A pessoa sob ventilação invasiva: a intervenção de enfermagem de reabilitação no desmame ventilatório / The person under invasive ventilation: rehabilitation nursing intervention in ventilatory weaning

Neste Relatório de Estágio encontra-se a descrição e análise reflexiva do percurso de desenvolvimento de competências especializadas de Enfermagem de Reabilitação, efetuado durante a prestação de cuidados à pessoa a vivenciar processos complexos de saúde-doença, nomeadamente a pessoa sob ventilação mecânica invasiva. Nos últimos anos, o envelhecimento da população e o aumento de doenças crónicas aliado ao desenvolvimento científico, conduziu a uma crescente necessidade de unidades de cuidados intensivos, sendo o recurso a ventilação mecânica invasiva a principal causa de internamento. Contudo, o seu uso prolongado assume-se atualmente como um problema real, associado ao desenvolvimento de complicações multissistémicas, que levam ao declínio da capacidade funcional e diminuição da qualidade de vida, com expressão no aumento de tempo de internamento e das taxas de morbilidade e mortalidade. O presente relatório de estágio tem como objetivo evidenciar o desenvolvimento de competências especializadas na área de Enfermagem de Reabilitação, no cuidado à pessoa sob ventilação invasiva. Neste contexto, o Enfermeiro Especialista em Enfermagem de Reabilitação detém competências que lhe permitem implementar planos de cuidados multidimensionais, centrados na pessoa e família, que visem particularmente as alterações respiratórias e neuromusculares, com o objetivo de prevenir, minimizar e controlar eventuais complicações, melhorar a capacidade funcional e adaptar ao défice residual. O processo crítico e reflexivo das competências específicas de Enfermeiro Especialista de Enfermagem de Reabilitação desenvolvidas neste percurso, foi norteado pela Teoria Geral do Défice de Autocuidado de Dorothea Orem, bem como por uma revisão narrativa da literatura. As experiências vivenciadas na Unidade de Cuidados Intensivos Neurocríticos e Equipa de Cuidados Continuados Integrados, permitiram a realização de um conjunto de atividades que deu resposta ao objetivo delineado.

This internship report contains the description and reflective analysis regarding the route of development of specialized competences of Rehabilitation Nursing, performed during the rendering of care to the person experiencing complex processes of healthdisease, namely to the person placed under invasive mechanical ventilation. During the last few years, the aging of the population and the increase in chronical illnesses, allied to scientific development, has led to an increasing need for intensive care, the recourse to invasive mechanical ventilation being the principal cause of inpatient treatment. Currently, its prolonged use assumes itself as a real problem, associated to the development of multisystemic complications, which lead to the decline of functional capacity and decrease of quality of life, which is expressed in the increase of time spent in inpatient treatment and in morbidity and mortality rates. This internship report aims to highlight the development of specialized skills in the area of Rehabilitation Nursing in the care of the person under invasive ventilation. In this context, the Rehabilitation Nursing Specialist Nurse possesses capabilities which allow them to implement multidimensional care plans, centered on the person and their family, particularly contemplating respiratory and neuromuscular alterations, with the goal of preventing, minimizing and controlling eventual complications, bettering functional capacity and adapting to the residual deficit. The critical and reflexive process of the specific competences of the Rehabilitation Nursing Specialist Nurse developed in this course was guided by the General Theory of Deficit of Self-Care by Dorothea Orem, as well as by a narrative revision of the literature. The experiences lived in the Neurocritical Intensive Care Unit and the Team of Integrated Continual Care has allowed for the performance of a number of activities that met the outlined goals.

Design of a Clinical Practice Guideline in Nurse-Led Ventilator-Weaning for Nursing Training.

