Chlorhexidine cleaning of re-usable bougies.

Bougies are susceptible to becoming contaminated before or during use. Chlorhexidine wipes may have a residual antibacterial effect, potentially minimising bacterial transmission after bougie use or storage. We evaluated the decontaminant and antibacterial effectiveness of 70% alcohol/2% chlorhexidine wipes in laboratory, clinical and accelerated ageing studies, and conducted a telephone survey of normal practice. In the laboratory tests, chlorhexidine wipes were completely effective against Escherichia coli and methicillin-resistant Staphylococcus aureus, and prevented recontamination for 24 h. Clinical introduction of chlorhexidine wipes reduced bougie contamination from 33% to 0%. Following 150 cleaning episodes, there was no physical or functional damage to the bougies. Eight out of nine hospitals in the East of England Health Region use re-usable bougies. We recommend that following decontamination, bougies should be wiped with 70% alcohol/2% chlorhexidine wipes, to retain antimicrobial activity during handling.

Modification in prescribing practices for third-generation cephalosporins and ciprofloxacin is associated with a reduction in meticillin-resistant Staphylococcus aureus bacteraemia rate.

To decrease the incidence of hospital infections caused by meticillin-resistant Staphylococcus aureus (MRSA), an educational intervention study was performed in which the use of intravenous ciprofloxacin and third-generation cephalosporins was discouraged. The effect was assessed by observing the MRSA bacteraemia rate both within the hospital and the intensive care unit for 18 months before, and 16 months after, the two-month intervention programme. MRSA bacteraemia rate throughout the hospital was reduced by 62.9% (P<0.001) by the end of the study and MRSA colonisation rate was reduced by 38.4% (not significant). There was no concomitant decrease in episodes of bacteraemia caused by meticillin-susceptible Staphylococcus aureus (MSSA) during the study period. There was a fall in hospital dispensing of both ciprofloxacin (80.4%) and third-generation cephalosporins (75.2%). The overall incidence of MRSA bloodstream infections within critical care was reduced (4.200 vs 0.272 per 1000 occupied bed-days) but this was not significant.

Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay.

AIM: To study the factors that contribute to postoperative stay following colorectal surgery. DESIGN: A prospective observational study. SETTING: Three colorectal surgical units - a teaching hospital, a large district general hospital and a district general hospital. PARTICIPANTS: 350 patients undergoing colorectal surgery. MAIN OUTCOME MEASURES: 28 pre-, peri- and postoperative patient- and treatment-related factors. RESULTS: Stepwise regression analysis suggests that the factors that significantly lengthen postoperative stay include a low albumin on admission, stoma formation, operative blood loss, urinary and respiratory complications, wound infections, postoperative ventilation and social delay at the time of discharge. The postoperative stay was not affected by patient age or by the seniority of the surgical team. CONCLUSIONS: Factors have been identified that determine the postoperative length of stay. These data may allow better planning and treatment of patients undergoing colorectal surgery.

Gel lubrication of the tracheal tube cuff reduces pulmonary aspiration.

BACKGROUND: Leakage of fluid occurs along the longitudinal folds within the wall of an inflated high-volume, low-pressure cuff. Theoretically, lubrication of the cuff with a water-soluble gel might prevent aspiration by plugging the channels in the cuff wall. Pulmonary aspiration during anesthesia has been linked with postoperative pneumonia and during critical illness causes ventilator-associated pneumonia. METHODS: Lubricated cuffs were compared with nonlubricated cuffs for leakage of dye placed in the subglottic space to the tracheobronchial tree in a benchtop model (n = 5) and in a prospective double-blinded randomized controlled trial of anesthetized patients (n = 36). The duration of the efficacy of the lubricant was determined in a prospective open observational study of critically ill patients with tracheostomies (n = 9). Dye was detected clinically by dye coloration of secretions during tracheal suctioning. RESULTS: In the benchtop model the incidence of leakage was 0% in the lubrication group and 100% in the nonlubrication group (P < 0.01). Dye leakage in anesthetized patients was 11% in the lubrication group and 83% in the nonlubrication group (P < 0.0001). In the critically ill patients with lubricated cuffed tracheostomy tubes, leakage first occurred after a median period of 48 h (range, 24-120 h). CONCLUSIONS: Cuff lubrication with a water-soluble gel reduces pulmonary aspiration in anesthetized patients. In the critically ill patient with a tracheostomy the protective effect is lost after 24-120 h.

Out-of-hours consultant cover and case-mix-adjusted mortality in intensive care.

UK national recommendations include 24 h non-resident availability of consultants with a sessional commitment to intensive care (intensivists). We tested whether continual availability of such specialists improved standardised mortality ratios compared with non-specialist cover by anaesthetists who also cover other hospital departments. The case-mix-adjusted hospital mortality of intensive-care patients improved significantly in the intensivist group compared with the non-specialist group (standardised mortality ratios 0.81 vs 1.11 ratio 0.73 [95% CI 0.55-0.97]). Introduction of 24 h intensivist cover, therefore, seems to improve outcomes in intensive-care units.

The prevention of pulmonary aspiration with control of tracheal wall pressure using a silicone cuff.

