A computerized bibliographic search of published research and a citation review of English-language publications about prone positioning of patients with acute respiratory distress syndrome were done. Information on prone positioning related to technique, patients' responses, complications, and recommendations to prevent complications was extracted. In the 20 pertinent clinical studies found, 297 patients (mean age, 39 years) with acute respiratory failure were positioned prone. Timing from the onset of respiratory failure to when the patient was first positioned prone varied, as did the frequency of prone positioning. Patients spent from 30 minutes to 42 hours prone. In 47% of the studies in which abdominal position was noted, chest and pelvic cushions were used to allow the abdomen to protrude while the patient was prone. Improved oxygenation within 2 hours was reported in 69% of patients, and the improvements were cumulative and persistent. Aside from early intervention, factors predictive of patients' responses were inconsistent, and patients' initial responses were not predictive of subsequent responses. Iatrogenic critical events were rare. Dependent edema of the face was prevalent. Pressure ulcers were reported in studies with longer periods of prone positioning. The most serious complication, corneal abrasion requiring corneal transplantation, was reported in one patient. Clinical knowledge about prone positioning is limited. Phase 1 studies focusing on how to safely turn and care for critically ill patients positioned prone for prolonged periods are needed.

OBJECTIVE: The purpose of the study was to describe the patterns of weaning from mechanical ventilation in young children recovering from acute hypoxemic respiratory failure. METHODS: Decision-making rules on progressive weaning were developed and applied to existing data on 82 patients 2 weeks to 6 years old in the Pediatric Acute Respiratory Distress Syndrome Data Set. RESULTS: Three patterns of weaning progress were detected: sprint, consistent, and inconsistent. Length of ventilation and weaning progressively increased from the sprint, to the consistent, to the inconsistent subset. Patients in the inconsistent subset were most likely to have a systemic (sepsis or shock) trigger of acute respiratory distress syndrome and to be rated as having at least moderate disability at discharge. Hypothesis-generating univariate and then multivariate logistic regression analyses indicated that patients who experienced more days of mechanical ventilation before the start of weaning and who had a higher oxygenation index during the weaning process were most likely to have an inconsistent pattern of weaning. CONCLUSION: Patterns of weaning are discernible in a population of young children and indicate a subset at risk for inconsistent weaning. Knowing the patterns of weaning may help clinicians anticipate, perhaps plot, and then modulate a patient's weaning trajectory.

Given the current demands of the healthcare environment, a clear sense of the unique contributions of nursing to patients' outcomes is critical. This paper articulates a model that describes nursing practice on the basis of the needs and characteristics of patients. The model was developed by the American Association of Critical-Care Nurses Certification Corporation to link certified practice to patients' outcomes. The fundamental premise of this model, known as the Synergy Model, is that patients' characteristics drive nurses' competencies. When patients' characteristics and nurses' competencies match and synergize, outcomes for the patient are optimal. This paper presents the major tenets of the Synergy Model: patients' characteristics of concern to nurses, nurses' competencies important to patients, and patients' outcomes that result when patients' characteristics and nurses' competencies are mutually enhancing. By creating safe passage for patients, nurses make a significant contribution to the quality of patients' care, containment of costs, and patients' outcomes. Although the Synergy Model will be used as a blueprint for the certification of acute and critical care nurses, it is conceptually relevant to the entire profession. Dissemination of this model may help situate nursing within the current healthcare environment and facilitate intradisciplinary dialogue.