Cardiothoracic intensive care unit (CICU) nurses have shared the role and responsibility for ventilator-weaning to expedite decision-making in patient care. However, the actions taken are based on individual's unstructured training experience as there is no clinical practice guideline (CPG) for nurses in Malaysia. Hence, this study aims to design a CPG for the process of weaning from mechanical ventilation (MV) for a structured nursing training in a CICU at the National Heart Institute (Institut Jantung Negara, IJN) Malaysia. The Fuzzy Delphi Method (FDM) was employed to seek consensus among a panel of 30 experts in cardiac clinical practice on the guidelines. First, five experts were interviewed and their responses were transcribed and analyzed to develop the items for a FDM questionnaire. The questionnaire, comprising of 73 items, was distributed to the panel and their responses were analyzed for consensus on the design of the CPG. The findings suggested that the requirements expected for the nurses include: (a) the ability to interpret arterial blood gases, (b) knowledge and skills on the basics of mechanical ventilation, and (c) having a minimum 1-year working experience in the ICU. On the other hand, the CPG should mainly focus on developing an ability to identify criteria of patient eligible for weaning from MV. The learning content should focus on: (a) developing the understanding and reasoning for weaning and extubating and (b) technique/algorithm for extubating and weaning. Also, the experts agreed that the log book/competency book should be used for evaluation of the program. The CPG for structured nursing training at IJN in the context of the study is important for developing the professionalism of CICU nurses in IJN and could be used for training nurses in other CICUs, so that decision for ventilator-weaning from postcardiac surgery could be expedited.

Effect of a Sedation and Ventilator Liberation Protocol vs Usual Care on Duration of Invasive Mechanical Ventilation in Pediatric Intensive Care Units: A Randomized Clinical Trial.

Importance: There is limited evidence on the optimal strategy for liberating infants and children from invasive mechanical ventilation in the pediatric intensive care unit. Objective: To determine if a sedation and ventilator liberation protocol intervention reduces the duration of invasive mechanical ventilation in infants and children anticipated to require prolonged mechanical ventilation. Design, Setting, and Participants: A pragmatic multicenter, stepped-wedge, cluster randomized clinical trial was conducted that included 17 hospital sites (18 pediatric intensive care units) in the UK sequentially randomized from usual care to the protocol intervention. From February 2018 to October 2019, 8843 critically ill infants and children anticipated to require prolonged mechanical ventilation were recruited. The last date of follow-up was November 11, 2019. Interventions: Pediatric intensive care units provided usual care (n = 4155 infants and children) or a sedation and ventilator liberation protocol intervention (n = 4688 infants and children) that consisted of assessment of sedation level, daily screening for readiness to undertake a spontaneous breathing trial, a spontaneous breathing trial to test ventilator liberation potential, and daily rounds to review sedation and readiness screening and set patient-relevant targets. Main Outcomes and Measures: The primary outcome was the duration of invasive mechanical ventilation from initiation of ventilation until the first successful extubation. The primary estimate of the treatment effect was a hazard ratio (with a 95% CI) adjusted for calendar time and cluster (hospital site) for infants and children anticipated to require prolonged mechanical ventilation. Results: There were a total of 8843 infants and children (median age, 8 months [interquartile range, 1 to 46 months]; 42% were female) who completed the trial. There was a significantly shorter median time to successful extubation for the protocol intervention compared with usual care (64.8 hours vs 66.2 hours, respectively; adjusted median difference, -6.1 hours [interquartile range, -8.2 to -5.3 hours]; adjusted hazard ratio, 1.11 [95% CI, 1.02 to 1.20], P = .02). The serious adverse event of hypoxia occurred in 9 (0.2%) infants and children for the protocol intervention vs 11 (0.3%) for usual care; nonvascular device dislodgement occurred in 2 (0.04%) vs 7 (0.1%), respectively. Conclusions and Relevance: Among infants and children anticipated to require prolonged mechanical ventilation, a sedation and ventilator liberation protocol intervention compared with usual care resulted in a statistically significant reduction in time to first successful extubation. However, the clinical importance of the effect size is uncertain. Trial Registration: isrctn.org Identifier: ISRCTN16998143.

Compassionate Removal of Heated High-Flow Nasal Cannula for End of Life: Case Series and Protocol Development.

Patients often receive burdensome care at the end of life in the form of interventions that may need to be removed. Heated high-flow oxygen delivered through a nasal cannula (HHFNC) is one such intervention that can be delivered in the hospital yet is rarely available outside of this setting. During the COVID-19 (coronavirus disease 2019) pandemic, health care systems continue to face the possibility of rationing critical life-sustaining equipment that may include HHFNC. We present a clinical protocol designed for weaning HHFNC to allow a natural death and ensuring adequate symptom management throughout the process. This was a retrospective chart review of 8 patients seen by an inpatient palliative care service of an academic tertiary referral hospital who underwent terminal weaning of HHFNC using a structured protocol to manage dyspnea. Eight patients with diverse medical diagnoses, including COVID-19 pneumonia, underwent terminal weaning of HHFNC according to the clinical protocol with 4 down-titrations of approximately 25% for both fraction of inspired oxygen and liter flow with preemptive boluses of opioid and benzodiazepine. Clinical documentation supported good symptom control throughout the weaning process. This case series provides preliminary evidence that the clinical protocol proposed has the ability to ensure comfort through terminal weaning of HHFNC.

