Prospective assessment of a score for assessing basic critical-care transthoracic echocardiography skills in ventilated critically ill patients.

BACKGROUND: We studied a score for assessing basic transthoracic echocardiography (TTE) skills exhibited by residents who examined critically ill patients receiving mechanical ventilation. METHODS: We conducted a prospective study in the 16 residents who worked in our medical-surgical ICU between 1 May 2008 and 1 November 2009. The residents received theoretical teaching (two hours) then performed supervised TTEs during their six-month rotation. Their basic TTE skills in mechanically ventilated patients were evaluated after one (M1), three (M3), and six (M6) months by two experts, who used a scoring system devised for the study. After scoring, residents gave their hemodynamic diagnosis and suggested a treatment. RESULTS: The 4 residents with previous TTE skills obtained a significantly higher total score than did the 12 novices at M1 (18 (16 to 19) versus 13 (10 to 15), respectively, P = 0.03). In the novices, the total score increased significantly during training (M1, 13 (10 to 14); M3, 15 (12 to 16); and M6, 17 (15 to 18); P < 0.001) and correlated significantly with the number of supervised TTEs (r = 0.68, P < 0.0001). In the overall population, agreement with experts regarding the diagnosis and treatment was associated with a significantly higher total score (17 (16 to 18) versus 13 (12 to 16), P = 0.002). A total score ≥ 19/20 points had 100% specificity (95% confidence interval, 79 to 100%) for full agreement with the experts regarding the diagnosis and treatment. CONCLUSIONS: Our results validate the scoring system developed for our study of the assessment of basic critical-care TTE skills in residents.

Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: a prospective before-after study.

BACKGROUND: Monitoring of residual gastric volume (RGV) to prevent aspiration is standard practice in mechanically ventilated patients receiving early enteral nutrition (EN). No data are available to support a correlation between RGV and adverse event rates. We evaluated whether not measuring RGV affected EN delivery, vomiting, or risk of nosocomial pneumonia. METHODS: Two hundred and five eligible patients with nasogastric feeding within 48 hours after intubation were included in a 7-day prospective before-after study. Continuous 24-hour nutrition was started at 25 mL/h then increased by 25 mL/h every 6 hours, to 85 mL/h. In both groups, intolerance was treated with erythromycin (250 mg IV/6 h) and a delivery rate decrease to the previously well-tolerated rate. RGV monitoring was used during the first study period (n = 102), but not during the subsequent intervention period (n = 103). Intolerance was defined as RGV >250 mL/6 h or vomiting in the standard-practice group and as vomiting in the intervention group. RESULTS: Groups were similar for baseline characteristics. Median daily volume of enteral feeding was higher in the intervention group (1489; interquartile range [IQR], 1349-1647) than in the controls (1381; IQR, 1151-1591; P = .002). Intolerance occurred in 47 (46.1%) controls and 27 (26.2%) intervention patients (P = .004). The vomiting rate did not differ between controls and intervention group patients (24.5% vs 26.2%, respectively; P = .34), and neither was a difference found for ventilator-associated pneumonia (19.6% vs 18.4%; P = .86). CONCLUSION: Early EN without RGV monitoring in mechanically ventilated patients improves the delivery of enteral feeding and may not increase vomiting or ventilator-associated pneumonia.

Before-after study of a standardized ICU protocol for early enteral feeding in patients turned in the prone position.

BACKGROUNDS & AIMS: To evaluate an intervention for improving the delivery of early enteral nutrition (EN) in patients receiving mechanical ventilation with prone positioning (PP). METHODS: Eligible patients receiving EN and mechanical ventilation in PP were included within 48h after intubation in a before-after study. Patients were semi-recumbent when supine. Intolerance to EN was defined as residual gastric volume greater than 250ml/6h or vomiting. In the before group (n=34), the EN rate was increased by 500ml every 24h up to 2000ml/24h; patients were flat when prone and received erythromycin (250mgIV/6h) to treat intolerance. In the intervention group (n=38), the EN rate was increased by 25ml/h every 6h to 85ml/h, 25 degrees head elevation was used in PP, and prophylactic erythromycin was started at the first turn. RESULTS: Compared to the before group, larger feeding volumes were delivered in the intervention group (median volume per day with PP, 774ml [IQR 513-925] vs. 1170ml [IQR 736-1417]; P<0.001) without increases in residual gastric volume, vomiting, or ventilator-associated pneumonia. CONCLUSION: An intervention including PP with 25 degrees elevation, an increased acceleration to target rate of EN, and erythromycin improved EN delivery.

Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal.

