scholarly journals Evidence to Support Tooth Brushing in Critically Ill Patients

2011 ◽  
Vol 20 (3) ◽  
pp. 242-250 ◽  
Author(s):  
Nancy J. Ames
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Oral Care ◽  
Standard Of Care ◽  
Tooth Brushing ◽  
Oral Microbiome ◽  
Respiratory Pathogens ◽  
Adults And Children ◽  
Critically Ill Adults ◽  
Powered Toothbrush

Tooth brushing in critically ill patients has been advocated by many as a standard of care despite the limited evidence to support this practice. Attention has been focused on oral care as the evidence accumulates to support an association between the bacteria in the oral microbiome and those respiratory pathogens that cause pneumonia. It is plausible to assume that respiratory pathogens originating in the oral cavity are aspirated into the lungs, causing infection. A recent study of the effects of a powered toothbrush on the incidence of ventilator-associated pneumonia was stopped early because of a lack of effect in the treatment group. This review summarizes the evidence that supports the effectiveness of tooth brushing in critically ill adults and children receiving mechanical ventilation. Possible reasons for the lack of benefit of tooth brushing demonstrated in clinical trials are discussed. Recommendations for future trials in critically ill patients are suggested. With increased emphasis being placed on oral care, the evidence that supports this intervention must be evaluated carefully.

Oral Care in Critically Ill Patients Requiring Noninvasive Ventilation: An Evidence-Based Review

2021 ◽  
Vol 41 (4) ◽  
pp. 66-70
Author(s):  
Jace D. Johnny ◽  
Zachary Drury ◽  
Tracey Ly ◽  
Janel Scholine
Keyword(s):  
Critically Ill ◽  
Noninvasive Ventilation ◽  
Critically Ill Patients ◽  
Oral Care ◽  
Preventive Measure ◽  
Standard Of Care ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Hospital Acquired Pneumonia ◽  
Hospital Acquired

Topic Hospital-acquired pneumonia commonly develops after 48 hours of hospitalization and can be divided into non–ventilator-acquired and ventilator-acquired pneumonia. Prevention of non–ventilator-acquired pneumonia requires a multimodal approach. Implementation of oral care bundles can reduce the incidence of ventilator-acquired pneumonia, but the literature on oral care in other populations is limited. Clinical Relevance Use of noninvasive ventilation is increasing owing to positive outcomes. The incidence of non–ventilator-acquired pneumonia is higher in patients receiving noninvasive ventilation than in the general hospitalized population but remains lower than that of ventilator-acquired pneumonia. Non–ventilator-acquired pneumonia increases mortality risk and hospital length of stay. Purpose To familiarize nurses with the evidence regarding oral care in critically ill patients requiring noninvasive ventilation. Content Covered No standard of oral care exists for patients requiring noninvasive ventilation owing to variation in study findings, definitions, and methods. Oral care decreases the risk of hospital-acquired pneumonia and improves comfort. Nurses perform oral care less often for nonintubated patients, as it is perceived as primarily a comfort measure. The potential risks of oral care for patients receiving noninvasive ventilation have not been explored. Further research is warranted before this practice can be fully implemented. Conclusion Oral care is a common preventive measure for non–ventilator-acquired pneumonia and may improve comfort. Adherence to oral care is lower for patients not receiving mechanical ventilation. Further research is needed to identify a standard of care for oral hygiene for patients receiving noninvasive ventilation and assess the risk of adverse events.

scholarly journals Prone positioning of patients with moderate hypoxia due to COVID-19: A multicenter pragmatic randomized trial [COVID-PRONE]

2021 ◽  
Author(s):  
Mike Fralick ◽  
Michael Colacci ◽  
Laveena Munshi ◽  
Kevin Venus ◽  
Lee Fidler ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Critically Ill ◽  
Median Time ◽  
Critically Ill Patients ◽  
Primary Outcome ◽  
Standard Of Care ◽  
High Flow ◽  
Hospital Death ◽  
Prone Positioning ◽  
High Flow Oxygen