L'autonomie décisionnelle d'infirmières de soins intensifs lors du sevrage de la ventilation mécanique : une analyse de concept.

Nurses have a leading role in weaning patients from mechanical ventilation (WMV) given their constant presence and their continuous monitoring. To promote proper WMV, nurses must exercise autonomy and be involved in decision-making. However, in certain care contexts, there is little involvement of nurses. The purpose of this text is to establish the characteristics of the concept of autonomous decision-making applied to nursing during WMV. An analysis of this concept was carried out according to the evolutionary method of Rodgers. The identification of the attributes, antecedents, and consequences made it possible to note ambiguity in the definition of this concept. Nurses use autonomous decision-making for the execution of assigned tasks and when they make decisions according to a pre-prescribed decision-making algorithm. Significant foundations for the decision-making autonomy of critical care nurses during WMV emerged from this analysis : scope of practice, in-depth knowledge of the patient, and commitment to the success of WMV. Participation in interdependent decision-making allows nurses to bring the patient’s perspective into decisions. Avenues of reflection have also emerged, including decisions based on evidence to provide new avenues for autonomous decision-making.

Coronavírus: novos modelos de respiradores estão sendo desenvolvidos em São Paulo?

Saiba mais em www.saopaulo.sp.gov.br/coronavirus

Ciência SP COVID-19: tecnologia para ventiladores pulmonares

Um tomógrafo por impedância elétrica desenvolvido com apoio da FAPESP pela empresa Timpel monitora pacientes que necessitam de ventilação artificial. Seu uso ajuda a aumentar a disponibilidade de ventiladores pulmonares e, consequentemente, de leitos em unidades de terapia intensiva (UTIs) para pacientes com COVID-19 em estado grave.

The Effectiveness of Workshop and Multimedia Training Methods on the Nurses' Decision-Making Skills Regarding Weaning From Mechanical Ventilation.

BACKGROUND: Nurses can safely and effectively wean patients from mechanical ventilation (MV) by the use of proper instruments and planning. OBJECTIVE: The aim of this study was to compare the effectiveness of 2 training methods on the decision-making skill of intensive critical care (ICU) nurses with regard to weaning from MV. METHODS: In this quasi-experimental study, 80 nurses working in ICUs participated in 1 of 2 educational groups in 2016. The interventions were workshop and multimedia training for decision-making skill regarding weaning from MV. The data were gathered from a questionnaire based on the Burns Weaning Assessment Program tool before and 1 month after the intervention. Data were analyzed by independent t test, the χ test, and the Fisher exact test using the software SPSS v. 17. RESULTS: The decision-making skill with regard to awareness of weaning factors (physiological and respiratory) increased in both groups after the intervention (P ≤ .001), but the difference between the 2 groups was not statistically meaningful. Considering the mean scores before and after the intervention, the general skill of decision-making regarding weaning from MV was higher in the multimedia training group compared with the workshop training group (P ≤ .001). CONCLUSION: The multimedia training method, which has been more successful, is recommended owing to its characteristics of virtual education, such as accessibility, flexibility, learner centeredness, and expansibility, as well as nurses' lack of time.

Implementation of a nurse-driven ventilation weaning protocol in critically ill children: Can it improve patient outcome?

