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We assessed the impact of 2% daily patient bathing with chlorhexidine gluconate (CHG) washcloths on the incidence of hospital-acquired (HA) and central line-associated (CLA) bloodstream infections (BSI) in intensive care units (ICUs). We searched randomised studies in Medline, EMBASE, Cochrane Library (CENTRAL) and Web of Science databases up to April 2015. Primary outcomes were total HABSI, central line, and non-central line-associated BSI rates per patient-days. Secondary outcomes included Gram-negative and Gram-positive BSI rates and adverse events. Four randomised crossover trials involved 25 ICUs and 22,850 patients. Meta-analysis identified a total HABSI rate reduction (odds ratio (OR): 0.74; 95% confidence interval (CI): 0.60-0.90; p = 0.002) with moderate heterogeneity (I2 = 36%). Subgroup analysis identified significantly stronger rate reductions (p = 0.01) for CLABSI (OR: 0.50; 95% CI: 0.35-0.71; p < 0.001) than other HABSI (OR: 0.82; 95% CI: 0.70-0.97; p = 0.02) with low heterogeneity (I2 = 0%). This effect was evident in the Gram-positive subgroup (OR: 0.55; 95% CI: 0.31-0.99; p = 0.05), but became non-significant after removal of a high-risk-of-bias study. Sensitivity analysis revealed that the intervention effect remained significant for total and central line-associated HABSI. We suggest that use of CHG washcloths prevents HABSI and CLABSI in ICUs, possibly due to the reduction in Gram-positive skin commensals.
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Anti-Infecciosos Locais/uso terapêutico , Bacteriemia/prevenção & controle , Banhos/métodos , Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/efeitos adversos , Clorexidina/análogos & derivados , Infecção Hospitalar/prevenção & controle , Desinfetantes/administração & dosagem , Unidades de Terapia Intensiva , Bacteriemia/epidemiologia , Bacteriemia/microbiologia , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/microbiologia , Cateterismo Venoso Central/métodos , Clorexidina/administração & dosagem , Clorexidina/uso terapêutico , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/microbiologia , Estudos Cross-Over , Humanos , Ensaios Clínicos Controlados Aleatórios como AssuntoAssuntos
Anti-Infecciosos , Bacteriemia , Infecções por Pseudomonas , Sepse , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Criança , Humanos , Infecções por Pseudomonas/tratamento farmacológico , Pseudomonas aeruginosa , Estudos Retrospectivos , Sepse/tratamento farmacológicoAssuntos
Cuidados Críticos , Unidades de Terapia Intensiva , Úlcera por Pressão , Adulto , Humanos , Incidência , PrevalênciaRESUMO
BACKGROUND: Use of chlorhexidine gluconate wipes and pre-packed washcloths has been described for preventing pathogen spread in healthcare settings. AIM: To assess the impact of chlorhexidine washcloths/wipes in preventing the spread of pathogens. METHODS: Extensive and structured literature search from studies in Google Academic, Cochrane Library, Web of Science, Pubmed and Cinahl from their inception until November 2012. FINDINGS: Final analysis included 15 studies, 9 of which were randomised controlled trials. The most frequent setting was the intensive care unit. In intensive care units, a significant reduction of bloodstream infection was associated with intervention and 3 studies revealed a decrease in blood culture contamination. One study showed a decrease in staff and environmental contamination and no increase in chlorhexidine resistance with intervention. Positive blood cultures for multiple pathogens also declined with intervention. In a paediatric intensive care unit, intervention decreased bacteraemia and catheter-associated bloodstream infection. In hospital wards, intervention was associated to a 64% reduction of pathogen transmission. One study had no statistically significant results. Pre-surgical chlorhexidine use significantly decreased bacterial colonisation but had no impact on surgical site infections. Regarding maternal and perinatal setting, one study did not show reduction of early onset neonatal sepsis and pathogen transmission. Another study of vaginal and neonatal decolonisation with chlorhexidine wiping revealed significant reduction in colonisation. One study concluded that single and multiple umbilical cord cleansing reduced the likelihood for a positive swab in 25% and 29%, respectively. Neonatal wiping maintained low levels of skin colonisation for a 24h period, for multiple pathogens. CONCLUSION: Current evidence supports the usefulness of chlorhexidine washcloths and wipes in an intensive care, hospital and pre-surgical setting. More studies are required to encourage its use for prevention of perinatal and neonatal transmission of pathogens.
