BACKGROUND: Outcomes management that uses critical pathways may decrease costs while improving outcomes for patients who require prolonged mechanical ventilation. OBJECTIVE: To study the efficacy of an outcomes-managed approach to weaning patients from prolonged (more than 3 days) mechanical ventilation. METHODS: A method of multidisciplinary care delivery was designed that included an outcomes manager, a care pathway for patients receiving mechanical ventilation, and weaning protocols. Data collection consisted of three parts: a retrospective review of 124 patients who required prolonged ventilation during a 1-year period before implementation of the care model, a 6-month prospective study in which 91 patients were alternately assigned by month to an outcomes-managed approach or a non-outcomes-managed approach, and a 6-month prospective study of 90 patients in which an outcomes-managed approach without alternate-month assignment was used. RESULTS: Outcomes management had no significant effect on total duration of mechanical ventilation or length of stay in the hospital, days of mechanical ventilation without tracheostomy, days of mechanical ventilation with tracheostomy, or outcome (weaned, withdrawal from mechanical ventilation, death, or transfer without weaning). However, duration of mechanical ventilation was 1.3 days shorter, length of stay in the hospital was 2.1 days shorter, and the cost per case was $ 3341 less for patients in the outcomes-managed group than for patients in the non-outcomes-managed group. CONCLUSION: Outcomes-managed care did not have a significant effect on duration of ventilation, length of stay in the hospital, or outcome in patients receiving long-term mechanical ventilation.
BACKGROUND: Nasogastric tube displacement can result in serious complications such as aspiration and inadvertent migration of the tube into the lungs. Replacement of the tubes is costly, time- and effort-intensive, uncomfortable for the patients, and potentially dangerous. OBJECTIVE: To determine the best of three methods for securing nasogastric tubes in a medical intensive care population and to identify variables related to the failure of tube securing methods. METHODS: A convenience sample of 103 patients requiring duodenal or standard gastric tubes for feeding, medication delivery, or decompression were randomly assigned to one of three taping methods: pink tape, clear tape, or "butterfly," for a total of 264 taping episodes. Data collection included the mean time until failure of the securing methods as well as variables such as patient alertness and mobility. RESULTS: The mean time until failure was 100 hours with pink tape versus 56 hours with clear tape and 30 hours with the "butterfly." Differences were significant. Duodenal tubes stayed secured longer than standard sump tubes (mean time until failure was 86 vs 41 hours) for all taping methods, but not significant relationship was demonstrated between mean time until failure and variables such as alertness, sedation, confusion, mobility, and the use of restraints. CONCLUSION: Our results showed that the pink tape method was superior. Nasogastric tube securing methods in adult critical care patients vary in efficacy and should be selected carefully.
Although many investigators have attempted to identify weaning predictors and weaning modes for use in long-term mechanically ventilated patients, none has emerged as superior. Furthermore, few investigators have viewed the process of weaning as a dynamic continuum; thus, guidelines for care of these patients have yet to be developed. Facilitative methods and therapies to enhance weaning potential, although attractive, have little scientific basis for application. Care delivery systems, which focus on systematic, comprehensive and coordinated care, are promising because outcomes demonstrate that they are economical, safe, and effective. This article reviews the research on weaning adult, long-term mechanically ventilated patients, suggests future research directions, and highlights the scientific basis for practice guidelines.
The purposes of this article are to: identify gaps in the research literature on weaning adult patients from short-term mechanical ventilation, highlight the scientific base for practice guidelines, and suggest future research directions. Data bases from 1989 through June 1993 were reviewed, and relevant research articles were extracted, analyzed, and synthesized within the AACN Third National Study Group framework. Seminal work and other supportive literature also were used in this review. Despite considerable research on predictors and patient responses to weaning from short-term mechanical ventilation, few of the findings can be applied to clinical practice at this time. Less research is available on weaning modes and therapies that facilitate weaning from short-term mechanical ventilation; fruitful research in these areas depends in part on a better understanding of patient responses and accurate weaning predictors.
