Cost assessment of a new oral care program in the intensive care unit to prevent ventilator-associated pneumonia.

OBJECTIVES: Ventilator-associated pneumonia (VAP) is the most frequent hospital-acquired infections in intensive care units (ICU). In the bundle of care to prevent the VAP, the oral care is very important strategies, to decrease the oropharyngeal bacterial colonization and presence of causative bacteria of VAP. In view of the paucity of medical economics studies, our objective was to determine the cost of implementing this oral care program for preventing VAP. MATERIALS AND METHODS: In five ICUs, during period 1, caregivers used a foam stick for oral care and, during period 2, a stick and tooth brushing with aspiration. Budgetary effect of the new program from the hospital's point of view was analyzed for both periods. The costs avoided were calculated from the incidence density of VAP (cases per 1000 days of intubation). The cost study included device cost, benefit lost, and ICU cost (medication, employer and employee contributions, blood sample analysis…). RESULTS: A total of 2030 intubated patients admitted to the ICUs benefited from oral care. The cost of implementing the study protocol was estimated to be €11,500 per year. VAP rates decreased significantly between the two periods (p1 = 12.8% and p2 = 8.5%, p = 0.002). The VAP revenue was ranged from €28,000 to €45,000 and the average cost from €39,906 to €42,332. The total cost assessment calculated was thus around €1.9 million in favor of the new oral care program. CONCLUSION AND CLINICAL RELEVANCE: Our study showed that the implementation of a simple strategy improved the quality of patient care is economically viable. TRIAL REGISTRATION: NCT02400294.

High-Flow Nasal Oxygen vs Noninvasive Positive Airway Pressure in Hypoxemic Patients After Cardiothoracic Surgery: A Randomized Clinical Trial.

IMPORTANCE: Noninvasive ventilation delivered as bilevel positive airway pressure (BiPAP) is often used to avoid reintubation and improve outcomes of patients with hypoxemia after cardiothoracic surgery. High-flow nasal oxygen therapy is increasingly used to improve oxygenation because of its ease of implementation, tolerance, and clinical effectiveness. OBJECTIVE: To determine whether high-flow nasal oxygen therapy was not inferior to BiPAP for preventing or resolving acute respiratory failure after cardiothoracic surgery. DESIGN AND SETTING: Multicenter, randomized, noninferiority trial (BiPOP Study) conducted between June 15, 2011, and January 15, 2014, at 6 French intensive care units. PARTICIPANTS: A total of 830 patients who had undergone cardiothoracic surgery, of which coronary artery bypass, valvular repair, and pulmonary thromboendarterectomy were the most common, were included when they developed acute respiratory failure (failure of a spontaneous breathing trial or successful breathing trial but failed extubation) or were deemed at risk for respiratory failure after extubation due to preexisting risk factors. INTERVENTIONS: Patients were randomly assigned to receive high-flow nasal oxygen therapy delivered continuously through a nasal cannula (flow, 50 L/min; fraction of inspired oxygen [FiO2], 50%) (n = 414) or BiPAP delivered with a full-face mask for at least 4 hours per day (pressure support level, 8 cm H2O; positive end-expiratory pressure, 4 cm H2O; FiO2, 50%) (n = 416). MAIN OUTCOMES AND MEASURES: The primary outcome was treatment failure, defined as reintubation, switch to the other study treatment, or premature treatment discontinuation (patient request or adverse effects, including gastric distention). Noninferiority of high-flow nasal oxygen therapy would be demonstrated if the lower boundary of the 95% CI were less than 9%. Secondary outcomes included mortality during intensive care unit stay, changes in respiratory variables, and respiratory complications. RESULTS: High-flow nasal oxygen therapy was not inferior to BiPAP: the treatment failed in 87 of 414 patients with high-flow nasal oxygen therapy (21.0%) and 91 of 416 patients with BiPAP (21.9%) (absolute difference, 0.9%; 95% CI, -4.9% to 6.6%; P = .003). No significant differences were found for intensive care unit mortality (23 patients with BiPAP [5.5%] and 28 with high-flow nasal oxygen therapy [6.8%]; P = .66) (absolute difference, 1.2% [95% CI, -2.3% to 4.8%]. Skin breakdown was significantly more common with BiPAP after 24 hours (10% vs 3%; 95% CI, 7.3%-13.4% vs 1.8%-5.6%; P < .001). CONCLUSIONS AND RELEVANCE: Among cardiothoracic surgery patients with or at risk for respiratory failure, the use of high-flow nasal oxygen therapy compared with intermittent BiPAP did not result in a worse rate of treatment failure. The findings support the use of high-flow nasal oxygen therapy in similar patients. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01458444.

