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Purpose In this pilot study, we aimed to investigate the efficacy of an electronic medical record (EMR) order set for lubricating ointment (four times daily) in the prevention of exposure keratopathy in ventilated patients in the intensive care unit (ICU) at the University of Utah. We attempted to capture the magnitude of morbidity, cost, and care burden in ventilated patients, as well as the utility of a systematic EMR-based preventative lubrication protocol in the ICU setting. Methods After implementation of the order set, a retrospective chart review was performed to capture all ventilated ICU patients pre- and postintervention. Three separate study periods were used: (1) Six months prior to coronavirus disease 2019 (COVID-19) and prior to the ocular lubrication intervention; (2) the subsequent 6-month period including COVID-19 patients but prior to any intervention; and (3) the subsequent 6-month period postintervention, including COVID-19 patients. The primary endpoint of ointment use per day was analyzed with a Poisson regression model. Secondary endpoints including rates of ophthalmologic consultation and exposure keratopathy were compared with Fisher's exact test. A poststudy survey of ICU nurses was included. Results A total of 974 ventilated patients were included in the analysis. Ointment use per day increased by 155% (95% confidence interval [CI] 132-183%, p < 0.001) following the intervention. Rates also increased 80% (95% CI 63-99%, p < 0.001) during the COVID-19 study period but prior to intervention. The percentage of ventilated patients requiring a dilated eye exam for any indication was 3.2, 4, and 3.7% in each of the study periods, respectively. There was an overall down trend in the rate of exposure keratopathy which was diagnosed in 33.3, 20, and 8.3% of those receiving ophthalmologic consultation, though these rates were not statistically significant. Conclusion These preliminary data show a statistically significant increase in the rates of lubrication in mechanically ventilated patients using an EMR-based order set in the ICU setting. There was no statistically significant decrease in the rates of exposure keratopathy. Our preventative protocol with lubrication ointment was of minimal cost burden to the ICU. Further longitudinal and multicenter studies are needed to better assess the efficacy of such a protocol.
RESUMO
Allan-Herndon-Dudley syndrome is a rare X-linked neurologic condition caused by mutations in monocarboxylate transporter 8 ( MCT8), which leads to deficient thyroid hormone transport. Typical features include severe cognitive impairment, truncal hypotonia, spastic paraplegia, weakness, and speech difficulties. Minimal literature exists describing the ocular findings in patients with Allan-Herndon-Dudley syndrome. We describe 4 male siblings affected with Allan-Herndon-Dudley syndrome with a novel nonsense mutation (Q90X) in the MCT8 protein. All affected siblings presented with classic findings of Allan-Herndon-Dudley syndrome, and each of the siblings also developed intermittent esotropia. This group of affected siblings represents the first consistent documentation of strabismus in Allan-Herndon-Dudley syndrome, suggesting a possible association between this clinical finding and the neurologic syndrome.