ABSTRACT
Introduction: The pressure in the endotracheal tube cuff must be kept within an optimal range, to make sure tracheal capillaries circulation still stable during positive ventilation. This is essential to avoid oral and gastric stuffing aspiration
Objective: The objective of this study was to assess the endotracheal tube cuff pressure and time intervals measurements among intensive care units patients
Methods: This study was cross sectional designed to perform on 61 patients with oral intubation in the intensive care units, Rasht educational therapeutic centers, during the summer of 2013 for three months. A manometer was used to measure the cuff pressure twice every 6 hours interval. Different variables like age, sex, diagnosis, Body Mass Index and days intubated also were measured. All data obtained were analyzed using descriptive statistics [mean, standard deviation distribution] and inferential statistics [T test, Pearson, ANOVA]
Results: This study indicated that the cuff pressure was normal in 16.4% cases at the first step and after 6 hours, cuff pressure adjustment increased by 78.7%. The results show that correlation between days intubated and cuff pressure [in first evaluation P= 0.002, in second evaluation P=0.01] and BMI [in first evaluation P=0.007, in second evaluation P=0.03 were significant
Conclusion: This study showed that despite of 6 hours cuff pressure control, the range of miss regulation was 21.3%. This issue highlights that to prevent complication due to over and under inflation of cuff, a fewer intervals between cuff pressure control is required
ABSTRACT
Introduction: Delirium is the most common neurological diagnosis among patients in intensive care units. The prevalence of delirium in the ICU patients is high and this is associated with many complications. Thus, by assessment and identifying predictive factors of delirium, its incidence can largely be prevented in intensive care units
Objective: This study aims to determine predictive factors of delirium incidence in patients hospitalized in intensive care units
Methods: This study is a descriptive-analytic study which included all patients admitted to intensive care units [neurology, general and trauma] in one of the training centers, Rasht for three months in 2013 without any symptoms and signs of delirium before hospitalization. There was no age limit for selection of samples. At least 24 hours after admission to ICU, with and without mechanical ventilation, ability to see and hear, Persian language, conscious or semi-conscious, not receiving neuromuscular blockers, coma, history of severe nerve damage [such as acute stroke, dementia, aphasia], chronic renal failure, alcohol abuse and drug abuse were the study inclusion criteria. Patients who used painkiller and sedatives during the study were excluded. Thus, samples were selected gradually considering the inclusion criteria. Based on the preliminary results with 20 samples, the study sample size was estimated 81. The tools used in this study were Richmond Agitation Sedation Scale [RASS] and Confusion Assessment Method for the Intensive Care Unit [CAM-ICU]. RASS is the standard tool to assess the level of restlessness and sedation in ICU patients. CAM-ICU examines four main characteristics of delirium; acute change or fluctuations in mental status, lack of concentration, disturbance of consciousness and unorganized thinking. The first part consisted of demographic characteristics including age, sex, Charleson comorbidity index, Acute Physiology Score [APS] in three ranges of 0-9, 10-14-and ?15, white blood cell count, serum total bilirubin, days of mechanical ventilation, and days of ICU stay and hospitalization. Charlson comorbidity index had 19 conditions in which the patient is scored based on its potential impact on mortality rate. APS is the biggest part of APATCH [Acute Physiology and Chronic Health Evaluation], obtained from 13 clinical evaluations performed 24 hours after ICU admission in which higher scores is indicative of worsening patient's physical condition. The second part consisted of examining the incidence of delirium in which patients were assessed by RASS in terms of level of consciousness. This tool consisted of 10 items, each representing one level of consciousness [of Combative to Unarousable]. To determine RASS, without any interaction, the patient was only observed and if conscious, she was scored 0 to +4. If the patient was unconscious, his/her name was called loudly and asked to look at the researcher. If the patient responded to call, appropriate score [1-3] was assigned. If there was no response, the patient's shoulder was shaken. If no response was observed, his/her sternum was strongly squeezed and appropriate score [4-5] was given. In case of no consciousness level disorder based on RASS, the subjects were assessed by CAM-ICU for examining delirium which took about 3-5 minutes. The collected data were analyzed using descriptive and analytical statistics [Fisher and chi-square]. For multivariate analysis of the associated factors with delirium, Backward Logistic Regression model was used. P<0.05 was considered the significance level. The probability of exclusion from the model was considered P< 0.1