A prospective open randomized controlled study was performed to assess the ability of Euromedical ILM endotracheal tube cuff (silicone cuff) to prevent pulmonary aspiration. The inflation characteristics of this silicone cuff enables the control of tracheal wall pressure. The silicone cuffed tube was shortened and an adjustable flange was used to convert it to a cuffed tracheostomy tube. Twelve patients requiring a tracheostomy on a four-bed intensive care unit (ICU) in a district general hospital received either a silicone or a Shiley cuffed tracheostomy tube. Tracheal wall pressures of both cuffs were maintained at 30 cm H2O with a constant pressure inflation device. Blue food dye was instilled once daily into the subglottic space through a fine catheter above the cuff. There were six patients in the Shiley group and six patients in the silicone cuff group. Dye leaked to the trachea in six (100%) of the Shiley group compared with none (0%) of the silicone cuff group (P = 0.001). This study confirms the effectiveness of this silicone cuff at preventing aspiration and the high incidence of leakage with the conventional high-volume low-pressure tracheostomy tube cuff.

Compliance characteristics of the Portex Soft Seal Cuff improves seal against leakage of fluid in a pig trachea model.

BACKGROUND: The Portex Soft Seal high-volume, low-pressure cuffed tracheal tube was compared with the Mallinckrodt HiLo, Sheridan Preformed and Portex Profile tracheal tubes for leakage of dye placed in the subglottic space of a pig's trachea which was used in a benchtop mechanical ventilation model and in six isolated pig tracheas. RESULTS: There was no leakage, either in the ventilation model or in the isolated tracheas in the Portex Soft Seal group. There was rapid leakage in the ventilation model and in all the isolated tracheas for the Mallinckrodt HiLo, and five out of six isolated tracheas for the Sheridan Preformed and the Portex Profile group. CONCLUSIONS: This benchtop study suggests that the improved compliance characteristics of the Portex Soft Seal cuff are beneficial in preventing leakage of fluid in these models.

Improving the shape and compliance characteristics of a high-volume, low-pressure cuff improves tracheal seal.

A prototype design of a compliant latex, high-volume, low-pressure cuffed tracheal tube cuff (CHVLP) was compared with the Mallinckrodt Hi-Lo, Sheridan preformed and Portex Profile high-volume, low-pressure (HVLP) cuffed tracheal tubes for leakage of dye placed above the cuff in a benchtop mechanical ventilation model and in five isolated pig tracheas. There was no leakage in the ventilation model or in the pig tracheas with the prototype CHVLP. There was rapid leakage in the ventilation model and in all the pig tracheas for the Mallinckrodt Hi-Lo, the Sheridan preformed and the Portex Profile cuffs. This benchtop study suggests that improved HVLP cuff compliance characteristics may be beneficial in the prevention of leakage of fluid to the lungs known to occur with HVLP cuffs.

Serum albumin and colloid osmotic pressure in survivors and nonsurvivors of prolonged critical illness.

We retrospectively compared the changes in serum albumin concentration and colloid osmotic pressure between survivors and nonsurvivors of prolonged (> or = 7 days) critical illness over a 2-year period from 1 July 1995. All patients had serum albumin measured daily, and colloid osmotic pressure measured 5 days a week, throughout their ICU admission. They received crystalloid and colloid infusions as well as parenteral or enteral feeding. Infusions of albumin were not used to treat hypoalbuminaemia. One hundred and forty-five patients were included, 66 nonsurvivors and 79 survivors. Nonsurvivors were significantly older than survivors [mean (95% CI): 58 (3.8) and 49 (4.1) years, respectively] and had a greater risk of death [mean (95% CI): 0.44 (0.06) and 0.28 (0.05); p < 0.05]. There was no significant difference in gender, APACHE II score [mean (95% CI): 22 (2.7) (nonsurvivors); 18 (2.3) (survivors)] or length of stay [median (interquartile range): 14 (9-27) days (nonsurvivors); 15 (9-26) days (survivors)]. There was no difference between the two groups in the absolute minimum serum albumin concentrations reached, the time to reach that minimum or the minimum in the first 7 days. However, nonsurvivors had a significantly lower mean serum albumin concentration: [mean (95% CI): 15.7 (5.1) g.l-1 compared with 18.3 (4.6) g.l-1 in survivors; p < 0.05]. They also had a lower recovery mean (the weighted mean after the minimum value): [mean (95% CI): 13.3 (5.1) g.l-1 (nonsurvivors) and 18.6 (5.3) g.l-1 (survivors); p < 0.01]. Analysis of colloid osmotic pressure results showed no difference between the groups in mean, minimum or recovery mean. Regression analysis of mean colloid osmotic pressure and albumin revealed that albumin only contributed 17% of the colloid osmotic pressure in these patients. The similar decrease in albumin in nonsurvivors and survivors may reflect the acute inflammatory response and/or haemodilution. However, survivors showed an ability to increase serum albumin concentrations, possibly owing to resumption of synthesis. The colloid osmotic pressure varied little between or within either group of patients, possibly because of the use of artificial colloids. There was no relationship between death and colloid osmotic pressure.