Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure: A Randomized Clinical Trial

Physical rehabilitation in the intensive care unit (ICU) may improve the outcomes of patients with acute respiratory failure.  This US single centre randomised controlled trial compared standardized rehabilitation therapy (SRT) to usual ICU care in acute respiratory failure.  It was published in JAMA on the 28th June 2016.

Adult patients (mean age, 58 years; women, 55%) admitted to the ICU with acute respiratory failure requiring mechanical ventilation were randomized to SRT (n=150) or usual care (n=150) with 6-month follow-up. Patients in the SRT group received daily therapy until hospital discharge, consisting of passive range of motion, physical therapy, and progressive resistance exercise. The usual care group received weekday physical therapy when ordered by the clinical team.

The primary outcome was hospital length of stay (LOS) with secondary outcomes including ventilator days, ICU days and Short Physical Performance Battery (SPPB) score.  Among 300 randomized patients, the median hospital LOS was 10 days (IQR, 6 to 17) for the SRT group and 10 days (IQR, 7 to 16) for the usual care group (median difference, 0 [95% CI, -1.5 to 3], P = .41).  For the secondary indicators the SRT group showed a statistically significant improvement in some but not in others.

The trial concluded that amongst patients hospitalized with acute respiratory failure, SRT compared with usual care did not decrease hospital length of stay.

This journal is available to read in the healthcare library on Level D of the hospital or the full text can be accessed via this link which does not require a password.

Sepsis: recognition, diagnosis and early management NICE guideline

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This guideline covers the recognition, diagnosis and early management of sepsis for all populations. The guideline committee identified that the key issues to be included were: recognition and early assessment, diagnostic and prognostic value of blood markers for sepsis, initial treatment, escalating care, identifying the source of infection, early monitoring, information and support for patients and carers, and training and education.  This guideline is it for people with sepsis, their families and carers as well as healthcare professionals working in primary, secondary and tertiary care

This NICE guideline (NG51) was published in July 2016 with the full text available via this link.

First World Sepsis Congress: Online only 8th & 9th September 2016

The 1st World Sepsis Congress will take place completely online on September 8th and 9th, 2016, as a prelude and introduction to the fifth World Sepsis Day on September 13th, 2016.  Participation is open to everyone with an internet connection and is free of charge.

The first day commences with a session on “Sepsis a Global health Threat” followed by four sessions including prevention and patient safety and quality improvement.  The second day includes eight sessions including a discussion on the evidence base, pathogen detection and long term consequences.

For more details on the congress including how to participate follow this link

Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endoctrachael Intubation in Patients with Acute Respiratory Distress Syndrome: A Randomized Clinical Trial

Noninvasive ventilation with a face mask at preventing is relatively ineffective at preventing endotracheal intubation in patients with acute respiratory distress syndrome (ARDS).  Delivery of NIV with a helmet may be a superior strategy for these patients.  This RCT compared delivery by helmet vs face mask.  Amongst patients with ARDS, treatment with helmet NIV resulted in a significant reduction of intubation rates.  There was also a significant reduction in ninety day mortality with helmet NIV.

This trial was published in JAMA volume 315 number 22 14th June 2016.  It is available in print in the Healthcare Library on Level D of the hospital.  A full abstract and the full text for those with a personal subscription is available via this link.

Low Dose versus Standard Dose Intravenous Alteplase in Acute Ischemic Stroke

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Thrombolytic therapy for acute ischemic stroke with a lower than standard dose of intravenous alteplase may improve recovery.  It may also reduce the risk of intracerebral haemorrhage.  This randomised control trial compared low dose intravenous alteplaste (0.6 mg per kilogram of body weight) or the standard dose (0.9mg per kilogram).  Outcomes measured considered included the modified Rankin scale score to measure the degree of disability as well as mortality and intracerebral haemorrhage.  The trial did not show the noninferiority of low dose alteplaste to standard dose alteplaste with respect to death and disability at ninety days.  There were significantly fewer sympotomatic intracerebral hemorrhages with the low dose.

This study was published in the New England Journal of Medicine 16th June 2016, volume 374 number 24 pages 2313-23.  It is available in the healthcare library on Level D of the hospital.  You can view a full abstract or if you have a personal subscription the full text via this link.

Results of Implementing a Pain Management Algorithm in Intensive Care Unit Patients

Olsen, B.F. et al. Journal of Critical Care.Published online: 16 July 2016

B0003338 Artwork - pain and disturbance
Image source: Chris Nurse – Wellcome Images // CC BY-NC-ND 4.0

Image shows artwork representing pain and disturbance

Purpose: To measure the impact of implementing a pain management algorithm in adult intensive care unit (ICU) patients able to express pain. No controlled study has previously evaluated the impact of a pain management algorithm both at rest and during procedures, including both patients able to self-report and express pain behavior, intubated and non-intubated patients, throughout their ICU stay.

Materials and methods: The algorithm instructed nurses to assess pain and guided in pain treatment, and was implemented in three units. A time period after implementing the algorithm (intervention group) was compared with a time period the previous year (control group) on the outcome variables pain assessments, duration of ventilation, length of ICU stay, length of hospital stay, use of analgesic and sedative medications, and the incidence of agitation events.

