Maureen Seckel

An official American Thoracic Society/European Society of intensive care medicine/society of critical care medicine clinical practice guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome

Background: This document provides evidence‐based clinical practice guidelines on the use of mechanical ventilation in adult patients with acute respiratory distress syndrome (ARDS). Methods: A multidisciplinary panel conducted systematic reviews and metaanalyses of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: For all patients with ARDS, the recommendation is strong for mechanical ventilation using lower tidal volumes (4‐8 ml/kg predicted body weight) and lower inspiratory pressures (plateau pressure < 30 cm H2O) (moderate confidence in effect estimates). For patients with severe ARDS, the recommendation is strong for prone positioning for more than 12 h/d (moderate confidence in effect estimates). For patients with moderate or severe ARDS, the recommendation is strong against routine use of high‐frequency oscillatory ventilation (high confidence in effect estimates) and conditional for higher positive end‐expiratory pressure (moderate confidence in effect estimates) and recruitment maneuvers (low confidence in effect estimates). Additional evidence is necessary to make a definitive recommendation for or against the use of extracorporeal membrane oxygenation in patients with severe ARDS. Conclusions: The panel formulated and provided the rationale for recommendations on selected ventilatory interventions for adult patients with ARDS. Clinicians managing patients with ARDS should personalize decisions for their patients, particularly regarding the conditional recommendations in this guideline.

Correlation between the Sedation-Agitation Scale and the Bispectral Index in ventilated patients in the intensive care unit

BACKGROUND Oversedation masks neurologic changes and increases mortality/morbidity, whereas undersedation risks prolonged stress mobilization and patient injury. In situations such as deep sedation/analgesia, the Bispectral Index (BIS) has potential use as an adjunct to clinical assessment of sedation to help determine depth of sedation. Determining the correlation between clinical and BIS measures of sedation will help to determine the correct role of BIS in intensive care unit (ICU) practice settings. OBJECTIVE To evaluate the correlation between the clinical assessment of sedation using the Sedation-Agitation Scale (SAS) and the assessment using BIS in ventilated and sedated ICU patients. METHODS ICU patients requiring mechanical ventilation and sedation were monitored using the SAS and BIS. Nurses initiated event markers with BIS at the time of SAS assessment but were blinded to BIS scores. RESULTS Data were collected on 40 subjects generating 209 paired readings. Moderate positive correlation between BIS and SAS values was shown with a Spearman Rank coefficient r value of .502 and an r(2) of .252 (P < .0001). Wide ranges of BIS scores were observed, especially in very sedated patients. Strong positive correlation was noted between BIS and electromyography with an r value of .749 (P < .0001). Age and gender significantly influenced BIS/SAS correlations. CONCLUSION In situations in which the clinical assessment is equivocal, BIS monitoring may have an adjunctive role in sedation assessment. BIS values should be interpreted with caution, however, because electromyography activity and other factors seem to confound BIS scores. More research is necessary to determine the role of BIS monitoring in ICU practice.

Using the Comprehensive Unit-based Safety Program model for sustained reduction in hospital infections

BACKGROUND Prompted by the high number of central line-associated bloodstream infections (CLABSIs), our institution joined the national On the CUSP: Stop BSI initiative. We not only report the significant impact that the Comprehensive Unit-based Safety Program (CUSP) had in reducing CLABSI, but also report catheter-associated urinary tract infections (CAUTIs) and ventilator-associated pneumonia (VAP) in 2 intensive care units (ICUs). METHODS At our community-based academic health care system, 2 ICUs implemented CUSP tools and developed local interventions to reduce CLABSI and other safety problems. We measured CLABSI, CAUTI, and VAP during baseline, the CUSP period, and a post-CUSP period. RESULTS CLABSIs decreased from 3.9 per 1,000 catheter days at baseline to 1.2 during the CUSP period to 0.6 during the post-CUSP period (rate ratio, 0.16; 95% confidence interval [CI], 0.07-0.35). CAUTIs decreased from 2.4 per 1,000 patient days to 1.2 during the post-CUSP period (rate ratio, 0.4; 95% CI, 0.24-0.65). VAP rate decreased from 2.7 per 1,000 ventilator days to 1.6 during the CUSP and post-CUSP periods (rate ratio, 0.58; 95% CI, 0.30-1.10). Device utilization decreased significantly in both ICUs. CONCLUSIONS Implementation of CUSP was associated with significant decreases in CLABSI, CAUTI, and VAP. The CUSP model, allowing for implementation of evidence-based practices and engagement of frontline staff, creates sustainable improvements that reach far beyond the initial targeted problem.

Respiratory Compromise as a New Paradigm for the Care of Vulnerable Hospitalized Patients

Acute respiratory compromise describes a deterioration in respiratory function with a high likelihood of rapid progression to respiratory failure and death. Identifying patients at risk for respiratory compromise coupled with monitoring of patients who have developed respiratory compromise might allow earlier interventions to prevent or mitigate further decompensation. The National Association for the Medical Direction of Respiratory Care (NAMDRC) organized a workshop meeting with representation from many national societies to address the unmet needs of respiratory compromise from a clinical practice perspective. Respiratory compromise may arise de novo or may complicate preexisting lung disease. The group identified distinct subsets of respiratory compromise that present similar opportunities for early detection and useful intervention to prevent respiratory failure. The subtypes were characterized by the pathophysiological mechanisms they had in common: impaired control of breathing, impaired airway protection, parenchymal lung disease, increased airway resistance, hydrostatic pulmonary edema, and right-ventricular failure. Classification of acutely ill respiratory patients into one or more of these categories may help in selecting the screening and monitoring strategies that are most appropriate for the patients particular pathophysiology. Standardized screening and monitoring practices for patients with similar mechanisms of deterioration may enhance the ability to predict respiratory failure early and prevent its occurrence.

Normal saline and mucous plugging.

cialist in the medical critical care/pulmonary unit at Christiana Care Health System in Newark, Delaware. history of smoking along with chronic respiratory diseases such as cystic fibrosis, chronic obstructive pulmonary disease, asthma, and bronchiectasis. Other patient-related factors that may contribute include smoking, immobility, sedation, muscle weakness, and dehydration. A mucous plug occurs when excessive, tenacious mucous secretion blocks or “plugs” the airway lumen. Several mechanisms can improve secretion management and prevent mucous plugging.

Evidence-Based Practice: Percussion and Vibration Therapy

©2017 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ccn2017775 QMy facility is currently reviewing critical care beds with or without percussion and vibration therapy. I am seeing other hospital systems moving away from this therapy and focusing on early mobility. What is current evidence-based practice regarding this therapy? • Patients at risk for ventilatorassociated pneumonia, • Patients with increasing ventilator support needs that are refractory to usual treatment, or • Patients who have acute lung injury or acute respiratory distress syndrome.6