[Continuous monitoring of endotracheal tube cuff pressure: best practice in intensive care unit]. / Il monitoraggio pressorio continuo della cuffia del tubo endotracheale: best practice in terapia intensiva.

INTRODUCTION: The endotracheal tube cuff pressure must be maintained within an optimal range of 20-30 cmH2O, which ensures ventilation, prevents aspiration of secretions and guarantees a good tracheal perfusion. AIMS: To describe changes in the endotracheal tube cuff pressure over time through a continuous monitoring device, and assess the number of nursing actions. METHODS: Observation of 72 patients admitted to a general ICU and monitored for 12 hours, with a continuos monitoring device of endotracheal tube cuff pressure (PressureEasy(®)). RESULTS: During the first four hours 4 cases (5.6%) of underinflated cuff were observed, and 5 (6.9%) of overinflation. From the fifth to the eighth hour 7 (9.7%) patients showed a pressure <20 cmH2O, and 3 (4.2%) >30 cmH2O. During the last four hours 22 cases (30.5%) of underinflated cuff, and 4 (5.6%) of overinflation were observed. More than half of the patients (n=38, 52.8%) did not require any intervention of inflation or deflation of the cuff, 25 (34.7%) only one and 7 (9.7%) patients two, and twe patients, three. The majority of patients required the inflation of the cuff. CONCLUSION: Our study supports the need of continuous endotracheal tube cuff pressure monitoring to promptly identify deviations from the pressure ranges, allowing their rapid correction.

Cardiovascular aspects of septic shock: pathophysiology, monitoring, and treatment.

The care of patients with septic shock is exceedingly complex. New therapies and monitoring technologies are being rapidly developed. To create an effective plan of care that integrates these new therapies and technologies, critical care nurses must understand the underlying pathophysiology of septic shock, techniques to accurately monitor patients' status, and the rationale for care.

A comparison of gastric and rectal CO2 in cardiac surgery patients.

Critical care nurses assess and treat clinical conditions associated with inadequate oxygenation. Changes in regional organ (gut) blood flow are believed to occur in response to a decrease in oxygenation. Although the stomach is a widely accepted monitoring site, there are multiple methodological and measurement issues associated with the gastric environment that limit the accuracy of P CO2 detection. The rectum may provide nurses with an alternative site for monitoring changes in P CO2 without the limitations associated with gastric monitoring. This pilot study used a repeated measures design to examine changes in gastric and rectal P CO2 during elective coronary artery bypass grafting with cardiopulmonary bypass (CPB) and in the immediate 4-hr postoperative period in 26 subjects. The systemic indicators explained little variation in the regional indicators during protocol. A comparison of rectal and gastric P CO2 revealed no statistically significant differences in the direction or magnitude of change over any phase of cardiac surgery (baseline, CPB, post-CPB). A reduction in both rectal and gastric P CO2 occurred during CPB, and both values trended upward during the post-CPB phase. However, poor correlation and agreement was found between the measures of P CO2 at the two sites. Although clinically important, the cause is unclear. Possible explanations include variation in CO2 production between the gastric and rectal site, differences in sensitivity of the two monitoring instruments, or the absence of hemodynamic complications, which limited the extent of change in P CO2. Further investigation using patients with more profound changes in oxygenation are needed to identify response patterns and possible mechanisms.

Measuring the pressure applied to the skin surrounding pressure ulcers while patients are nursed in the 30 degree position.

The 30 degree laterally inclined and 30 degree head elevated positions (hereafter referred as the 'rule of 30' unless otherwise specified) are widely used as a means of both primary and secondary prevention of pressure ulcers as a result of reductions in localised pressures over bony prominences. However, the authors observed that some some parts of the wound margin were thickened. These thickened edges may be caused by use of the rule of 30 positioning and may also be responsible for a delay in the healing process. This study included five bedbound elderly patients with pressure ulcers located at the sacrum and coccyx. The local pressure was measured at the thickened edges and normal edges of the subjects' wounds by a newly developed sensor while the subjects were positioned according to the rule of 30. The results showed the maximum pressure as well as the average pressure of the thickened edges to be significantly greater than that of the normal edges. Thus, it is suggested that higher pressure on different areas of the wound margin may be responsible for the thickened edges phenomenon, which may consequently delay the healing process. Clinical use of the rule of 30 for patients with pressure ulcers in the sacrum and coccyx regions should be reconsidered.

The Minnesota tube: its use and care in bleeding esophageal and gastric varices.

