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Implementation of a guideline for the treatment of pain, sedation, agitation and neuromuscular blockade in the mechanically ventilated adult patient in the emergency departmentKristin E White1, Paul M Szumita1, Nicki Gilboy2, Hillary A Keenan3, Christian Arbelaez21Department of Pharmacy Services, 2Department of Emergency Medicine, 3Center for Clinical Investigation, Brigham and Women's Hospital, Boston, MA, USAPurpose: When emergency department (ED) overcrowding includes admitted mechanically ventilated (MV) critically-ill patients without an open intensive care unit (ICU) bed, emergency providers must deliver ICU level care in the ED. Implementing standardized hospital based clinical guidelines may help providers achieve uniform care standards for assessing and managing pain and sedation for the MV patient.Objective: This paper is a description of a hospital performance improvement project that was implemented in the ED. The objective of this study was to measure the degree of adoption of a hospital-wide clinical guideline for the management of pain, sedation and neuromuscular blockade in MV patients into clinical practice in the ED.Methods: A retrospective analysis was performed for all mechanically ventilated patients who were admitted from ED to an Intensive Care Unit (ICU). Patient charts were reviewed before (December 2005) and after the implementation of the guideline (June, August, and December 2006). Data was collected and analyzed for the ED visit only and no ICU data was used. The primary outcome was the degree of adoption of the guideline by emergency providers into their daily clinical practice.Results: A convenience sample of 170 adult MV patients who were admitted to the ICU during the preselected time period was analyzed. There were no demographic differences between groups of patients observed during each month interval, age (P = 0.34), gender (P = 0.40), race (P = 0.14), and Hispanic ethnicity (P = 0.84). Overall, there was an increase in the provider use of propofol (P < 0.01), RASS sedation scale (P < 0.01), and a decrease in the use of a paralytic agent (P < 0.01).Conclusion: There was partial adoption of a guideline into their clinical practice by emergency providers in a busy urban emergency department. Across the 12-month implementation period, there was improvement in the assessment of and use of analgesia and sedation for MV patients.Keywords: clinical guideline, critical care, ICU, emergency department, sedation, pain, neuromuscular blocker
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Measurement of skeletal muscle tissue oxygenation in the critically illShock is a state of acutely reduced tissue oxygenation. In cardiogenic shock oxygen delivery (DO2) is reduced, but oxygen extraction is preserved. In septic shock DO2 is preserved, but oxygen extraction is decreased because of microvascular changes and disturbed metabolism. Global assessment of DO2 and oxygen consumption does not tell us enough about adequacy of regional perfusion. The aim of this study was to assess the value of near infrared spectroscopy (NIRS) in detecting skeletal muscle tissue oxygenation (StO2) in critically ill patients. Patients in cardiogenic shock (n=17), septic shock (n=14), without shock but with localized infection (n=14) and healthy volunteers (n=15) were included. Thenar StO2 was measured with NIRS before (baseline StO2, %), between (downward StO2 slope, %/min) and after 90 seconds of upper arm stagnant ischemia (hyperemic StO2, %). Muscle oxygen extraction (mOER) was calculated as follows: mOER (%) = (1-baselineStO2/hyperemic StO2)*100. Repeatability was assessed using the Bland Altman method (95 % of values within limits of agreement), comparing 55 pairs of measurements performed in 5-minute intervals.Repeatability of measurements was clinically acceptable. Compared to septic shock patients, cardiogenic shock patients had lower baseline StO2 (68.9 ± 10.0 % vs. 84.3 ± 10.4 %; p < 0.05) and hyperemic StO2 (80.8 ± 7.8 % vs. 91.8 ± 8.3 %; p < 0.05), and a higher downward StO2 slope (-17.4 ± 31.7 %/min vs. -9.1 ± 2.6 %/min; p < 0.05). mOER was higher in healthy volunteers (11.9 ± 3.8 %) and volunteers with cardiogenic shock (14.8 ± 7.3 %) compared to septic shock patients (8.1 ± 7.8 %) and those with localized infection (7.6 ± 5.4 %) (p < 0.05).Repeatability of baseline StO2 and hyperemic StO2 is clinically acceptable. Results support the hypothesis that skeletal muscle oxygen extraction capability is preserved and extraction is increased in cardiogenic shock compared to septic shock.