BACKGROUND: Critically ill children treated with invasive mechanical ventilation in a paediatric intensive care unit (PICU) may suffer from complications leading to prolonged duration of ventilation and PICU stay. OBJECTIVE: The objective of this study is to find out if the use of a nurse-driven ventilation weaning protocol in a PICU can shorten the duration of mechanical ventilation. METHODS: In a prospective, pretest-posttest implementation study, we implemented a nurse-driven ventilation weaning protocol and compared its outcomes with those of the usual physician-driven weaning. In the posttest period, nurses weaned the patients until extubation as per this protocol. The primary outcome was duration of ventilation. The secondary outcomes were length of PICU stay, reintubation rate, and compliance with the protocol (measured by use of the prescribed support mode). RESULTS: In total, 424 patients aged from 0 to 18 years (212 pretest and 212 posttest) were included; in both groups, the median age was 3 months. The median duration of ventilation did not differ significantly between the pretest and posttest periods: 42.5 h. (interquartile range, IQR 14.3-121.3) vs. 44.5 h (IQR 12.3-107.0), respectively; p = 0.589. In the posttest period, the PICU stay was nonsignificantly shorter: 5.5 days (IQR 2-11) vs. 7 days (IQR 3-14) in the pretest period; p = 0.432. Compliance with the prescribed support mode was significantly higher in the posttest period: 69.9% vs. 55.7% in the pretest period; p = 0.005. The reintubation rate was not significantly different between the pretest and posttest periods (5% vs. 7%, respectively; p = 0.418). The extubation rate during nights was higher in the posttest period but not significantly different (p = 0.097). CONCLUSIONS: Implementation of a nurse-driven weaning protocol did not result in a significantly shorter duration of invasive mechanical ventilation but was safe and successful. The reintubation rate did not significantly increase compared with usual care.

Nurse-initiated spontaneous breathing trials in adult intensive care unit patients: a scoping review.

OBJECTIVE: The objective of this scoping review was to explore existing literature on protocols initiated by nurses for a spontaneous breathing trial in adult intensive care unit (ICU) patients in order to examine and conceptually map the evidence, and identify gaps in the literature. INTRODUCTION: Nurses are vital in the care of the critically ill mechanically ventilated patient. By involving the nurse in the weaning process through implementing the final stage of the weaning process, the spontaneous breathing trial, patients may liberate from mechanical ventilation more readily, thereby reducing the cost of care and number of complications associated with prolonged ventilation. INCLUSION CRITERIA: This review considered experimental and quasi-experimental study designs, analytical observational studies, case-control studies, analytical cross-sectional studies, descriptive observational studies, qualitative studies, and text and opinion papers. Adult ICU patients, aged 18 and over who were mechanically ventilated and candidates for weaning to spontaneous breathing trials, were included in the review. Adult ICUs included but were not limited to burn ICUs, cardiovascular ICUs, medical ICUs, neurological ICUs, surgical ICUs and trauma ICUs in all geographic locations. This scoping review considered studies that examined the use of nurse-initiated protocols for a spontaneous breathing trial. METHODS: The Joanna Briggs Institute scoping review methodology was used. Key information sources searched were Cochrane Database of Systematic Reviews, PubMed, PROSPERO, DARE, CINAHL, Embase, Scopus, Academic Search Premier, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, MedNar, ProQuest Dissertations and Theses, Papers First and societal websites with information relevant to the scoping review. Only studies published in English were included, and no date limits were applied. The data extraction tool was developed by the authors to examine information retrieved from the studies. RESULTS: Four studies, with 430 participants, were included in this review. One study was a non-randomized controlled trial, two were randomized controlled studies, and one was a text and opinion paper. The four studies included in the review identified both eligibility criteria for spontaneous breathing trial initiation, detailed elements of a spontaneous breathing trial, and criteria for success. Three of the four studies reported outcomes with the use of protocols for spontaneous breathing trials initiated by nurses. CONCLUSIONS: All included studies support the utilization of protocols and allowing the nurse to initiate the protocol, however variations in the eligibility criteria, details of the spontaneous breathing trial and success criteria create ambiguity in practice.

Implementing a Weaning Protocol for Cardiac Surgery Patients Using Simulation: A Quality Improvement Project.

BACKGROUND: Mechanical ventilation is the standard of care after cardiac surgery, but it imposes physiologic and psychological stress on patients. The Society of Thoracic Surgery recommends 6 hours as the goal for extubation, but 60% of our patients were not meeting this metric. OBJECTIVES: The objectives of this project were to decrease cardiac surgery patients' ventilation hours and intensive care unit length of stay using a ventilator weaning protocol. METHODS: An evidence-based ventilator weaning protocol was developed, and nurses were prepared for its implementation using a simulation education program. RESULTS: Ventilator hours were reduced from 7.74 to 6.27 (t = 2.5, P = .012). The percentage of patients extubated in 6 hours increased from 40% to 63.5% (χ = 7.757, P = .005). There was no statistically significant decrease in cardiovascular intensive care unit length of stay (17.15 to 15.99, t = 0.619, P = .537). Nurses' scores on a knowledge test increased significantly from pre (6.11) to post (7.79) (t = -5.04, P < .001). Their perception of confidence increased in weaning from pre (median, 4; IQR, 4,4) to post (median, 4; interquartile range [IQR], 4,5), z = -2.71, P = .007, and also in using the protocol from pre (median, 4; IQR, 3,4) to post (median, 4; IQR, 4,5) (z = -3.17, P = .002). DISCUSSION: Using a nurse-led ventilator weaning protocol resulted in decreased ventilator hours for patients and increased knowledge and confidence for nurses.