What is already known on this topic: Prone positioning is considered standard of care for mechanically ventilated patients who have severe acute respiratory distress syndrome. Recent data suggest prone positioning is beneficial for patients with COVID-19 who are requiring high flow oxygen. It is unknown of prone positioning is beneficial for patients not on high flow oxygen. What this study adds: Prone positioning is generally not well tolerated and innovative approaches are needed to improve adherence. Clinical and physiologic outcomes were not improved with prone positioning among hypoxic but not critically ill patients hospitalized with COVID-19. Objectives: To assess the effectiveness of prone positioning to reduce the risk of death or respiratory failure in non-critically ill patients hospitalized with COVID-19 Design: Pragmatic randomized clinical trial of prone positioning of patients hospitalized with COVID-19 across 15 hospitals in Canada and the United States from May 2020 until May 2021. Settings: Patients were eligible is they had a laboratory-confirmed or a clinically highly suspected diagnosis of COVID-19, required supplemental oxygen (up to 50% fraction of inspired oxygen [FiO2]), and were able to independently prone with verbal instruction. (NCT04383613). Main Outcome Measures: The primary outcome was a composite of in-hospital death, mechanical ventilation, or worsening respiratory failure defined as requiring at least 60% FiO2 for at least 24 hours. Secondary outcomes included the change in the ratio of oxygen saturation to FiO2 (S/F ratio). Results: A total of 248 patients were included. The trial was stopped early on the basis of futility for the pre-specified primary outcome. The median time from hospital admission until randomization was 1 day, the median age of patients was 56 years (interquartile range [IQR] 45,65), 36% were female, and 90% of patients were receiving oxygen via nasal prongs at the time of randomization. The median time spent prone in the first 72 hours was 6 hours total (IQR 1.5,12.8) for the prone arm compared to 0 hours (0,2) in the control arm. The risk of the primary outcome was similar between the prone group (18 [14.3%] events) and the standard care group (17 [13.9%] events), odds ratio 0.92 (95% CI 0.44 to 1.92). The change in the S/F ratio after 72 hours was similar for patients randomized to prone compared to standard of care. Conclusion: Among hypoxic but not critically patients with COVID-19 in hospital, a multifaceted intervention to increase prone positioning did not improve outcomes. Adherence to prone positioning was poor, despite multiple efforts. Subsequent trials of prone positioning should aim to develop strategies to improve adherence to awake prone positioning.

Application of Network Meta-Analysis to Assess the Comparative Effectiveness of Oral Care Interventions in Preventing Ventilator Associated Pneumonia in Critically Ill Patients.

2020 ◽  
Author(s):  
Satheeshkumar PS ◽  
Stephen Sonis
Keyword(s):  
Usual Care ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Povidone Iodine ◽  
Meta Analysis ◽  
Oral Care ◽  
Forest Plot ◽  
Care Groups ◽  
Ranking Order ◽  
Hierarchical Assessment

Abstract Background In this research, we assessed the efficacy of a novel analytic, network metanalysis (NMA), in creating a hierarchy to define the most effective oral care intervention (OCI) for the prevention and management of ventilation-associated pneumonia (VAP). Methods We applied NMA to a previously published robust pairwise meta-analysis (PMA). Statistical analyses were based on comparing rates of total VAP events between intervention groups and placebo-usual care groups. We synthesized a netgraph, reported ranking order of the treatment and summarized our output by a forest plot with a reference treatment placebo/usual care. Results With our inclusion and exclusion critiera for the NMA we extracted 25 studies (4473 subjects). The NMA included 16 treatments, 29 pairwise comparisons and 15 designs. Based on the results of multiple comparisons with frequentist ranking probability P scores, tooth brushing (P score fixed of 0.9353, P score random of 0.8892), toothbrushing with povidone iodine (P score fixed of 0.9091, P score random 0.8801), and furacillin (P score fixed of 0.8798, P score random 0.8358) were the best three interventions for preventing VAP. Conclusion NMA appeared to be an effective platform from which multiple interventions reported in disparate clinical trials could be compared to derive a hierarchical assessment of efficacy in the intervention of VAP. According to the NMA outcome, toothbrushing alone or toothbrushing along with a potent antiseptic mouthwash povidone iodine was related to the highest response rate in preventing VAP in critically ill patients followed by furacillin and chlorhexidine 0.2%, respectively.