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Anti-Infecciosos Locais/farmacologia , Clorexidina/análogos & derivados , Infecção Hospitalar/prevenção & controle , Controle de Infecções/instrumentação , Clorexidina/farmacologia , Humanos , Unidades de Terapia IntensivaRESUMO
OBJECTIVES: Late-onset sepsis is a frequent complication in neonatal intensive care units. This study aims to understand the effect of late-onset sepsis on mortality in hospitalised neonatal patients across different gestational ages. DESIGN: This is a single-centre, historical cohort study including neonates admitted to hospital during a 10-year period (2002 - 2011). Neonates were stratified by gestational age: extremely preterm (<28 weeks), very preterm (28 to 32 weeks), late preterm (33 to 36 weeks), full term (>37 weeks). SETTING: Tertiary NICU in Ghent, Belgium. MAIN OUTCOME MEASURES: Logistic regression analysis was used to assess adjusted relationships between late-onset sepsis and mortality, reported as odds ratio (OR) and 95% confidence interval (CI). RESULTS: A total of 4928 neonates were included, of which 2071 were term (42.0%), 1425 were late preterm (28.9%), 1165 very preterm (23.6%) and 264 were extremely preterm neonates (5.4%). 40 neonates developed late-onset sepsis (8.2 episodes/1000 patient days). Overall, in-hospital mortality was 5.4%. Late-onset sepsis was an independent risk factor for mortality in the total cohort (OR = 2.41; 95% CI = 1.46-3.96). However, when gestational age groups were considered separately, late-onset sepsis was associated with mortality in very preterm neonates (OR = 2.45; 95% CI = 1.03-5.84) and in the late preterm neonates (OR = 3.92; 95% CI = 1.41-10.87), but not in other neonates. Comorbidities burdening neonatal hospital survival include acute lung disease, brain damage, periventricular leukomalacia, surgery, and broncho-pulmonary dysplasia. CONCLUSION: Late-onset sepsis is an independent risk factor for mortality in very preterm and late preterm neonates. Understanding how late-onset sepsis among other factors impact mortality enables a patient and family-centred approach to nursing care including the anticipation of realistic milestones. IMPLICATIONS FOR CLINICAL PRACTICE: Late-onset sepsis is especially detrimental to preterm neonates and this could be taken into consideration by nurses when communicating with families in the perinatal period.
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Recém-Nascido Prematuro , Sepse , Recém-Nascido , Gravidez , Feminino , Humanos , Lactente , Idade Gestacional , Unidades de Terapia Intensiva Neonatal , Estudos de Coortes , Sepse/complicações , Estudos RetrospectivosRESUMO
Background: It is now a requirement that all qualified nurses act as practice supervisors and support student nurses' education in practice, hence preparing third-year students for this role is a priority. This study evaluates students' experiences of peer teaching in clinical skills setting from the perspective of these students taking up the supervisory role once they graduate. Method: An evaluative survey was utilised to explore and understand student nurse participation in peer teaching. Seventeen students took part in a questionnaire containing closed and open questions. Results: This research suggests that students who engaged in peer teaching gained confidence in their own skills, through the revision of their own skills and knowledge. It also triggered reflection upon continuous professional development and inspired students to consider a future career in teaching. Conclusion: Peer teaching provides an opportunity to reinforce the students' knowledge, clinical and communication skills. It helps prepare them for the role of practice supervisor upon qualifying by building confidence and enhancing their teaching skills.
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BACKGROUND: Pressure injuries are a frequent complication in intensive care unit (ICU) patients, especially in those with comorbid conditions such as chronic obstructive pulmonary disease (COPD). Yet no epidemiological data on pressure injuries in critically ill COPD patients are available. OBJECTIVE: To assess the prevalence of ICU-acquired pressure injuries in critically ill COPD patients and to investigate associations between COPD status, presence of ICU-acquired pressure injury, and mortality. STUDY DESIGN AND METHODS: This is a secondary analysis of prospectively collected data from DecubICUs, a multinational one-day point-prevalence study of pressure injuries in adult ICU patients. We generated a propensity score summarizing risk for COPD and ICU-acquired pressure injury. The propensity score was used as matching criterion (1:1-ratio) to assess the proportion of ICU-acquired pressure injury attributable to COPD. The propensity score was then used in regression modeling assessing the association of COPD with risk of ICU-acquired pressure injury, and examining variables associated with mortality (Cox proportional-hazard regression). RESULTS: Of the 13,254 patients recruited to DecubICUs, 1663 (12.5%) had documented COPD. ICU-acquired pressure injury prevalence was higher in COPD patients: 22.1% (95% confidence interval [CI] 20.2 to 24.2) vs. 15.3% (95% CI 14.7 to 16.0). COPD was independently associated with developing ICU-acquired pressure injury (odds ratio 1.40, 95% CI 1.23 to 1.61); the proportion attributable to COPD was 6.4% (95% CI 5.2 to 7.6). Compared with non-COPD patients without pressure injury, mortality was no different among patients without COPD but with pressure injury (hazard ratio [HR] 1.07, 95% CI 0.97 to 1.17) or COPD patients without pressure injury (HR 1.13, 95% CI 1.00 to 1.27). Mortality was higher among COPD patients with pressure injury (HR 1.35, 95% CI 1.15 to 1.58). CONCLUSION AND IMPLICATIONS: Critically ill COPD patients have a statistically significant higher risk of pressure injury. Moreover, those that develop pressure injury are at higher risk of mortality. As such, pressure injury may serve as a surrogate for poor prognostic status to help clinicians identify patients at high risk of death. Also, delivery of interventions to prevent pressure injury are paramount in critically ill COPD patients. Further studies should determine if early intervention in critically ill COPD patients can modify development of pressure injury and improve prognosis.