Early Mobility in the Intensive Care Unit: Evidence, Barriers, and Future Directions.

Early mobility is an element of the ABCDEF bundle designed to improve outcomes such as ventilator-free days and decreased length of stay. Evidence indicates that adherence to an early mobility protocol can prevent delirium and reduce length of stay in the intensive care unit and the hospital and may decrease length of stay in a rehabilitation facility. Yet many barriers exist to implementing early mobility effectively, including patient acuity, uncertainty about when to start mobilizing the patient, staffing and equipment needs, increased costs, and limited nursing time. Implementation of early mobility requires interdisciplinary collaboration, commitment, and tools that facilitate mobility and prevent injury to nurses. This article focuses on aspects of care that can affect patient outcomes, such as preventing delirium, reducing sedation, monitoring the patient's ability to wean from the ventilator, and encouraging early mobility. It also addresses the effects of immobility as well as challenges in achieving mobility and how to overcome them.

A systematic review of nurse-led weaning protocol for mechanically ventilated adult patients.

OBJECTIVES: The aim of this systematic review is to synthesize the current best evidence for the effectiveness of weaning protocols led by nurses compared with usual physician-led care. BACKGROUND: Protocol-directed weaning has been shown to reduce the duration of mechanical ventilation. Studies have reported that a weaning protocol administered by nurses leads to a reduction in the duration of mechanical ventilation and has a major effect on weaning outcomes. This can have especially positive consequences for critically ill patients. STUDY DESIGN: Systematic review with meta-analysis. SEARCH STRATEGY: The databases CINAHL, PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched from as far back as the database allowed until January 2016. INCLUSION AND EXCLUSION CRITERIA: Searches were performed to identify the best available evidence including quantitative studies of nurse-led weaning protocols for mechanically ventilated adult patients. We excluded all studies of weaning protocols implemented by non-nurses and non-invasive mechanical ventilation and studies that addressed patient populations younger than 18 years of age. RESULTS: The database searches resulted in retrieving 369 articles. Three eligible studies with a total of 532 patients were included in the final review. Pooled data showed a statistically significant difference in favour of the nurse-led weaning protocol for reducing the duration of mechanical ventilation (mean differences = -1.69 days, 95% confidence interval = -3.23 to 0.16), intensive care unit length of stay (mean differences = -2.04 days, 95% confidence interval = -2.57 to -1.52, I2 = 18%, and p = 0.00001); and hospital length of stay (mean differences = -2.9 days, 95% confidence interval = -4.24 to -1.56, I2 = 0%, and p = 0.00001). CONCLUSION: There is evidence that the use of nurse-led weaning protocols for mechanically ventilated adult patients has a positive impact on weaning outcomes and patient safety. RELEVANCE TO CLINICAL PRACTICE: This review provides evidence supporting intensive care unit nurses' crucial role and abilities to lead weaning from mechanical ventilation.

Mechanical Ventilation and Extracorporeal Membrane Oxygena tion in Acute Respiratory Insufficiency