A variety of treatments are available for bleeding esophageal varices. Treatments include pharmacologic (propanolol, somatostatin, octreotide, vasopressin, and nitroglycerin), endoscopic (injection sclerotherapy and banding), vascular (transjugular intrahepatic portosystemic shunt), surgical (portovariceal disconnection and portosystemic shunts), and tamponade (via use of the Minnesota tube). This article will focus on use and care of the Minnesota tube, including numerous suggestions from the literature. Tamponade for treatment of esophageal varices may be accompanied by numerous complications, some of which are major or lethal. For this reason, extreme caution should be used when implementing this method. While hemostasis is not achievable via tamponade in 8-50% of patients and 50% of patients rebleed, use of tamponade may achieve stabilization of a patient so that sclerotherapy or surgery becomes a treatment option.

Gastric tonometry and monitoring gastrointestinal perfusion: using research to support nursing practice.

The principles and physiological underpinnings of gastric tonometry are reviewed. Tonometric variables, including the PtCO2, pHi and CO2 gap, are described and critiqued as measurements of gastrointestinal perfusion. Increases in gastrointestinal CO2 unrelated to gastrointestinal hypoperfusion are discussed within different clinical contexts. The technical limitations of gastric tonometry, including procedural errors and PtCO2 measurement are discussed in relation to the accuracy of tonometric measurements. Tonometric measurement using semi-continuous air tonometry is introduced as a strategy to minimize technical limitations.

Two devices that facilitate the use of the Minnesota tube.

Two devices that facilitate the use of the Minnesota tube (C. R. Bard, Covington, GA) are described in this article. One device is the Lopez enteral valve (ICU Medical, San Clemente, CA), a three-way stopcock-like device that facilitates inflation of the gastric balloon with air, as measured by a 60-mL Foley-tip syringe. The second device is a handheld aneroid manometer with integral bulb and valve (Tycos, Welch Allyn) that can be easily attached directly to the Y-set of the esophageal and gastric balloons for continuous monitoring of pressure. The enhanced ease of continuous monitoring of balloon pressures helps prevent complications, ensure hemostasis, and facilitate better patient outcomes.

Nursing care for raised intra-abdominal pressure and abdominal decompression in the critically ill.

Abdominal assessment is one of a number of continuous assessments that critical care nurses undertake. Since 1988 in the Department of Critical Care Medicine (DCCM), the technique of abdominal decompression has become another therapy for severe critical illness. The critical care nurse requires to have an understanding of raised intra-abdominal pressure assessment, pressure measurement and the care of abdominal polypropylene mesh insertion in the critical care setting. Our experience has been that the use of polypropylene mesh insertion halved since 1993. A retrospective study (Torrie et al. 1996) of 68 occasions (64 patients) of polypropylene mesh insertion, showed that seven patients developed fistulas and 32 patients died. There was no dehiscence of the mesh from the fascia. Forty-two wounds had primary fascial closure (28 with primary skin closure, 3 with secondary skin closure, 11 left to granulate) and 3 of them later dehisced. At follow-up (27 patients, median 7.5 months), 6 had stitch sinuses, and 5 had incisional hernias. Care of patients with polypropylene mesh inserted requires vigilant nursing practice but decompression of raised intra-abdominal pressure can be life-saving and complications are manageable.

Three-dimensional imaging of the anal sphincter: a new approach to anorectal manometry.

Anorectal dysfunction can be an extreme embarrassment and inconvenience to persons afflicted with the condition, disrupting their lifestyle. Evaluation of the anal sphincter and the distinction between muscular and neural etiology is essential. Three-dimensional imaging of the anal sphincter by use of anorectal manometry with an eight-port perfused catheter combined with computer analysis aids in defining anal sphincter function. The use of three-dimensional imaging is valuable to the physician in the determination of the presence of a muscular defect, the location of the defect and the appropriateness of surgical intervention to resolve the anal dysfunction.

Preparing children for endoscopy and manometry.

Properly preparing children for endoscopy and manometry contributes to the child's ability to cope and to the nurse's efficiency and effectiveness. Therapeutic play has been documented as the ideal way to prepare children for procedures. Because of time limitations, therapeutic play is not always an alternative in the endoscopy unit. Knowledge of the different developmental stages of childhood is helpful in preparing children for procedures. The nurse's approach and preparation of the child are based on her assessment of the child's developmental age, cognitive level, past experiences and coping skills. Using her assessment of the child, the nurse establishes trust with the child and the parent prior to beginning preparation of the child. A brief overview of the abilities and needs of the infant, toddler, preschooler and school age child is presented. Suggestions are made for nursing intervention before and during the endoscopic procedure or esophageal manometry.