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Estado Terminal , Úlcera por Pressão , Doença Pulmonar Obstrutiva Crônica , Adulto , Humanos , Mortalidade Hospitalar , Unidades de Terapia Intensiva , Pontuação de Propensão , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
PURPOSE: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. METHODS: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. RESULTS: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9-27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6-16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score < 19, ICU stay > 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2-1.8), stage II (OR 1.6; 95% CI 1.4-1.9), and stage III or worse (OR 2.8; 95% CI 2.3-3.3). CONCLUSION: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat.
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Unidades de Terapia Intensiva , Úlcera por Pressão , Adulto , Idoso , Humanos , Masculino , Mortalidade Hospitalar , Alta do Paciente , Prevalência , Respiração Artificial , Fatores de Risco , Úlcera por Pressão/epidemiologia , FemininoRESUMO
BACKGROUND: Neonatal research evaluates many different outcomes using multiple measures. This can prevent synthesis of trial results in meta-analyses, and selected outcomes may not be relevant to former patients, parents and health professionals. OBJECTIVE: To define a core outcome set (COS) for research involving infants receiving neonatal care in a high-income setting. DESIGN: Outcomes reported in neonatal trials and qualitative studies were systematically reviewed. Stakeholders were recruited for a three-round international Delphi survey. A consensus meeting was held to confirm the final COS, based on the survey results. PARTICIPANTS: Four hundred and fourteen former patients, parents, healthcare professionals and researchers took part in the eDelphi survey; 173 completed all three rounds. Sixteen stakeholders participated in the consensus meeting. RESULTS: The literature reviews identified 104 outcomes; these were included in round 1. Participants proposed 10 additional outcomes; 114 outcomes were scored in rounds 2 and 3. Round 1 scores showed different stakeholder groups prioritised contrasting outcomes. Twelve outcomes were included in the final COS: survival, sepsis, necrotising enterocolitis, brain injury on imaging, general gross motor ability, general cognitive ability, quality of life, adverse events, visual impairment/blindness, hearing impairment/deafness, retinopathy of prematurity and chronic lung disease/bronchopulmonary dysplasia. CONCLUSIONS AND RELEVANCE: A COS for clinical trials and other research studies involving infants receiving neonatal care in a high-income setting has been identified. This COS for neonatology will help standardise outcome selection in clinical trials and ensure these are relevant to those most affected by neonatal care.
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Pesquisa Biomédica , Neonatologia , Avaliação de Resultados em Cuidados de Saúde , Humanos , LactenteRESUMO
INTRODUCTION: Neonatal sepsis is a major cause of morbidity and mortality. Late-onset sepsis affects a significant percentage of infants admitted to the neonatal intensive care unit (NICU). Most affected newborns are preterm or low birth weight, but late-onset sepsis also affects late preterm and term infants. Understanding how gestational age affects the epidemiology of late-onset sepsis can be of use when defining strategies for its prevention and clinical management in NICU. Areas covered: Available evidence suggests the incidence and mortality of late-onset sepsis is higher in preterm and VLBW infants, but pathogen distribution and risk exposure is similar across all infants admitted to NICU. More research is required for late-onset sepsis in late preterm and term infants admitted to NICU. There is some research insight on the impact of gut bacteria in the epidemiology of Gram-negative sepsis, which could benefit from further dedicated studies. Expert commentary: Understanding the manner in which some infants develop severe sepsis and others don't and what the long-term outcomes are is fundamental to guide management strategies. Further research should focus both on infants' characteristics and on pathogenic processes. The ultimate goal is to be able to design guidelines for prevention and management of sepsis that are adapted to a varied neonatal population.