Results: Totally 650 patients were included. The number of pain assessments was higher in the intervention group compared with the control group. Additionally, duration of ventilation and length of ICU stay decreased significantly in the intervention group compared with the control group. This difference remained significant after adjusting for patient characteristics.

Conclusion: Several outcome variables were significantly improved after implementation of the algorithm compared with the control period.

Read the abstract here

Treatment of Meningococcal Disease

Nadel, S. Journal of Adolescent Health. Volume 59(2). pp. S21-S28

Abstract

B0001735 Ultrasonic meningitis test - positive sample
Image source: Dr Mike Sobanski – Wellcome Images // CC BY-NC-ND 4.0

Image shows a positive test result for meningitis using the ultrasound enhanced diagnostic test

Meningococcal disease is a life-threatening infection that may progress rapidly, even after appropriate treatment has commenced. Early suspicion of the diagnosis is vital so that parenteral antibiotic treatment can be administered as soon as possible to reduce the complications of infection. The outcome of meningococcal disease is critically dependent on prompt recognition of two important complications: shock and raised intracranial pressure. Rapid recognition of disease and of these complications, together with appropriate management is crucial to the outcome of affected patients. This article summarizes the clinical features of invasive meningococcal disease, diagnostic tools, treatment modalities, and common post-infection sequelae.

Read the full article here

Views from the NHS frontline: Intensive Care Nurse

The Guardian. Published online: 25 July 2016

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My job as an intensive care nurse has made me realise that life is fleeting, fragile and unpredictable

“There’s a lot people don’t know about dying.

Most people are terrified of it. We don’t talk about it, and when we do it’s with hushed voices and delicate words. Most of us are blissfully ignorant until it forces us to take notice of it, whether it be because of a terminal illness, a fatal car accident or a loved one snatched from our lives. We are woefully unprepared for it. What are we supposed to do? What should we say? You never imagine it happening to you.

It is a sensitive subject, because deep down we know that it is the one thing in all our lives that is inevitable. Death does not discriminate, and it makes every single one of us equal. I was terrified of it too, but after seven years as an intensive care nurse I am familiar enough with death to be able to see it differently to most.

Death is ugly. It’s not glamorous, and most people do not close their eyes and slip away peacefully at home in their beds, surrounded by loving family. The death I see comes with plastic tubes and cannulas shoved into oozing blood vessels, giant machines that hiss, click and shriek alarms as they mechanise the life of a human being, and a rainbow of bad smells. It comes with cheap fabric curtains, stiff white sheets and sunken, fluid-swollen skin. It comes with an unexpected phone call that drags you from your bed into cold and uncomfortable waiting rooms at 3am. Even if it is expected, it still comes with an icy shock and a deep, gut-wrenching sadness.”

Read the full news article here

Mechanical ventilation strategies for intensive care unit patients without acute lung injury or acute respiratory distress syndrome

Guo, L. et al. Critical Care. Published online: 22 July 2016.

Background: It has been shown that the application of a lung-protective mechanical ventilation strategy can improve the prognosis of patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). However, the optimal mechanical ventilation strategy for intensive care unit (ICU) patients without ALI or ARDS is uncertain. Therefore, we performed a network meta-analysis to identify the optimal mechanical ventilation strategy for these patients.

Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, MEDLINE, CINAHL, and Web of Science for studies published up to July 2015 in which pulmonary compliance or the partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FIO2) ratio was assessed in ICU patients without ALI or ARDS, who received mechanical ventilation via different strategies. The data for study characteristics, methods, and outcomes were extracted. We assessed the studies for eligibility, extracted the data, pooled the data, and used a Bayesian fixed-effects model to combine direct comparisons with indirect evidence.

Results: Seventeen randomized controlled trials including a total of 575 patients who received one of six ventilation strategies were included for network meta-analysis. Among ICU patients without ALI or ARDS, strategy C (lower tidal volume (VT) + higher positive end-expiratory pressure (PEEP)) resulted in the highest PaO2/FIO2 ratio; strategy B (higher VT + lower PEEP) was associated with the highest pulmonary compliance; strategy A (lower VT + lower PEEP) was associated with a shorter length of ICU stay; and strategy D (lower VT + zero end-expiratory pressure (ZEEP)) was associated with the lowest PaO2/FiO2 ratio and pulmonary compliance.

Conclusions: For ICU patients without ALI or ARDS, strategy C (lower VT + higher PEEP) was associated with the highest PaO2/FiO2 ratio. Strategy B (higher VT + lower PEEP) was superior to the other strategies in improving pulmonary compliance. Strategy A (lower VT + lower PEEP) was associated with a shorter length of ICU stay, whereas strategy D (lower VT + ZEEP) was associated with the lowest PaO2/FiO2 ratio and pulmonary compliance.

Read the full article here

High dose vitamin D administration in ventilated intensive care unit patients: A pilot double blind randomized controlled trial

This trial is reported in the latest issue of the Journal of Clinical and Translational Endocrinology (Volume 4, June 2016).  It is the first double blind RCT of vitamin D therapy in mechanically ventilated patients.  It demonstrated that treatment with placebo, 250,000 IU or 500,000 IU enteral vitamin D3 was well tolerated.  Results showed a significant increase in plasma 25(OH)D from baseline to day 7, significant decrease in hospital length of stay for vitamin D3 treated subjects and no change in plasma LL-37 according to treatment group.

The full text of the article is available freely via this internet link.