Results: 64.2% of the subjects were male and most of them [48.1%] were hospitalized in the general ward. The majority of samples [49.4%] scored 0-9 in terms of APS. Charlson comorbidity index also showed most cases [29.6%] with 1-2 scores. The mean and SD of patients were 50.95 +/- 21.33 years, the maximum tracheal intubation days was 146 days. The maximum duration of ICU stay was 147 days and 150 days in the hospital. Furthermore, the maximum total bilirubin was 4.2 mg dl and the highest number of white blood cells was 29.2000 mg dl. Delirium was observed in 27.2% of samples using CAM-ICU. Delirium distribution was not significant based on qualitative variables; sex, ward and Charlson score whereas APS score which was significant [p=0.048]. Distribution of delirium was significant in terms of age [P=0.06]. However, it was not statistically significant in terms of the number of mechanical ventilation days, hospitalization and ICU stay, total bilirubin and white blood cell count. Based on logistic regression model, age, sex, days of tracheal intubation, ICU and hospitalization days, total bilirubin, white blood cell count, and Charlson index were not predictors of delirium. Only APS [considering the range of 0-9 scores as the reference] in two ranges of 10-14 [P<0.038] and ?15 [P<0.043] were identified as predictors of delirium. Thus, individuals with a score of APS=10-14 [OR = 3.3, 95% CI: 1.03-10.71] and APS ?15 [OR = 4.2, 95% CI: 1.08-16.7] had higher delirium compared to those with APS =0-9
Conclusion: Patients with APS points higher than those with lower scores are more likely to develop delirium
ABSTRACT
Introduction: Ventilator-associated pneumonia [VAP] is a subset of hospital infections occurring 24 hours after intubation or mechanical ventilation. Considering the outcome of VAP, prevention is of a high importance in the care of patients who are being treated by mechanical ventilation. Thus, evidence-based guidelines have been published by researchers to prevent ventilator-associated pneumonia and can effectively reduce its incidence
Objective: The purpose of this study was to review the knowledge on these evidence-based guidelines in prevention of ventilator-associated pneumonia
Method: This is a descriptive -analytical, cross-sectional study which used census sampling method. 171 nurses with bachelor and master degree participated in the study. To determine their knowledge of evidence-based guidelines for prevention of ventilator-associated pneumonia, a two-part questionnaire was used. The first part included demographic information including age, sex, nursing position title, university degree, working experience and years in the intensive care unit as well as ICU specifications such as type and number of beds and internet access. The second part had Labeau et al. questionnaire that consisted of 9 multiple-choice questions. Questionnaires were given to the participants during morning, afternoon and night shifts by a researcher in each ward. The response time was 15 minutes. After collecting the questionnaires, correct responses were calculated in percentage and the mean of total score was determined. In this study, evaluations and judgments were based on the mean of score. In order to analyze the data, descriptive statistics were used to estimate the frequency. Chi-square, t-test and ANOVA were used to examine the relationship between level of knowledge, demographic variables and characteristics of intensive care unit
Results: 171 of 219 ICU nurses participated in this study and 48 patients were excluded due to vaccation at the time of sampling or unwillingness. Most of the study population was women [93.6%] with a Bachelor's Degree [94.7%] and nurse position title [89.5%].In this study, 59.9% of the nurses had not passed any ICU-specific training course. 42.7% of them were in ICU with more than 8 beds. The majority of them [40.4%] had between 1-5 years of working experience. Furthermore, the mean score of nine one-score questions equaled 4.63 +/- 1.708. The most wrong answers belonged to the questions about "ventilator set's replacement frequency" and "the moisturizer's replacement period". The most correct answers were about "choosing a semi-sitting position for reducing VAP". Mean of scores obtained by women was higher than men. The independent t-test showed no significant difference between the two groups [P=0.721]. The mean score was higher in nurses with master degree and the ones who had passed specific ICU nursing courses than the ones who did not. Independent t-test manifested no significant difference [P=0.189, P=0.204] in this regard. Among the participants who had replacement nurse position, nurses working in ICUs with more than 8 beds and nurses with more than 10 years of experience had a higher mean score. Yet, ANOVA showed no significant difference among these groups [P =0.168, P=0.882, P=0.327]
Conclusion: This results in more attention to training purposes in some parts of the guidelines. Lack of nurses' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia is one of the potential barriers and increasing the awareness level will be the first step in a successful training program. The findings seem to highlight the importance of specific parts of the guidelines that should be considered in trainings. Lack of nurses' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia is one of the potential barriers. Increasing their awareness will be the first step for a successful training program on VAP prevention