BACKGROUND: Despite extensive data acquired in the area of weaning, clinicians still struggle with the questions of how and when to begin the process. Clinical weaning indices, designed to predict weaning potential, are often difficult to use. They provide an answer at a specific time; extrapolation to the weaning process is rarely possible. No single index has proven to be superior. OBJECTIVES: To test the efficacy of five clinical weaning indices (Burns Weaning Assessment Program; Weaning Index; frequency tidal volume ratio; compliance, resistance, oxygenation and pressure index; and negative inspiratory pressure) at regular intervals during withdrawal of ventilatory support and to determine threshold levels for the program. METHODS: A prospective convenience sample consisted of 37 adult critical care patients requiring mechanical ventilation for at least 7 days and identified as stable and ready to wean. Data were collected on all weaning indices every other day until the patient was weaned. RESULTS: With the exception of the Burns Weaning Assessment Program, weaning indices did not change significantly from preweaning scores. Furthermore, the results failed to demonstrate that any of the five clinical weaning indices have strong predictive power related to weaning trial outcomes, although all the indices had negative predictive values that may be helpful in predicting unsuccessful weaning trials. CONCLUSIONS: The results of this study suggest that the process of weaning may be enhanced by comprehensive, systematic approaches and that clinical weaning indices like the Burns Weaning Assessment Program might best serve as tools to track trends in progress, keep care planning on target, and prevent unsuccessful weaning trials.
BACKGROUND: Nursing textbooks and tradition suggest that the high-Fowler's position is best to optimize diaphragmatic excursion and effective breathing pattern. The optimal position for intubated patients with obesity, ascites or abdominal distention has yet to be determined but is important because weaning trial outcomes may reflect the effect of position rather than weaning trial tolerance. OBJECTIVE: To determine the body position that optimizes breathing pattern (tidal volume and respiratory rate) in spontaneously breathing, intubated patients with a large abdomen. METHODS: Nineteen intubated patients with abdominal distention, ascites or obesity who were on continuous positive airway pressure or the pressure support ventilation mode were studied in the 0 degrees, 45 degrees, 90 degrees and reverse Trendelenburg's at 45 degrees positions for 5 minutes prior to data collection. RESULTS: The RT at 45 degrees position resulted in a significantly larger tidal volume and lower respiratory rate than the 90 degrees position in intubated, spontaneously breathing patients with a large abdomen. The 45 degrees position resulted in a significantly lower respiratory rate than at 90 degrees; however, no difference in tidal volume was demonstrated. DISCUSSION: A high respiratory rate and low tidal volume potentiates atelectasis and ultimately failure to wean. It is important that the effect of positioning on breathing pattern in intubated patients be determined so that care planning results in optimal outcomes. CONCLUSIONS: The results of this study have implications for the selection of chair and bed positioning during weaning trials.
BACKGROUND: Continuous infusion of IV vasopressin have been widely used to lower portal pressure and reduce bleeding from esophageal varices. Recently, the combination of vasopressin and nitroglycerin has been noted to be superior to vasopressin alone. This is due to the ability of nitroglycerin to reduce the detrimental effects of vasopressin while preserving its beneficial effects. In September 1989 the authors initiated a protocol in the medical intensive care unit of a large university teaching center that directed caregivers in the simultaneous use of vasopressin and nitroglycerin for use in variceal bleeding. OBJECTIVE: To determine whether the protocol was being used correctly and whether the addition of nitroglycerin produced the desired cardiovascular effects. METHOD: Nineteen patients (25 separate episodes) assigned to the vasopressin/nitroglycerin protocol were monitored retrospectively over a 20-month period for a total of 1068 hours of vasopressin/nitroglycerin infusion. Twenty-four patients received nitroglycerin at 10 to 50 micrograms per minute, 13 at 50 to 100 micrograms per minute and 6 at 100 to 400 micrograms per minute. RESULTS: Nitroglycerin dosage was not advanced appropriately in 78% of episodes despite evidence of bradycardia, hypertension and peripheral vasoconstriction. CONCLUSIONS: Revision of the protocol, giving additional guidance to clinicians on assessment and nitroglycerin advancement, was necessary and was accomplished.