Robyn Schaiff

Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.

OBJECTIVE To compare a practice of protocol-directed sedation during mechanical ventilation implemented by nurses with traditional non-protocol-directed sedation administration. DESIGN Randomized, controlled clinical trial. SETTING Medical intensive care unit (19 beds) in an urban teaching hospital. PATIENTS Patients requiring mechanical ventilation (n = 321). INTERVENTIONS Patients were randomly assigned to receive either protocol-directed sedation (n = 162) or non-protocol-directed sedation (n = 159). MEASUREMENTS AND MAIN RESULTS The median duration of mechanical ventilation was 55.9 hrs (95% confidence interval, 41.0-90.0 hrs) for patients managed with protocol-directed sedation and 117.0 hrs (95% confidence interval, 96.0-155.6 hrs) for patients receiving non-protocol-directed sedation. Kaplan-Meier analysis demonstrated that patients in the protocol-directed sedation group had statistically shorter durations of mechanical ventilation than patients in the non-protocol-directed sedation group (chi-square = 7.00, p = .008, log rank test; chi-square = 8.54, p = .004, Wilcoxons test; chi-square = 9.18, p = .003, -2 log test). Lengths of stay in the intensive care unit (5.7+/-5.9 days vs. 7.5+/-6.5 days; p = .013) and hospital (14.0+/-17.3 days vs. 19.9+/-24.2 days; p < .001) were also significantly shorter among patients in the protocol-directed sedation group. Among the 132 patients (41.1%) receiving continuous intravenous sedation, those in the protocol-directed sedation group (n = 66) had a significantly shorter duration of continuous intravenous sedation than those in the non-protocol-directed sedation group (n = 66) (3.5+/-4.0 days vs. 5.6+/-6.4 days; p = .003). Patients in the protocol-directed sedation group also had a significantly lower tracheostomy rate compared with patients in the non-protocol-directed sedation group (10 of 162 patients [6.2%] vs. 21 of 159 patients [13.2%], p = .038). CONCLUSIONS The use of protocol-directed sedation can reduce the duration of mechanical ventilation, the intensive care unit and hospital lengths of stay, and the need for tracheostomy among critically ill patients with acute respiratory failure.

Experience with a clinical guideline for the treatment of ventilator-associated pneumonia.

Objective To evaluate a clinical guideline for the treatment of ventilator-associated pneumonia. Design Prospective before-and-after study design. Setting A medical intensive care unit from a university-affiliated, urban teaching hospital. Patients Between April 1999 and January 2000, 102 patients were prospectively evaluated. Interventions Prospective patient surveillance, data collection, and implementation of an antimicrobial guideline for the treatment of ventilator-associated pneumonia. Measurements and Main Results The main outcome evaluated was the initial administration of adequate antimicrobial treatment as determined by respiratory tract cultures. Secondary outcomes evaluated included the duration of antimicrobial treatment for ventilator-associated pneumonia, hospital mortality, intensive care unit and hospital lengths of stay, and the occurrence of a second episode of ventilator-associated pneumonia. Fifty consecutive patients with ventilator-associated pneumonia were evaluated in the before period and 52 consecutive patients with ventilator-associated pneumonia were evaluated in the after period. Severity of illness using Acute Physiology and Chronic Health Evaluation II (25.8 ± 5.7 vs. 25.4 ± 8.1, p = .798) and the clinical pulmonary infection scores (6.6 ± 1.0 vs. 6.9 ± 1.2, p = .105) were similar for patients during the two treatment periods. The initial administration of adequate antimicrobial treatment was statistically greater during the after period compared with the before period (94.2% vs. 48.0%, p < .001). The duration of antimicrobial treatment was statistically shorter during the after period compared with the before period (8.6 ± 5.1 days vs. 14.8 ± 8.1 days, p < .001). A second episode of ventilator-associated pneumonia occurred statistically less often among patients in the after period (7.7% vs. 24.0%, p = .030). Conclusions The application of a clinical guideline for the treatment of ventilator-associated pneumonia can increase the initial administration of adequate antimicrobial treatment and decrease the overall duration of antibiotic treatment. These findings suggest that similar types of guidelines employing local microbiological data can be used to improve overall antibiotic utilization for the treatment of ventilator-associated pneumonia.

Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial

BACKGROUND This study sought to compare 2 strategies for the administration of enteral feeding to mechanically ventilated medical patients. METHODS The prospective, controlled, clinical trial was carried out in a medical intensive care unit (19 beds) in a university-affiliated, urban teaching hospital. Between May 1999 and December 2000, 150 patients were enrolled. Patients were scheduled to receive their estimated total daily enteral nutritional requirements on either day 1 (early-feeding group) or day 5 (late-feeding group) of mechanical ventilation. Patients in the late-feeding group were also scheduled to receive 20% of their estimated daily enteral nutritional requirements during the first 4 days of mechanical ventilation. RESULTS Seventy-five (50%) consecutive eligible patients were entered into the early-feeding group and 75 (50%) patients were enrolled in the late-feeding group. During the 5 five days of mechanical ventilation, the total intake of calories (2370 +/- 2000 kcal versus 629 +/- 575 kcal; p < .001) and protein (93.6 +/- 77.2 g versus 26.7 +/- 26.6 g; p < .001) were statistically greater for patients in the early-feeding group. Patients in the early-feeding group had statistically greater incidences of ventilator-associated pneumonia (49.3% versus 30.7%; p = .020) and diarrhea associated with Clostridium difficile infection (13.3% versus 4.0%; p = .042). The early-feeding group also had statistically longer intensive care unit (13.6 +/- 14.2 days versus 9.8 +/- 7.4 days; p = .043) and hospital lengths of stay (22.9 +/- 19.7 days versus 16.7 +/- 12.5 days; p = .023) compared with patients in the late-feeding group. No statistical difference in hospital mortality was observed between patients in the early-feeding and late-feeding groups (20.0% versus 26.7%; p = .334). CONCLUSIONS The administration of more aggressive early enteral nutrition to mechanically ventilated medical patients is associated with greater infectious complications and prolonged lengths of stay in the hospital. Clinicians must balance the potential for complications resulting from early enteral feeding with the expected benefits of such therapy.

