patients who are critically ill remains undertreated despite decades of research, guideline development and distribution, and intense educational efforts. By nature of their complex medical conditions, these patients present unique challenges to the delivery of optimal pain treatment. Outdated clinical practices and faulty systems, such as a formulary that allows dangerous prescriptions, present additional obstacles. A multidisciplinary and patient-centered continuous quality improvement process is essential to identifying barriers and implementing evidence-based solutions to the problem of undertreated pain in hospital ICUs. This article addresses barriers common to the ICU setting and presents a number of structured approaches that have been shown to be successful in improving pain treatment in patients who are critically ill.

Mouth Care in Nursing Homes: Knowledge, Beliefs, and Practices of Nursing Assistants

UNLABELLED The purpose of this study was to examine the knowledge, beliefs, and practices of nursing assistants (NAs) providing oral hygiene care to frail elders in nursing homes, with the intent of developing an educational program for NAs. METHODS The study occurred in two economically and geographically diverse nursing homes. From a sample size of 202 NAs, 106 returned the 19-item Oral Care Survey. RESULTS The NAs reported satisfactory knowledge regarding the tasks associated with providing mouth care. The NAs believed that tooth loss was a natural consequence of aging. They reported that they provided mouth care less frequently than is optimal but cited challenges such as caring for persons exhibiting care-resistive behaviors, fear of causing pain, and lack of supplies. CONCLUSION Nurses are in a powerful position to support NAs in providing mouth care by ensuring that they have adequate supplies and knowledge to respond to resistive behaviors.

Pain Management Within the Palliative and End-of-Life Care Experience in the ICU*

In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss.

Early, single chlorhexidine application reduces ventilator-associated pneumonia in trauma patients

BACKGROUND Ventilator-associated pneumonia (VAP) is an important complication of mechanical ventilation and is particularly common in trauma, burn, and surgical patients. Interventions that kill bacteria in the oropharynx reduce the pool of viable organisms available for translocation to the lung and thereby lessen the likelihood of developing VAP. Repeated administration of chlorhexidine (CHX) to the mouth and oropharynx has been shown to reduce the incidence of VAP, but use of a single dose has not been studied. This randomized, controlled clinical trial tested an early (within 12 hours of intubation) application of CHX by swab versus control (no swab) on oral microbial flora and VAP. METHODS A total of 145 trauma patients requiring endotracheal intubation were randomly assigned to the intervention (5 mL CHX) or control group. VAP (Clinical Pulmonary Infection Score [CPIS] ≥ 6) was evaluated on study admission and at 48 and 72 hours after intubation. RESULTS A total of 145 patients were enrolled; 71 and 74 patients were randomized to intervention and control groups, respectively. Seventy percent of the patients were male, and 60% were white; their mean age was 42.4 years (±18.2). A significant treatment effect was found on CPIS both from admission to 48 hours (P = .020) and to 72 hours (P = .027). In those subjects without pneumonia at baseline (CPIS < 6), 55.6% of the control patients (10/18) had developed VAP by 48 or 72 hours versus only 33.3% of the intervention patients (7/21). CONCLUSION an early, single application of CHX to the oral cavity significantly reduces CPIS and thus VAP in trauma patients.