Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation

Implementing early mobilisation in the intensive care unit: An integrative review.

Purpose. Patients admitted to the intensive care unit (ICU) are generally confined to bed leading to limited mobility that may have
detrimental effects on different body systems. Early mobilization prevents or reduces these effects and improves outcomes in
patients following critical illness. +e purpose of this review is to summarize different aspects of early mobilization in intensive
care. Methods. Electronic databases of PubMed, Google Scholar, ScienceDirect, and Scopus were searched using a combination of
keywords. Full-text articles meeting the inclusion criteria were selected. Results. Fifty-six studies on various aspects such as the
effectiveness of early mobilization in various intensive care units, newer techniques in early mobilization, outcome measures for
physical function in the intensive care unit, safety, and practice and barriers to early mobilization were included. Conclusion: Early
mobilization is found to have positive effects on various outcomes in patients with or without mechanical ventilation. +e newer
techniques can be used to facilitate early mobilization. Scoring systems—specific to the ICU—are available and should be used to
quantify patients’ status at different intervals of time. Early mobilization is not commonly practiced in many countries. Various
barriers to early mobilization have been identified, and different strategies can be used to overcome them.

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Effectiveness, Safety, and Barriers to Early Mobilization in the Intensive Care Unit

Background and aim: Unplanned extubations (UE) are getting more and more relevant in Critical Care, becoming a quality and care safeness outcome. This happens because after an UE the patient can face some complications concerning the airway management, respiratory and hemodynamic problems, lengthen in the hospital stay and in the mechanical ventilation time.  The aim of this review is identify and classify the factors that could increase UE risk. Methodology: A systematic review of scientific articles was performed consulting the databases PubMed, Cinahl, Medline, EBSCOhost and Google Scholar. Articles from 2006 to 2011 were included. Pediatric Care settings were excluded. Results: 21 articles were selected. From the results emerged that risk factors associated to the patient are widely controversial. Yet restlessness, a low level of sedation and a high level of consciousness seem to be highly related to UE. Organizational risk factors, as workload, nurse:patient ratio, and the use of interdisciplinary protocols seem to play an important role in UE. Conclusion : According the current literature, the research on UE still has to handle a wide uncertainty. There is the need for more studies developing conclusive evidences on the role of different risk factors. Anyway, literature highlights the importance of the nurse and of the healthcare system organization in reducing UE incidence.

Unplanned Extubations in Intensive Care Unit: evidences for risk factors. A literature review.

Improving Outcomes for Critically Ill Cardiovascular Patients Through Increased Physical Therapy Staffing

Introduction:Evolving strategies for ventilator management could reduce the frequency of complications, but there is limited information about complications in contemporary intensive care units.Methods:We retrospectively collected information about patient demographics, chest x-ray abnormalities, complications, including pneumothoraces, ventilator-associated events, self-extubation, and resource utilization in 174 patients who required mechanical ventilation in 2013.Results:The mean age was 57.8 ± 16.8 years, the number of ventilator days was 7.5 ± 7, and the overall in-hospital mortality was 32.2%. The mean fluid balance per day during the mechanical ventilation period was 1539 ± 1721 mL. Three (1.7%) patients developed pneumothoraces, and 5 patients required chest tubes. Twenty-five (14.4%) patients had ventilator-associated events. Ten patients had episodes of self-extubation, and 11 had episodes of failed extubation. Chest X-rays showed new or increasing infiltrates in 113 (64.9%) patients and new or ...

Complications and Resource Utilization Associated With Mechanical Ventilation in a Medical Intensive Care Unit in 2013.