Inadequate treatment of nosocomial infections is associated with certain empiric antibiotic choices.

ObjectiveThe purpose of this study was to determine the impact of scheduled changes of antibiotic classes, used for the empirical treatment of suspected or documented Gram-negative bacterial infections, on the occurrence of inadequate antimicrobial treatment of nosocomial infections. DesignProspective observational study. SettingMedical (19-bed) and surgical (18-bed) intensive care units in an urban teaching hospital. PatientsA total of 3,668 patients requiring intensive care unit admission were prospectively evaluated during three consecutive time periods. InterventionsDuring each time period, one antibiotic class was selected for the empirical treatment of Gram-negative bacterial infections as follows: time period 1 (baseline period) (1,323 patients), ceftazidime; time period 2 (1,243 patients), ciprofloxacin; and time period 3 (1,102 patients), cefepime. Measurements and Main ResultsThe overall administration of inadequate antimicrobial treatment for nosocomial infections decreased during the course of the study (6.1%, 4.7%, and 4.5%;p = .15). This was primarily because of a statistically significant decrease in the administration of inadequate antibiotic treatment for Gram-negative bacterial infections (4.4%, 2.1%, and 1.6%;p < .001). There were no statistically significant differences in the overall hospital mortality rate among the three time periods (15.6%, 16.4%, and 16.2%;p = .828) despite a significant increase in severity of illness as measured with Acute Physiology and Chronic Health Evaluation (APACHE) II scores (15.3 ± 7.6, 15.7 ± 8.0, and 20.7 ± 8.6;p < .001). The hospital mortality rate decreased significantly during time period 3 (20.6%) compared with time period 1 (28.4%;p < .001) and time period 2 (29.5%;p < .001) for patients with an APACHE II score ≥15. ConclusionsThese data suggest that scheduled changes of antibiotic classes for the empirical treatment of Gram-negative bacterial infections can reduce the occurrence of inadequate antibiotic treatment for nosocomial infections. Reducing inadequate antibiotic administration may improve the outcomes of critically ill patients with APACHE II scores ≥15.

Enoxaparin-associated dermal necrosis: a consequence of cross-reactivity with heparin-mediated antibodies.

Objective To describe a patient with enoxaparin-induced dermal necrosis and to review previously reported cases of skin manifestations associated with low-molecular-weight heparins. Case Summary A 43-year-old white woman with adult respiratory distress syndrome developed localized dermal necrosis and thrombocytopenia secondary to subcutaneous administration of unfractionated heparin. Upper extremity thrombi that had developed after administration of subcutaneous heparin at an outside hospital were treated with subcutaneous enoxaparin. Although platelet counts remained stable during enoxaparin therapy, dermal necrosis developed at the injection site. Parenteral anticoagulant therapy was discontinued and the necrotic lesions secondary to enoxaparin resolved with minimal local care. Discussion Numerous cases of dermal necrosis secondary to heparin administration have been reported while this reaction secondary to enoxaparin use has been reported only briefly. It has been postulated that dermal necrosis secondary to heparin is associated with heparin-induced thrombocytopenia and is a result of heparin-mediated thrombosis in the microvasculature. Antibodies to heparin have cross-reactivity with enoxaparin; therefore, dermal necrosis secondary to enoxaparin may occur by a similar mechanism. Conclusions Although enoxaparin-associated dermal necrosis appears to be a rare occurrence, we advise against the use of enoxaparin or other low-molecular-weight heparins in patients with a previous history of heparin-associated thrombocytopenia or heparin-induced dermal necrosis.

The Efficacy of Inhaled Beclomethasone in Chronic Obstructive Airway Disease

The objective of this study was to examine the effectiveness of inhaled beclomethasone in the treatment of stable chronic obstructive airway disease (COAD). Eight patients completed a randomized, double‐blind, placebo‐controlled, crossover trial of inhaled beclomethasone and oral prednisone. Each patient received 3 treatment regimens given for 14 days: inhaled beclomethasone, prednisone, and placebo. There were no statistically significant differences in pulmonary function tests, oxygen cost diagram, or 12‐minute walking distance test among the regimens. The only improvement in arterial blood gasses was partial pressure of oxygen, which was negligibly increased during prednisone treatment compared with beclomethasone and with placebo (p <0.05). Evaluation of 95% confidence intervals indicated that clinically significant mean differences were unlikely with either beclomethasone or prednisone. Larger studies are required to determine if a responsive subgroup exists, and to determine if this form of therapy has a role in treatment of COAD.