Effect of synbiotic therapy on the incidence of ventilator associated pneumonia in critically ill patients: a randomised, double-blind, placebo-controlled trial.

OBJECTIVE: To investigate the effect of enteral Synbiotic 2000 FORTE (a mixture of lactic acid bacteria and fibre) on the incidence of ventilator associated pneumonia (VAP) in critically ill patients. DESIGN: Prospective, randomised, double blind, placebo controlled trial. SETTING: Tertiary referral centre, general Adult Intensive Care Unit (ICU). PATIENTS AND PARTICIPANTS: 259 enterally fed patients requiring mechanical ventilation for 48 h or more were enrolled. INTERVENTION: All patients were enterally fed as per a standard protocol and randomly assigned to receive either synbiotic 2000 FORTE (twice a day) or a cellulose-based placebo for a maximum of 28 days. MEASUREMENTS AND RESULTS: Treatment group (n = 130) was well matched with placebo group (n = 129) for age (mean 49.5 and 50 years, respectively) and APACHE II score (median 17 for both). Oropharyngeal microbial flora and colonisation rates were unaffected by synbiotics. The overall incidence of VAP was lower than anticipated (11.2%) and no statistical difference was demonstrated between groups receiving synbiotic and placebo in the incidence of VAP (9 and 13%, P = 0.42), VAP rate per 1,000 ventilator days (13 and 14.6, P = 0.91) or hospital mortality (27 and 33%, P = 0.39), respectively. CONCLUSIONS: Enteral administration of Synbiotic 2000 FORTE has no statistically significant impact on the incidence of VAP in critically ill patients.

Improving performance in the management of severely injured patients in critical care.

OBJECTIVE: To determine opportunities for improvement (OI) in the critical care management of severely injured patients in a general adult intensive care unit through a performance improvement (PI) process. METHODS: Retrospective review of patient records from intensive care patients who had sustained traumatic injuries, except isolated head injury, over a 1-year period. Three assessors independently audited the notes using performance improvement methodology to determine complications, errors in management and preventability. Complications were included when two or more assessors independently detected the complication. MEASUREMENTS AND RESULTS: Records from 90 patients with a diagnosis of 'trauma' were reviewed, 14 patients with isolated head injury were excluded. The mean injury severity score was 23 (range 4-43). No complications or errors of management were identified from 41 patients, including ten patients who died. Seventy-two complications were identified in 35 patients including 15 pneumonias, 6 cases of peri-operative hypothermia and 5 recurrent pneumothoraces. Fourteen preventable complications were identified. CONCLUSIONS: The PI OI process highlighted specific opportunities for the improvement of critical care management of trauma patients in our unit. These will be addressed through the introduction of formal tertiary surveys and clinical management guidelines addressing hypothermia and management of coagulopathy.