Patients' exposure to PVC plasticizers from ECMO circuits.

BACKGROUND: ECMO is a therapeutic act with a high risk of exposure to diethylhexylphthalate (DEHP), plasticizer from PVC tubings. The replacement of this plasticizer with alternative compounds is recommended but the risks associated with the use of new plasticizers have not been evaluated in ECMO situations. METHODS: Ex vivo ECMO models were performed with different flow rates over 6 days to evaluate the migration of plasticizers and their potential toxic risk for patient. The release of plasticizers during ECMO was measured and compared to reference value (derived no effect level, DNEL) and to cytotoxic concentration carried out with MTT test. RESULTS: Trioctyltrimellitate (TOTM), main plasticizer present in circuit (44% w/w), is weakly released during ECMO. Concentrations are not cytotoxic and exposure doses are lower than DNEL. In contrast, DEHP doses are higher than the DNEL despite a lower presence of DEHP in the circuit (0.2%). We have shown that DEHP is not coming from the circuit but from the priming bag. Replacing this bag with a multilayer one avoids the exposure to DEHP. CONCLUSION: Our study shows that circuits made of PVC plasticized with TOTM against DEHP improves the safety of ECMO.

Comparative study of 2 oral care protocols in intensive care units.

BACKGROUND: The quality of oral care is important in limiting the emergence of ventilator-associated pneumonia (VAP) in intubated patients. Our main objective was to measure the quality improvement in oral care following the implementation of a new oral care protocol. We also monitored VAP rates. MATERIAL/METHODS: This was a cohort study of patients in 5 adult ICUs covering different specialties. During period 1, caregivers used a foam stick for oral care and during period 2 a stick and tooth brushing with aspiration. Oral chlorhexidine was used during both periods. The caregivers rated improvement in oral health on the basis of 4 criteria (tongue, mucous membranes, gingivae, and teeth). Caregiver satisfaction was also assessed. The incidence of VAP was monitored. RESULTS: A total of 2,030 intubated patients admitted to intensive care units benefited from oral care. The patient populations during the 2 periods were similar with regard to demographic data and VAP potential risk factors. Oral health was significantly better from the third day of oral care in period 2 onward (period 1, 6.4 ± 2.1; period 2, 5.6 ± 1.8; P = .043). Caregivers found the period 2 protocol easier to implement and more effective. VAP rates decreased significantly between the 2 periods (period 1, 12.8%; period 2, 8.5%; P = .002). CONCLUSIONS: Our study showed that the implementation of a simple strategy improved the quality of oral care of patients in intensive care units, and decreased VAP rates.

Are all heparins safe for on-pump heart surgery?

BACKGROUND: Intravenous Panpharma heparin(®) was used in all on-pump cardiac surgery in our heart-surgery department for a short period. This brand of heparin replaced the previous Choay heparin(®) heparin supplied by the Sanofi-Aventis Laboratory. Unusual postoperative bleedings over this period prompted us to evaluate postoperative hemostasis by comparing these two heparins. METHODS: We compared data from patients who had undergone on-pump cardiac surgery during Panpharma heparin(®) period (group P, 257 patients) to those how received Choay heparin(®) (group C, 194 patients). RESULTS: Despite group P receiving a significantly lower dose of heparin (mean dose 21,000 IU/CEC) compared to group C (mean dose 22,000 IU/CEC) (p = 0.05), the number of surgical re-explorations needed to perfect postoperative hemostasis was significantly higher for group P (3.5% vs. 0) (p = 0.01). Heparin anti-Xa activity after surgery was higher in group P at postoperative h1 and h12 compared to group C, which explained reoperations for hemostasis. CONCLUSION: Despite standardization, variations remain regarding anticoagulant activity between different manufacturing processes and heparin preparations. Surgical teams need to be aware that the biological effects of different brands of heparin may not be as expected and could endanger a usually safe procedure, such as cardiac surgery.