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Idade Gestacional , Unidades de Terapia Intensiva Neonatal , Sepse/epidemiologia , Feminino , Humanos , Incidência , Recém-Nascido de Baixo Peso , Recém-Nascido , Recém-Nascido Prematuro , Gravidez , Sepse/microbiologia , Sepse/mortalidadeRESUMO
Although deregulation of EPHB signaling has been shown to be an important step in colorectal tumorigenesis, the role of EPHB6 in this process has not been investigated. We found here that manipulation of EPHB6 levels in colon cancer cell lines has no effect on their motility and growth on a solid substrate, soft agar or in a xenograft mouse model. We then used an EphB6 knockout mouse model to show that EphB6 inactivation does not efficiently initiate tumorigenesis in the intestinal tract. In addition, when intestinal tumors are initiated genetically or pharmacologically in EphB6+/+ and EphB6-/- mice, no differences were observed in animal survival, tumor multiplicity, size or histology, and proliferation of intestinal epithelial cells or tumor cells. However, reintroduction of EPHB6 into colon cancer cells significantly reduced the number of lung metastasis after tail-vein injection in immunodeficient mice, while EPHB6 knockdown in EPHB6-expressing cells increased their metastatic spread. Consistently, although EPHB6 protein expression in a series of 130 primary colorectal tumors was not associated with patient survival, EPHB6 expression was significantly lower in lymph node metastases compared to primary tumors. Our results indicate that the loss of EPHB6 contributes to the metastatic process of colorectal cancer.
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Biomarcadores Tumorais , Neoplasias Colorretais/genética , Neoplasias Colorretais/patologia , Receptores da Família Eph/deficiência , Animais , Linhagem Celular Tumoral , Movimento Celular/genética , Proliferação de Células , Transformação Celular Neoplásica/genética , Neoplasias Colorretais/metabolismo , Neoplasias Colorretais/mortalidade , Modelos Animais de Doenças , Expressão Gênica , Humanos , Imuno-Histoquímica , Camundongos , Camundongos Knockout , Metástase Neoplásica , Estadiamento de Neoplasias , Prognóstico , Receptores da Família Eph/genética , Receptores da Família Eph/metabolismoAssuntos
Manejo da Dor , Tato , Calcanhar , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , DorRESUMO
The intensive care unit is a work environment where superior dedication is crucial for optimizing patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the numerous research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovation in the field. This article broadly summarizes new developments in multidisciplinary intensive care. It provides elementary information about advanced insights in the field via brief descriptions of selected articles grouped by specific topics. Issues considered include care for heart patients, mechanical ventilation, delirium, nutrition, pressure ulcers, early mobility, infection prevention, transplantation and organ donation, care for caregivers, and family matters.
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Cuidados Críticos/métodos , Administração dos Cuidados ao Paciente/métodos , Cuidados Críticos/normas , Humanos , Unidades de Terapia Intensiva , Administração dos Cuidados ao Paciente/normasAssuntos
Unidades de Terapia Intensiva Neonatal , Sepse , Criança , Coagulase , Humanos , Recém-Nascido , StaphylococcusRESUMO
The intensive care unit is a work environment where superior dedication is pivotal to optimize patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the abundance of research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovations in the field. This article broadly summarizes new developments in multidisciplinary intensive care, providing elementary information about advanced insights in the field by briefly describing selected articles bundled in specific topics. Issues considered include cardiovascular care, monitoring, mechanical ventilation, infection and sepsis, nutrition, education, patient safety, pain assessment and control, delirium, mental health, ethics, and outcomes research.
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Enfermagem de Cuidados Críticos/educação , Cuidados Críticos/tendências , Unidades de Terapia Intensiva/tendências , Equipe de Assistência ao Paciente/tendências , Segurança do Paciente/normas , Respiração Artificial/normas , Simulação por Computador , Cuidados Críticos/métodos , Enfermagem de Cuidados Críticos/normas , Enfermagem de Cuidados Críticos/tendências , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/etiologia , Infecção Hospitalar/prevenção & controle , Desinfecção/métodos , Desinfecção/normas , Humanos , Capacitação em Serviço/normas , Capacitação em Serviço/tendências , Unidades de Terapia Intensiva/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/normas , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Desmame do Respirador/métodos , Desmame do Respirador/normas , Recursos HumanosRESUMO
Activation of the small GTPase RHOA has strong oncogenic effects in many tumour types, although its role in colorectal cancer remains unclear. Here we show that RHOA inactivation contributes to colorectal cancer progression/metastasis, largely through the activation of Wnt/ß-catenin signalling. RhoA inactivation in the murine intestine accelerates the tumorigenic process and in human colon cancer cells leads to the redistribution of ß-catenin from the membrane to the nucleus and enhanced Wnt/ß-catenin signalling, resulting in increased proliferation, invasion and de-differentiation. In mice, RHOA inactivation contributes to colon cancer metastasis and reduced RHOA levels were observed at metastatic sites compared with primary human colon tumours. Therefore, we have identified a new mechanism of activation of Wnt/ß-catenin signalling and characterized the role of RHOA as a novel tumour suppressor in colorectal cancer. These results constitute a shift from the current paradigm and demonstrate that RHO GTPases can suppress tumour progression and metastasis.