scholarly journals Analysis of the impact of secondary prophylaxis on Clostridioides difficile recurrence in critically ill adults

2020 ◽  
Vol 8 ◽  
pp. 205031212093089
Author(s):  
Kathryn A Connor ◽  
Kelly M Conn
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Low Dose ◽  
Secondary Prophylaxis ◽  
Infection Prophylaxis ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Critically Ill Adults ◽  
Ill Adults ◽  
Infection Recurrence

Introduction: Clostridioides (formerly Clostridium) difficile infection recurrence in patients re-exposed to antibiotics for treatment of a non- Clostridioides difficile infection is high at approximately 33%. Low-dose per os vancomycin (e.g. 125 mg q12 h) or metronidazole (e.g. 500 mg intravenous/per osq8 h) may help prevent recurrences, but study of secondary prophylaxis in critically ill patients is needed. Objectives: To determine whether critically ill adults receiving low-dose per os vancomycin for secondary Clostridioides difficile infection prophylaxis have fewer recurrences of Clostridioides difficile infection in 90 days compared with patients receiving metronidazole for secondary Clostridioides difficile infection prophylaxis or control (no secondary prophylaxis). Methods: This was a retrospective, two-center, observational study in a large academic medical center and affiliated community hospital. Included patients had a history of Clostridioides difficile infection within 1 year of receiving antibiotics for clinical care. We compared patients receiving secondary prophylaxis with vancomycin or metronidazole and control patients; in addition, an unplanned fourth group (vancomycin/metronidazole combination) was identified and analyzed. The primary outcome was Clostridioides difficile infection recurrence within 90 days of a course of broad-spectrum antibiotic therapy. Fisher’s exact, analysis of variance, and Kruskal–Wallis tests were used to compare Clostridioides difficile infection recurrence with prophylaxis group and additional contributing factors. Results: Eighty-two patients were included: 38 control (46.3%), 20 metronidazole (24.4%), 17 vancomycin (20.7%), and 7 combination (8.5%). Ten of 82 patients (12.2%) had at least one Clostridioides difficile infection recurrence; 8/38 patients in the control group (21.1%), 1/7 patients in the combination group (14.3%), 1/17 patients in the per os vancomycin group (5.9%), and 0/20 in the metronidazole group (0%; p = 0.073). As a post hoc secondary analysis, the three prophylaxis groups were coalesced into one group and compared with control (4.5% vs 21%; p = 0.039). Additional factors (e.g. age, obesity, immunosuppression, acid suppression) were not significantly associated with Clostridioides difficile infection recurrence or with prophylaxis group. Conclusion: There was no difference in Clostridioides difficile infection recurrence between prophylaxis groups, however, given the low recurrence rate, prospective evaluation with a larger sample of critically ill patients is necessary.

scholarly journals Glucose Management Technologies for the Critically Ill

2019 ◽  
Vol 13 (4) ◽  
pp. 682-690 ◽  
Author(s):  
Pedro D. Salinas ◽  
Carlos E. Mendez
Keyword(s):  
Insulin Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
New Technologies ◽  
Point Of Care ◽  
Glucose Monitoring ◽  
Standard Of Care ◽  
Optimal Method ◽  
Intravenous Insulin ◽  
Glucose Management