OBJECTIVE: To assess decisions to forego life-sustaining treatment (LST) in patients too sick for intensive care unit (ICU) admission, comparatively to patients admitted to the ICU. DESIGN: Prospective observational cohort study. SETTING: A medical-surgical ICU. PATIENTS: Consecutive patients referred to the ICU during a one-yr period. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Of 898 triaged patients, 147 were deemed too well to benefit from ICU admission. Decisions to forego LST were made in 148 of 666 (22.2%) admitted patients and in all 85 patients deemed too sick for ICU admission. Independent predictors of decisions to forego LST at ICU refusal rather than after ICU admission were: age; underlying disease; living in an institution; preexisting cognitive impairment; admission for medical reasons; and acute cardiac failure, acute central neurologic illness, or sepsis. Hospital mortality after decisions to forego LST was not significantly different in refused and admitted patients (77.5% vs. 86.5%; p = .1). Decisions to forego LST were made via telephone in 58.8% of refused patients and none of the admitted patients. Nurses caring for the patient had no direct contact with the ICU physicians for 62.3% of the decisions in refused patients, whereas meetings between nurses and physicians occurred in 70.3% of decisions to forego LST in the ICU. Patients or relatives were involved in 28.2% of decisions to forego LST at ICU refusal compared with 78.4% of decisions to forego LST in ICU patients (p < .001). CONCLUSIONS: All patients deemed too sick for ICU admission had decisions to forego LST. These decisions were made without direct patient examination in two-thirds of refused patients (vs. none of admitted patients) and were associated with less involvement of nurses and relatives compared with decisions in admitted patients. Further work is needed to improve decisions to forego LST made under the distinctive circumstances of triage.

Short-term effects of prone position in chronic obstructive pulmonary disease patients with severe acute hypoxemic and hypercapnic respiratory failure.

OBJECTIVE: To assess the short-term effects of prone positioning (PP) in chronic obstructive pulmonary disease (COPD) patients with severe hypoxemic and hypercapnic respiratory failure requiring invasive mechanical ventilation. DESIGN AND SETTING: Prospective observational study in the general intensive care unit of a university-affiliated hospital. PATIENTS: 11 consecutive COPD patients with persistent hypoxemia (PaO2/FIO2 < or = 200 mmHg with FIO2 > or = 0.6) and hypercapnia requiring invasive mechanical ventilation. Patients with adult respiratory distress syndrome or left ventricular failure were excluded. Mean age was 73+/-11 years, mean weight 86+/-31 kg, mean SAPS II 53+/-10, and ICU mortality 36%. INTERVENTIONS: Patients were turned every 6 h. MEASUREMENTS AND RESULTS: A response to PP (20% or greater PaO2/FIO2 increase) was noted in 9 (83%) patients. Blood gases were measured in the PP and supine (SP) positions 3 h after each turn, for 36 h, yielding six measurement sets (SP1, PP1, SP2, PP2, SP3, and PP3). PaO2/FIO2 was significantly better in PP: 190+/-26 vs. 113+/-9 mmHg for PP1/SP1, 175+/-22 vs. 135+/-16 mmHg for PP2/SP2, and 199+/-24 vs. 151+/-13 mmHg for PP3/SP3. After PP1 PaO2/FIO2 remained significantly improved, and the PaO2/FIO2 improvement from SP1 to SP2 was linearly related to PaO2/FIO2 during PP1 (r=0.8). The tracheal aspirate volume improved significantly from SP1 to PP1. PaCO2 was not significantly affected by position. CONCLUSIONS: PP was effective in treating severe hypoxemia in COPD patients. The first turn in PP was associated with increased tracheal aspirate.

Early enteral nutrition in mechanically ventilated patients in the prone position.

OBJECTIVE: To assess the tolerance of early enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position. DESIGN: Prospective, comparative study. SETTING: General intensive care unit in a university-affiliated hospital. PATIENTS: A total of 71 consecutive patients receiving invasive mechanical ventilation with early nasogastric enteral nutrition were studied for 5 days while being treated continuously in the supine position (supine position group, n = 37) or with intermittent prone positioning for severe hypoxemia (prone position group, n = 34). INTERVENTIONS: Inclusion occurred within 24 hrs of mechanical ventilation initiation. Daily 18-hr enteral nutrition via a 14F gastric tube was initiated. Prone position patients were turned every 6 hrs as long as PaO2/FiO2 remained at <150, with a FiO2 of 0.6 and positive end-expiratory pressure of 10; the head was slightly elevated. When supine, patients in both groups were semirecumbent. Residual gastric volume was measured every 6 hrs, and enteral nutrition was discontinued if it exceeded 250 mL or vomiting occurred. MEASUREMENTS AND MAIN RESULTS: The groups were similar for age, sex, Simplified Acute Physiology Score II, mortality, and risk factors for enteral nutrition intolerance. At baseline, PaO2/FiO2 was lower in prone position patients than in supine position patients (127 +/- 55 vs. 228 +/- 102; p <.001). As compared with supine position patients, prone position patients had significantly greater residual gastric volumes on days 1, 2, and 4 and experienced more vomiting episodes (median, 1 [interquartile range, 0-2] vs. 0 [interquartile range, 0-1]; p <.05). Enteral nutrition was stopped in 82% of prone position patients and 49% of supine position patients (p <.01) so that daily enteral nutrition volumes were lower with prone position patients. In the prone position group, vomiting occurred more frequently in the prone than in the supine position (relative risk, 2.5; 95% confidence interval, 1.5-4.0; p <.001). CONCLUSION: In critically ill patients receiving invasive mechanical ventilation in the prone position, early enteral nutrition is poorly tolerated. Prokinetic agents or transpyloric feeding and semirecumbency should be considered to enhance gastric emptying and to prevent vomiting in patients receiving mechanical ventilation in the prone position.