Impact of extended lung protection during mechanical ventilation on lung recovery in patients with COVID-19 ARDS: a phase II randomized controlled trial.

BACKGROUND: Protective ventilation seems crucial during early Acute Respiratory Distress Syndrome (ARDS), but the optimal duration of lung protection remains undefined. High driving pressures (ΔP) and excessive patient ventilatory drive may hinder lung recovery, resulting in self-inflicted lung injury. The hidden nature of the ΔP generated by patient effort complicates the situation further. Our study aimed to assess the feasibility of an extended lung protection strategy that includes a stepwise protocol to control the patient ventilatory drive, assessing its impact on lung recovery. METHODS: We conducted a single-center randomized study on patients with moderate/severe COVID-19-ARDS with low respiratory system compliance (CRS < 0.6 (mL/Kg)/cmH2O). The intervention group received a ventilation strategy guided by Electrical Impedance Tomography aimed at minimizing ΔP and patient ventilatory drive. The control group received the ARDSNet low-PEEP strategy. The primary outcome was the modified lung injury score (mLIS), a composite measure that integrated daily measurements of CRS, along with oxygen requirements, oxygenation, and X-rays up to day 28. The mLIS score was also hierarchically adjusted for survival and extubation rates. RESULTS: The study ended prematurely after three consecutive months without patient enrollment, attributed to the pandemic subsiding. The intention-to-treat analysis included 76 patients, with 37 randomized to the intervention group. The average mLIS score up to 28 days was not different between groups (P = 0.95, primary outcome). However, the intervention group showed a faster improvement in the mLIS (1.4 vs. 7.2 days to reach 63% of maximum improvement; P < 0.001), driven by oxygenation and sustained improvement of X-ray (P = 0.001). The intervention group demonstrated a sustained increase in CRS up to day 28 (P = 0.009) and also experienced a shorter time from randomization to room-air breathing (P = 0.02). Survival at 28 days and time until liberation from the ventilator were not different between groups. CONCLUSIONS: The implementation of an individualized PEEP strategy alongside extended lung protection appears viable. Promising secondary outcomes suggested a faster lung recovery, endorsing further examination of this strategy in a larger trial. Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT04497454) on August 04, 2020.

Surgical counts in open abdominal and pelvic surgeries in a university hospital: a best practice implementation project.

INTRODUCTION: Counting of accountable items used during surgery, frequently called 'the count', is a fundamental practice to ensure that items such as surgical instruments, sponges and sharps are not forgotten within patients. Although inadvertently leaving behind a sponge or instrument at the end of an operation is a rare event, it is an error that may have serious implications. OBJECTIVES: The aim of this evidence implementation project was to contribute to promoting evidence-based practice in surgical counts in open abdominal and pelvic surgeries and thereby improving the outcomes of the surgical patients at a surgical centre of a university hospital. METHODS: The current evidence implementation project used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice (GRiP) audit and feedback tool. The JBI Practical Application of Clinical Evidence System and GRiP framework for promoting evidence-based healthcare involves three phases of activity: first, establishing a project team and undertaking a baseline audit based on evidence-informed criteria; second, reflecting on the results of the baseline audit and designing and implementing strategies to address non-compliance found in the baseline audit informed by the JBI GRiP framework; third, conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice, and identify future practice issues to be addressed in subsequent audits. These three phases were performed over a period of 6 months, from August 2017 to March 2018. RESULTS: The baseline audit revealed deficits between old and best practice in all criteria. Barriers for implementation of a protocol for surgical counts were identified, and strategies were implemented. The postimplementation (follow-up) audit showed improvement in compliance with best practice in six of the audit criteria selected except two, a multidisciplinary team approach to decrease retained surgical items, and limited staff hand-offs during surgical procedures to ensure the same team is present in all counting episodes. CONCLUSION: The main achievements of the study included substantial increases in compliance with best practice. However, registration and report and commitment of all members of surgical team to apply the entire protocol, avoiding to skip any step, persist as challenges.

Factors associated with the increased bleeding in the postoperative period of cardiac surgery: A cohort study.

AIMS AND OBJECTIVES: To identify factors associated with the increased bleeding in patients during the postoperative period after cardiac surgery. BACKGROUND: Bleeding is among the most frequent complications that occur in the postoperative period after cardiac surgery, representing one of the major factors in morbidity and mortality. Understanding the factors associated with the increased bleeding may allow nurses to anticipate and prioritise care, thus reducing the mortality associated with this complication. DESIGN: Prospective cohort study. METHODS: Adult patients in a cardiac hospital who were in the postoperative period following cardiac surgery were included. Factors associated with the increased bleeding were investigated by means of linear regression, considering time intervals of 6 and 12 hr. RESULTS: The sample comprised 391 participants. The factors associated with the increased bleeding in the first 6 hr were male sex, body mass index, cardiopulmonary bypass duration, anoxia duration, metabolic acidosis, higher heart rate, platelets and the activated partial thromboplastin time in the postoperative period. Predictors in the first 12 hr were body mass index, cardiopulmonary bypass duration, metabolic acidosis, higher heart rate, platelets and the activated partial thromboplastin time in the postoperative. CONCLUSIONS: This study identified factors associated with the increased postoperative bleeding from cardiac surgery that have not been reported in previous studies. The nurse is important in the vigilance, evaluation and registry of chest tube drainage and modifiable factors associated with the increased bleeding, such as metabolic acidosis and postoperative heart rate, and in discussions with the multiprofessional team. RELEVANCE TO CLINICAL PRACTICE: Knowledge of the factors associated with the increased bleeding is critical for nurses so they can provide prophylactic interventions and early postoperative treatment when needed.