A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients

Introduction To compare outcomes from early post-pyloric to gastric feeding in ventilated, critically ill patients in a medical intensive care unit (ICU). Methods Prospective randomized study. Ventilated patients were randomly assigned to receive enteral feed via a nasogastric or a post-pyloric tube. Post-pyloric tubes were inserted by the bedside nurse and placement was confirmed radiographically. Results A total of 104 patients were enrolled, 54 in the gastric group and 50 in the post-pyloric group. Bedside post-pyloric tube insertion was successful in 80% of patients. Patients who failed post-pyloric insertion were fed via the nasogastric route, but were analysed on an intent-to treat basis. A per protocol analysis was also performed. Baseline characteristics were similar for all except Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was higher in the postpyloric group. There was no difference in length of stay or ventilator days. The gastric group was quicker to initiate feed 4.3 hours (2.9 - 6.5 hours) as compared to post-pyloric group 6.6 hours (4.5 - 13.0 hours) (P = 0.0002). The time to reach target feeds from admission was also faster in gastric group: 8.7 hours (7.6 - 13.0 hours) compared to 12.3 hours (8.9 - 17.5 hours). The average daily energy and protein deficit were lower in gastric group 73 Kcal (2 - 288 Kcal) and 3.5 g (0 - 15 g) compared to 167 Kcal (70 - 411 Kcal) and 6.5 g (2.8 - 17.3 g) respectively but was only statistically significant for the average energy deficit (P = 0.035). This difference disappeared in the per protocol analysis. Complication rates were similar. Conclusions Early post-pyloric feeding offers no advantage over early gastric feeding in terms of overall nutrition received and complicationsGriffith Health, School of MedicineFull Tex

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

An in vitro analysis of the effect of acidosis on coagulation in chronic disease states - a thromboelastograph study

Thrombosis is a complication of many chronic illnesses. Chronic obstructive pulmonary disease (COPD) and diabetes mellitus are common medical conditions frequently associated with a hypercoagulable state. Acidaemia has been shown to reduce coagulation. COPD and diabetes mellitus during acute deterioration can present with a severe acidaemia. The impact of this acidaemia on coagulation is poorly studied. Patients presenting with a diagnosis of diabetic ketoacidosis or type II respiratory failure from COPD and a pH of less than 7.2 were included in our study. A coagulation screen and a thromboelastograph (TEG) were performed on admission and 24 hours later. The mean pH on admission was 7.07 and mean base excess was –16.3. The activated partial thromboplastin time was associated with pH change but remained within the normal range (26–41 s). All other coagulation and TEG parameters failed to show evidence of association (p>0.05). In the two models of non-haemorrhagic acidosis investigated, coagulation was not altered by the changes in pH. More work is needed to understand the complex relationship between factors affecting coagulation in individual disease processes

Early rehabilitation in the intensive care unit: An integrative literature review

Objectives: The aim of this review is to appraise current research which examines the impact of early rehabilitation practices on functional outcomes and quality of life in adult intensive care unit (ICU) survivors. Review method used: A systematic literature search was undertaken; retrieved data was evaluated against a recognised evaluation tool; research findings were analysed and categorised into themes; and a synthesis of conclusions from each theme was presented as an integrated summation of the topic. Data sources: Electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline and Google Scholar were searched using key search terms ‘ICU acquired weakness’, ‘early rehabilitation’ ‘early mobility’ and ‘functional outcomes’ combined with ‘intensive care’ and ‘critical illness’. Additional literature was sourced from reference lists of relevant original publications. Results: Five major themes related to the review objectives emerged from the analysis. These themes included: critically ill patients do not always receive physical therapy as a standard of care; ICU culture and resources determine early rehabilitation success; successful respiratory and physical rehabilitation interventions are tailored according to individual patient impairment; early exercise in the ICU prevents the neuromuscular complications of critical illness and improves functional status; early exercise in the ICU is effective, safe and feasible. Conclusions: A limited body of research supports early rehabilitation interventions to optimise the short term outcomes and long term quality of life for ICU survivors. Critical care nurses are in an excellent position to drive change within their departments ensuring that early rehabilitation practices are adopted and implemented.Griffith Health, School of MedicineNo Full Tex

The utility of thromboelastography in monitoring low molecular weight heparin therapy in the coronary care unit

Low molecular weight heparins (LMWHs) are used for prevention and management of vascular thrombosis. In general, monitoring of anticoagulant activity is not required, however, certain populations may be susceptible to overdosing or underdosing. As anti-activated factor X(anti-Xa) activity testing is not readily available, it was our aim to investigate the usefulness of thromboelastography (TEG; Haemoscope Corporation, Skokie, Illinois, USA) for the assessment of coagulation in patients on LMWH. All patients admitted to the coronary care unit on therapeutic dose of enoxaparin were included (1 mg/kg twice daily). Blood samples were collected 4 h after the morning dose of enoxaparin once the participant had received at least three doses. When anti-Xa activity was classified as low (0-0.5), correct (0.5-1.0) or high (>1.0), the distribution of reaction time (R) and dose per kg showed little association with anti-Xa activity. The difference between mean R for the high anti-Xa group and the correct anti-Xa group was statistically nonsignificant using two-sample t-test (P=0.26). A linear regression model showed no evidence of association between dose per kg and anti-Xa (P=0.95). However, there was evidence of positive association between dose per kg and R (P=0.011) wherein a 10% increase in dose per kg was associated with an increase in R of 2.7 (95% confidence interval 0.6-4.7). There was no evidence of association between R and anti-Xa (P=0.38). TEG was unable to be used to predict anti-Xa activity. However, TEG R was prolonged in more than 90% patients and correlated with dose of enoxaparin. As enoxaparin dose correlated poorly with anti-Xa activity, a more global test might be necessary to adjust dosing of LMWH in sick, hospitalized patients