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Incidencia, características y evolución del barotrauma durante la ventilación mecánica con apertura pulmonar Incidence, characteristics and outcome of barotrauma during open lung ventilationObjetivo: Describir la incidencia y principales características clínicas del barotrauma durante la ventilación mecánica con apertura pulmonar. Diseño: Estudio retrospectivo, observacional, descriptivo, en 100 pacientes con insuficiencia respiratoria aguda e infiltrados pulmonares bilaterales. Intervenciones: 1) maniobra de reclutamiento pulmonar (MRP) con presión de ventilación fija e incrementos progresivos de presión positiva al final de la espiración (PEEP), seguida de decrementos escalonados hasta establecer la PEEP de apertura en el valor asociado a la máxima distensibilidad respiratoria; 2) ventilación asistida/controlada por presión ajustada para un volumen tidal de 6-8ml/kg; y 3) radiografía de tórax después de la MRP y diariamente mientras persistió la insuficiencia respiratoria. Resultados: Nueve pacientes, 7 con neumonía y 2 con trauma torácico, desarrollaron barotrauma (2 enfisema subcutáneo y 7 neumotórax), lo cual supuso una incidencia total del 9% y del 16% en aquellos pacientes con lesión pulmonar primaria. En 7 pacientes fue tan solo de un hallazgo radiológico; en los otros dos, se manifestó como un neumotórax bilateral y a tensión, cursando con hipoventilación pulmonar. Únicamente en estos dos casos se modificó la estrategia ventilatoria. No hubo diferencias en las presiones ni en los volúmenes respiratorios entre pacientes con o sin barotrauma. La mortalidad fue similar en ambos grupos. Conclusiones: El barotrauma resultó una complicación exclusiva de pacientes con lesión pulmonar primaria, en los que tuvo una incidencia elevada. En la mayoría de las ocasiones fue un hallazgo radiológico sin manifestaciones clínicas, manteniéndose la ventilación con apertura pulmonar. Su aparición no se relacionó con presiones ni volúmenes respiratorios mayores, ni se asoció a mayor mortalidad.<br>Objective: To describe the incidence and main clinical characteristics of barotrauma during open lung ventilation (OLV). Design: A retrospective, observational, descriptive study was made of 100 patients with acute respiratory failure and bilateral pulmonary infiltrates. Interventions: 1) A lung recruitment maneuver (LRM) with fixed ventilation pressure and progressive positive end-expiratory pressure (PEEP) elevations was carried out, followed by stepwise decreases until establishing open-lung PEEP at the value associated to maximum respiratory compliance; 2) assisted/controlled pressure ventilation to achieve a tidal volume of 6-8ml/kg; and 3) chest X-rays after LRM and daily for as long as respiratory failure persisted. Results: Nine patients, 7 with pneumonia and 2 with chest trauma, developed barotrauma (2 subcutaneous emphysemas and 7 cases of pneumothorax), representing an overall incidence of 9% and 16% in patients with primary lung injury. In 7 patients barotrauma was only a radiological finding; in the other 2 patients, it manifested as bilateral and tension pneumothorax, inducing pulmonary hypoventilation without hemodynamic impairment. Only in these two cases was the ventilatory strategy modified. There were no differences in the airway pressures or volumes between patients with and without barotrauma. Mortality was similar in both groups. Conclusions: Barotrauma was an exclusive complication of patients with primary lung injury, and the incidence in this group was high. In most cases, there were only radiological findings without clinical significance that did not require the suspension of OLV. Barotrauma was neither related to high pressures and volumes nor associated with increased mortality.