Mechanical ventilation is life-saving for patients with acute respiratory insufficiency. In a German prevalence study, 13.6% of patients in intensive care units received mechanical ventilation for more than 12 hours; 20% of these patients received mechanical ventilation as treatment for acute respiratory distress syndrome (ARDS). The new S3 guideline is the first to contain recommendations for the entire process of treatment in these groups of patients (indications, ventilation modes/parameters, accompanying measures, treatments for refractory impairment of gas exchange, weaning, and follow-up care). This guideline was developed according to the GRADE methods. Pertinent publications were identified by a systematic search of the literature, the quality of the evidence was evaluated, a risk/benefit assessment was conducted, and recommendations were issued by interdisciplinary consensus. Mechanical ventilation is recommended as primary treatment for patients with severe ARDS. In other patient groups, non-invasive ventilation can lower mortality. If mechanical ventilation is needed, ventilation modes allowing spontaneous breathing seem beneficial (quality of evidence [QoE]: very low). Protective ventilation (high positive end-expiratory pressure, low tidal volume, limited peak pressure) improve the survival of ARDS patients (QoE: high). If a severe impairment of gas exchange is present, prone positioning lessens mortality (QoE: high). Veno-venous extracorporeal membrane oxygenation (vvECMO) has not unequivocally been shown to improve survival. Early mobilization and weaning protocols can shorten the duration of ventilation (QoE: moderate). Recommendations for patients undergoing mechanical ventilation include lung-protective ventilation, early spontaneous breathing and mobilization, weaning protocols, and, for those with severe impairment of gas exchange, prone positioning. It is further recommended that patients with ARDS and refractory impairment of gas exchange should be transferred to an ARDS/ECMO center, where extracorporeal methods should be applied only after application of all other therapeutic options.

Score for Predicting Ventilator Weaning Duration in Patients With Tracheostomies.

BACKGROUND: Factors affecting the timing of ventilator liberation among patients requiring prolonged mechanical ventilation (≥21 consecutive days) are poorly understood. After tracheostomy placement, ventilator liberation typically involves daily reductions in ventilator support as patients regain the capacity to breathe independently. OBJECTIVES: To determine the association between ventilator requirements on the day after tracheostomy placement and subsequent weaning duration. METHODS: Retrospective review of medical records of adults with tracheostomies treated at an academic medical center from 2011 to 2015. A new ventilator independence score based on ventilator settings on the day after tracheostomy was developed. Scores range from 0% to 100%; higher scores reflect greater levels of unassisted breathing for a greater proportion of the day. A multi-variable competing-risk survival regression model was used to determine the association between the ventilator independence score and time from tracheostomy placement to ventilator liberation. RESULTS: Of 372 patients, 72% were liberated from mechanical ventilation. The ventilator independence score measured on the day after tracheostomy placement had an area under the receiver operating characteristic curve value of 0.71 (95% CI, 0.65-0.76) for differentiating patients who were liberated within the next 14 days from those who were not. Median time from tracheostomy placement to ventilator liberation was 41 days for patients with a score of 0%, 20 days for scores between 0% and 50%, 15 days for scores between 50% and 75%, and 10 days for scores between 75% and 100%. CONCLUSIONS: A score derived from ventilator settings may help clinicians predict the timing of ventilator liberation in patients requiring prolonged mechanical ventilation.

Person-centred care during prolonged weaning from mechanical ventilation, nurses' views: an interview study.

OBJECTIVE: To determine: 1) if the three elements of person-centred care (initiating, working and safeguarding the partnership) were present, and 2) to identify evidence of barriers to person-centred care during prolonged weaning from mechanical ventilation. RESEARCH METHODOLOGY: Secondary analysis of semi structured interviews with 19 critical care nurses using theoretical thematic analysis. SETTING: This study was conducted in three Swedish intensive care units, one in a regional hospital and two in a university hospital. FINDINGS: Three themes and nine subthemes related to person-centred care were identified. The three themes included: 1) 'finding a person behind the patient' related to the 'initiating the partnership' phase, 2) 'striving to restore patient́s sense of control' related to 'working the partnership' phase and 3) 'impact of patient involvement' related to 'safeguarding the partnership' phase of person-centred care'. Additionally a further theme 'barriers to person-centred care' was identified. CONCLUSION: We found evidence of all three person-centred care routines. Barriers to person-centred care comprised of lack team collaboration and resources. Facilitating patients to actively participate in decision-making during the weaning process may optimise weaning outcomes and warrants further research.

Nurses' Sedation Practices During Weaning of Adults From Mechanical Ventilation in an Intensive Care Unit.