Short-notice (48 hours) ACCREDITATION trial in Australia: stakeholder perception of assessment thoroughness, resource requirements and workforce engagement

BackgroundExternal, independent accreditation assessments of healthcare organisations are necessary to ensure the nationally legislated minimum standards of quality and safety (QS) are met. The predetermined scheduling of the assessments continues to be criticised due to the high level of organisational emphasis on preparing for accreditation.ObjectivesTo determine the stakeholder perception of assessment thoroughness, staff resource requirements and workforce engagement changes if only 48 hours’ notice is given to an organisation prior to an accreditation assessment, compared with the standard-notice accreditation process.MethodsLogan and Beaudesert Hospitals in Brisbane, Australia, trialled the ‘Short-Notice Survey Accreditation Assessment Process’ (SNAAP) between August 2017 and December 2018. The organisation was given just 48 hours’ notice prior to an accreditation assessment. Staff perception of the standard-notice accreditation process and short-notice process was assessed using a 5-point Likert scale repeated measures questionnaire (pretrial, 6 and 12 months after SNAAP launch).ResultsThere was a statistically significant stakeholder opinion that SNAAP more effectively identified the true strengths and achievements of the organisation’s QS compared with ‘standard-notice’ survey (p=0.033). There was a significantly lower overall perceived proportion of staff resources required for SNAAP preparation in contrast to ‘standard-notice’ process (Baseline Av=21.38% vs Follow-up 1 and 2 Av=9.75%–6.25%, p=0.021). The questionnaire results reflected that SNAAP increased staff engagement in QS activities (Av=3.75 and 3.69, 95% CI=3.45–4.05 and 3.45–3.94).ConclusionsWith sufficient cultural and operational preparation to move to SNAAP, hospitals can potentially use SNAAP as a truer validation of QS standards, require less staffing resources to prepare for accreditation assessments and improve staff engagement in QS assurance and improvement.</jats:sec

Short-notice (48 hours) ACCREDITATION trial in Australia: stakeholder perception of assessment thoroughness, resource requirements and workforce engagement

Background External, independent accreditation assessments of healthcare organisations are necessary to ensure the nationally legislated minimum standards of quality and safety (QS) are met. The predetermined scheduling of the assessments continues to be criticised due to the high level of organisational emphasis on preparing for accreditation.Objectives To determine the stakeholder perception of assessment thoroughness, staff resource requirements and workforce engagement changes if only 48 hours’ notice is given to an organisation prior to an accreditation assessment, compared with the standard-notice accreditation process.Methods Logan and Beaudesert Hospitals in Brisbane, Australia, trialled the ‘Short-Notice Survey Accreditation Assessment Process’ (SNAAP) between August 2017 and December 2018. The organisation was given just 48 hours’ notice prior to an accreditation assessment. Staff perception of the standard-notice accreditation process and short-notice process was assessed using a 5-point Likert scale repeated measures questionnaire (pretrial, 6 and 12 months after SNAAP launch).Results There was a statistically significant stakeholder opinion that SNAAP more effectively identified the true strengths and achievements of the organisation’s QS compared with ‘standard-notice’ survey (p=0.033). There was a significantly lower overall perceived proportion of staff resources required for SNAAP preparation in contrast to ‘standard-notice’ process (Baseline Av=21.38% vs Follow-up 1 and 2 Av=9.75%–6.25%, p=0.021). The questionnaire results reflected that SNAAP increased staff engagement in QS activities (Av=3.75 and 3.69, 95% CI=3.45–4.05 and 3.45–3.94).Conclusions With sufficient cultural and operational preparation to move to SNAAP, hospitals can potentially use SNAAP as a truer validation of QS standards, require less staffing resources to prepare for accreditation assessments and improve staff engagement in QS assurance and improvement

Multi-disciplinary evaluation of an ICU enteral feeding algorithm

No Full Tex

Effectiveness of the ABCDEF bundle on delirium, functional outcomes and quality of life in intensive care patients: a study protocol for a randomised controlled trial with embedded process evaluation

IntroductionHospital mortality for critically ill patients has decreased significantly throughout the developed world over the past two decades, attributable to improvements in the quality of intensive care, advances in critical care medicine and technologies that provide long-term multiorgan support. However, the long-term outcomes of intensive care unit (ICU) survivors is emerging as a real issue. Cognitive and physical impairments suffered by ICU survivors are common including profound weakness, pain and delirium which are inextricably linked. This study aims to determine the effectiveness of the Assess, prevent and manage pain; Both spontaneous awakening and spontaneous breathing trials; Choice of sedation and analgesia; Delirium: assess, prevent and manage; Early mobility and exercise; Family engagement and empowerment (ABCDEF) bundle in reducing ICU-related short-term and long-term consequences of critical illness through a randomised controlled trial (RCT).Methods and analysisThe study will be a single-centre, prospective RCT. A total of 150 participants will be recruited and randomised to either receive the ABCDEF bundle protocol or non-protocolised standard care for the duration of the participant’s admission in the ICU. The primary outcome is delirium status measured using the Confusion Assessment Measure for ICU (CAM-ICU). Secondary outcomes include physical function measured by the Functional Independence Measure and quality of life measured by the European Quality of Life five dimensions, five-level questionnaire. A mixed-method process evaluation will contribute to understanding the experience of health teams who implement the ABCDEF bundle into practice.Ethics and disseminationEthics approval was provided by the Metro South Health Human Research Ethics Committee (HREC) (EC00167) and the Griffith University’s HREC prior to study commencement.Study results will be disseminated by presentations at conferences and via publications to peer-review journals.Trial registration numberACTRN12620000736943; Pre-results.</jats:sec