Hyperglycemia is common in the intensive care unit (ICU) both in patients with and without a previous diagnosis of diabetes. The optimal glucose range in the ICU population is still a matter of debate. Given the risk of hypoglycemia associated with intensive insulin therapy, current recommendations include treating hyperglycemia after two consecutive glucose >180 mg/dL with target levels of 140-180 mg/dL for most patients. The optimal method of sampling glucose and delivery of insulin in critically ill patients remains elusive. While point of care glucose meters are not consistently accurate and have to be used with caution, continuous glucose monitoring (CGM) is not standard of care, nor is it generally recommended for inpatient use. Intravenous insulin therapy using paper or electronic protocols remains the preferred approach for critically ill patients. The advent of new technologies, such as electronic glucose management, CGM, and closed-loop systems, promises to improve inpatient glycemic control in the critically ill with lower rates of hypoglycemia.

scholarly journals Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - a meta-analysis of randomized controlled trials with trial sequential analysis

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Xiaoyang Zhou ◽  
Hanyuan Fang ◽  
Jianfei Xu ◽  
Peifu Chen ◽  
Xujun Hu ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Sequential Analysis ◽  
Stress Ulcer ◽  
Meta Analysis ◽  
Trial Sequential Analysis ◽  
Gi Bleeding ◽  
Ulcer Prophylaxis ◽  
Critically Ill Adults ◽  
Ill Adults

Abstract Background Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults. Methods Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed. Results Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42–0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR = 0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR = 0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR = 0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR = 0.27; 95% CI: 0.04–2.09). Conclusions SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.

Nutrition support in critically ill adults and children

2020 ◽  
pp. 587-604
Author(s):  
Sharon Y. Irving ◽  
Liam McKeever ◽  
Vijay Srinivasan ◽  
Charlene Compher
Keyword(s):  
Critically Ill ◽  
Nutrition Support ◽  
Adults And Children ◽  
Critically Ill Adults ◽  
Ill Adults

Delirium Assessment Tools for Use in Critically Ill Adults: A Psychometric Analysis and Systematic Review

2018 ◽  
Vol 38 (1) ◽  
pp. 38-49 ◽  
Author(s):  
Céline Gélinas ◽  
Mélanie Bérubé ◽  
Annie Chevrier ◽  
Brenda T. Pun ◽  
E. Wesley Ely ◽  
...  
Keyword(s):  
Psychometric Properties ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Assessment Tools ◽  
Cognitive Test ◽  
Delirium Assessment ◽  
Nursing Delirium Screening Scale ◽  
Detection Score ◽  
Critically Ill Adults ◽  
Ill Adults

BACKGROUNDDelirium is highly prevalent in critically ill patients. Its detection with valid tools is crucial.OBJECTIVETo analyze the development and psychometric properties of delirium assessment tools for critically ill adults.METHODSDatabases were searched to identify relevant studies. Inclusion criteria were English language, publication before January 2015, 30 or more patients, and patient population of critically ill adults (>18 years old). Search terms were delirium, scales, critically ill patients, adult, validity, and reliability. Thirty-six manuscripts were identified, encompassing 5 delirium assessment tools (Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Cognitive Test for Delirium, Delirium Detection Score, Intensive Care Delirium Screening Checklist (ICDSC), and Nursing Delirium Screening Scale). Two independent reviewers analyzed the psychometric properties of these tools by using a standardized scoring system (range, 0–20) to assess the tool development process, reliability, validity, feasibility, and implementation of each tool.RESULTSPsychometric properties were very good for the CAM-ICU (19.6) and the ICDSC (19.2), moderate for the Nursing Delirium Screening Scale (13.6), low for the Delirium Detection Score (11.2), and very low for the Cognitive Test for Delirium (8.2).CONCLUSIONSThe results indicate that the CAM-ICU and the ICDSC are the most valid and reliable delirium assessment tools for critically ill adults. Additional studies are needed to further validate these tools in critically ill patients with neurological disorders and those at various levels of sedation or consciousness.

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