BACKGROUND: Sedation and analgesia have an important impact on the outcome of patients treated with mechanical ventilation. International guidelines recommend use of sedation protocols to ensure best patient care. OBJECTIVE: To determine the sedation practice of intensive care nurses weaning adults from mechanical ventilation. METHODS: A cross-sectional survey with a self-administered questionnaire was used to determine sedation practices of Flemish critical care nurses during weaning. Consensus on content validity was achieved through a Delphi procedure among experts. Data were collected during the 32nd Annual Congress of the Flemish Society of Critical Care Nurses in Ghent, Belgium, December 2014. RESULTS: A total of 342 nurses were included in the study. Of these, 43.7% had a sedation protocol in their unit that was used by 61.8% of the respondents. Sedation protocols were more often available (P < .001) in academic hospitals (72%) than in general hospitals (41.5%). Sedatives were administered via continuous infusion with bolus doses if needed (81%). Level of sedation was assessed every 2 hours (56%), mostly via the Richmond Agitation-Sedation Scale (59.1%). Daily interruption of sedation was used by 16.5% of respondents. The biggest barriers to daily interruption were patient comfort (49.4%) and fear of respiratory worsening (46.6%). CONCLUSIONS: A considerable discrepancy exists between international recommendations and actual sedation practices. Standardization of sedation practices across different institutions on a regional and national level may improve the quality of care.

Diseño e implantación de un protocolo de destete de ventilación mecánica invasiva en pacientes posquirúrgicos / Design and implementation of protocolized weaning from invasive mechanical ventilation in postquirurgical patients

Objetivo. Estandarizar el proceso de destete de ventilación mecánica invasiva a través de la construcción de un protocolo de destete y su algoritmo para pacientes posquirúrgicos consensuado por un equipo multidisciplinar. Método. Se realizó una revisión de la literatura comprendida desde el 1 de enero de 2010 hasta el 31 de diciembre de 2015 en las bases de datos Pub- Med, LILACS, Cochrane Library, SciELO y Science Direct. Resultados. Protocolo de destete de ventilación mecánica invasiva. Conclusiones. Los protocolos son herramientas de trabajo efectivas para disminuir el tiempo de destete en el paciente conectado a la ventilación mecánica invasiva y capaces de influir en la morbimortalidad, en la estancia y costes hospitalarios. La evidencia es confusa en el acuerdo sobre qué modo ventilatorio es superior a la hora de iniciar el destete, aunque la prueba de oxígeno en T y la prueba de respiración espontánea son indicadores con altas probabilidades de éxito a la hora de conocer si el paciente podrá ser extubado. Se recomienda la utilización de ventilación de protección pulmonar con volúmenes bajos. Si el paciente falla el proceso de destete, es aconsejable la espera de 24 horas antes de volver a intentarlo, y que el paciente permanezca con un soporte ventilatorio cómodo. Los predictores de destete y las recomendaciones basadas en la evidencia son de gran utilidad. La participación de la enfermera en la creación, implantación y ejecución de los protocolos de destete es de gran relevancia (AU)

Objective. To determine the relevance of de ventilación mecánica invasiva en pacientes posquirúrgicos Diseño e implantación de un protocolo de destete developing a standardize weaning protocol from invasive mechanical ventilation, based on an agreed protocol and algorithm for postsurgical patients by a multidisciplinary professional team. Method. A literature review in the following databases was performed between January, 1st 2010 and December, 31st 2015: PubMed, LILACS, Cochrane Library, SciELO and Science Direct. Results. Several weaning protocols from invasive mechanical ventilation were found. Conclusions. Protocols are effective tools that help reduce weaning time for patients connected to invasive mechanical ventilation. They have an effect on morbidity, mortality, hospital stay and costs. Evidence about which ventilation method is superior to the others when it comes to weaning processes is unclear. However, we found T-piece trials and spontaneous breathing trials (SBT) to be high probability success indicators to determine whether patients were ready for extubation. The use of lung-protective ventilation with low tidal volumes is recommended. If a patient fails during weaning process, it is advisable to wait 24 hours before trying weaning again, keeping the patient stable with a comfortable ventilation support. Successful weaning predictors and evidence-based recommendations are very useful. Nurse involvement in the creation, implementation and execution of weaning protocols is of great importance (AU)

Nurse initiated protocols for spontaneous breathing trials in adult intensive care unit patients: a scoping review protocol.

REVIEW OBJECTIVES/QUESTIONS: The objectives of this scoping review are to explore the existing literature regarding protocols initated by nurses for a spontaneous breathing trial (SBT) in adult intensive care unit (ICU) patients, to examine and conceptually map the evidence, and to identify any gaps in the literature.The questions of this review are.