American Journal of Critical Care. 2008;17: 406
Copyright © 2008 by the American Association of Critical-Care Nurses.
Clinical Pearls
By
Mary Jo Grap, RN, PhD, Section Editor.
 |
Survey of Cuff Management Practices
|
|---|
How do you manage and monitor endotracheal tube cuff pressures in your unit? Do you have a written protocol? Is it a nursing or solely a respiratory therapy responsibility? Unfortunately, there are few if any "gold standards" in this area.
In this issue, Rose and Redl describe their findings related to the current practices in Australia and New Zealand. Some issues to consider:
- Underinflation of the endotracheal cuff can lead to aspiration, especially during inspiration, and overinflation can result in tracheal ischemic damage.
- Four methods for monitoring cuff inflation are used around the world, but there are no data to support one over the other. However, the palpation of the pilot balloon method is used infrequently because it is very subjective and can result in excessive cuff pressures.
- Cuff pressure may be affected by body position, head alignment, tube migration, coughing, lung compliance, and airway and intrathoracic pressures, so frequent assessments should be conducted.
- Serial cuff pressure measurements are recommended, but optimal frequency has not been determined.
- To detect laryngeal edema, the endotracheal cuff-leak test (performed by using cuff deflation and then calculating the difference between expired tidal volume as measured with and without cuff deflation) has high levels of sensitivity and specificity.
See Article, pp 428–435
|
Evaluating the Evidence: A New Use for ICDs
|
|---|
Evidence-based practice is the foundation of critical care nursing, including the ability to critically evaluate that evidence.
In this issue, Chapa and colleagues provide an excellent example of such an evaluation process related to use of implantable cardioverter-defibrillators in patients with heart failure without ventricular arrhythmias.
As these authors illustrate, there are several issues to consider when evaluating the evidence:
- Do the studies have similar purposes and/or outcomes?
- Are the study designs, definitions, populations used, and processes similar? Or are the studies comparing "apples and oranges"?
- What is the strength of the evidence? Is it based on multiple, large studies published in high-quality, peer-reviewed journals?
- Is the effect large enough and cost-effective enough to warrant a change in clinical practice?
All evidence may not meet these criteria, as it may not be possible to conduct randomized, clinical trials in every case. Still, practice must be based on a critical review of the best possible evidence available.
See Article, pp 443–453
|
Physical Restraints and Unplanned Extubation
|
|---|
Unplanned extubation occurs frequently, whether patients are restrained or not, and can result in life-threatening outcomes such as cardiopulmonary arrest. Reintubation can often lead to hemodynamic and airway complications.
In this issue, Chang and colleagues evaluate the influence of physical restraint on unplanned extubations. They found the following:
- an incidence rate of unplanned extubation of 8.7%;
- risk factors for unplanned extubation include use of physical restraints, presence of nosocomial infection, and level of consciousness at ICU admission;
- a GCS score of 9 or greater on ICU admission increases the risk by 1.98 times, the presence of nosocomial infection increases the risk by 2.02 times, and the use of physical restraint increases the risk by 3.11 times;
- episodes of unplanned extubation increased the ICU length of stay.
See Article, pp 408–416
Clinical Pearls is designed to help implement evidence-based care at the bedside by summarizing some of the most clinically useful material from select articles in each issue. Readers are encouraged to photocopy this ready-to-post page and share it with colleagues. Please be advised, however, that any substantive change in patient care protocols should be carefully reviewed and approved by the policy-setting authorities at your institution.
Related articles in AJCC:
- Influence of Physical Restraint on Unplanned Extubation of Adult Intensive Care Patients: A Case-Control Study
- Li-Yin Chang, Kai-Wei Katherine Wang, and Yann-Fen Chao
AJCC 2008 17: 408-415.
[Abstract]
[Full Text]
- Survey of Cuff Management Practices in Intensive Care Units in Australia and New Zealand
- Louise Rose and Leanne Redl
AJCC 2008 17: 428-435.
[Abstract]
[Full Text]
- Reducing Mortality With Device Therapy in Heart Failure Patients Without Ventricular Arrhythmias
- Deborah W. Chapa, Hyeon-Joo Lee, Chi-Wen Kao, Erika Friedmann, Sue A. Thomas, Jill Anderson, and Gust H. Bardy
AJCC 2008 17: 443-452.
[Abstract]
[Full Text]
Top
Survey of Cuff Management...
Evaluating the Evidence: A...