Objectives To provide a guideline for intensive care unit (ICU) early mobilization program development and implementation and to describe the patient characteristics and endpoints for those who participated in our hospital's early mobilization program. Methods An ICU early mobilization program was developed with five guiding principles: analgesia/sedation optimization, sedation minimization, protocol of progressive mobility, physical therapy and occupational therapy recruitment, and nursing education. This program began in April 2014, and the initial 32 patients who ambulated while receiving mechanical ventilation were retrospectively assessed and their characteristics described. Results After program implementation, more than 50 mechanically ventilated patients ambulated in the first year following early mobilization initiation. Patients with an FiO2 as high as 1.0 and on nonconventional modes of mechanical ventilation successfully ambulated without adverse events. The mean ambulation distance was 102 ± 152 f. and usually required three ICU staff members with 5 to 10 minutes of preparation before ambulation. After implementation, a retrospective analysis revealed a decrease in the average length of ICU stay, from 4.8 to 4.1 days. Conclusions Addressing analgesia and sedation practices, along with instituting a progressive mobility protocol and recruiting physical and occupational therapy, may serve as a guide to the creation of a successful early mobilization program. This study provides additional supportive evidence that early mobilization in the ICU is safe and effective.

Making of a Successful Early Mobilization Program for a Medical Intensive Care Unit.

Background:Recent studies suggest that patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) frequently develop hyperglycemia, which has been linked to adverse outcomes.Methods:We retrospectively collected information about patient demographics, admission diagnosis, comorbidities, use of insulin, and glucose levels and related tests in 174 patients who required mechanical ventilation for acute respiratory failure.Results:These patients had a mean age of 57.8 ± 16.8 years, a mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 13.8 ± 6.1, and an overall mortality of 32.2%. The mean number of ventilator days was 7.5 ± 7.1. The mean highest glucose level was 239.3 ± 88.9 mg/dL in patients with COPD (n = 41) and 259.1 ± 131.7 mg/dL in patients without COPD (n =133). Patients with diabetes had higher glucose levels than patients without this diagnosis (P .05). The mortality rate...

Glucose Levels in Patients With Acute Respiratory Failure Requiring Mechanical Ventilation.

The incidence of unplanned extubations per 100 intubated patients, which includes both self-extubation and accidental extubation, ranges from 0.514.2 patients. In a retrospective study of 273 patients admitted to the ICU and requiring intubation, Singh reported a 12.4% incidence of self-extubation.1 When calculated per 100 intubation days, the incidence of unplanned extubation is 0.3-4.0 per 100 days. Selfextubation, defined as a deliberate action taken by the patient to remove the endotracheal tube, accounts for 68%-95% of all unplanned extubations.2 Accidental extubation refers to any non-deliberate action, such as coughing, tube manipulation, etc., taken by either medical personnel or the patient that results in removal of the endotracheal tube.2

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Self-extubation in ICU patients

Objective: To compare the effects of a propofol-based versus dexmedetomidine-based sedation regimen for mechanically ventilated patients with sepsis. Methods: Single-center, randomized, open-label interventional study of critically ill patients admitted to the intensive care unit with sepsis and respiratory failure requiring mechanical ventilation. Patients were sedated with either propofol or dexmedetomidine. Results: Thirty-six patients with sepsis and respiratory failure requiring mechanical ventilation were randomly assigned to receive sedation with either dexmedetomidine or propofol. Fentanyl was used for analgesia in both groups. The primary end point was duration of mechanical ventilation, and secondary end points included 28-day mortality, the duration of ICU stay, and the duration of vasopressor support. There was a non-statistically significant trend toward decreased duration of mechanical ventilation in the dexmedetomidine group (p = 0.107), and multivariable analysis demonstrated a small to moderate effect size in the sample. There were no significant differences in 28-day mortality, duration of ICU stay, or duration of vasopressor requirement. No patients required discontinuation of study drug due to adverse effects. Conclusions: Although underpowered for statistical significance, there was a trend toward decreased duration of mechanical ventilation with dexmedetomidine. More studies with higher patient enrollment are needed to determine whether the duration of mechanical ventilation in patients with sepsis who receive sedation with dexmedetomidine is reduced when compared to propofol.

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Mark Sigler

Papers

Complications and Resource Utilization Associated With Mechanical Ventilation in a Medical Intensive Care Unit in 2013.

Making of a Successful Early Mobilization Program for a Medical Intensive Care Unit.

Glucose Levels in Patients With Acute Respiratory Failure Requiring Mechanical Ventilation.

Self-extubation in ICU patients

Comparison of dexmedetomidine and propofol in mechanically ventilated patients with sepsis: A pilot study