Frequency of ETT Movement

Unplanned Extubation in Adult Critical Care

Comparison of high and low pillow heights for tracheal tube intubation with the Pentax-AWS Airwayscope®: a prospective randomized clinical trial

Preoxygenation and Prevention of Desaturation During Emergency Airway Management

<p>Although great strides have been made to tackle hospital-acquired pressure ulcers (HAPUs), there is a need for greater recognition of device-related pressure ulcers (DRPUs), including their causes, management and prevention. This consensus statement, an updated second edition, aims to continue raising awareness of these largely preventable injuries and, crucially, to stimulate action. DRPUs are relatively common and account for a growing proportion of HAPUs. Updated information on the incidence of DRPUs is described in chapter 1. Although it is recognised that DRPUs increase the financial burden of healthcare, there is little formal analysis of their economic impact. This needs to be addressed; robust evidence on the burden of DRPUs and the value that can be released by adopting prevention strategies is needed to help drive action. Our understanding of the pathophysiology of DRPUs has improved significantly over the past few years; this is described in chapter 2. One crucial difference between PUs and DRPUs is that body-weight forces are less significant in DRPUs, with the force being exerted from a device that is typically strapped or taped onto the body. Devices and their securement may generate high stress concentrations in tissues, leading to cell and tissue-damage pathways associated with sustained deformation. As more evidence is published on DRPUs, recurring themes are emerging, as outlined in chapter 3: The most vulnerable patients are bearing the brunt of DRPUs; paediatric and neonatal patients, and all those needing critical care are particularly susceptible. During the COVID-19 pandemic, a new high-risk population (people with severe COVID-19 infection) emerged. They are at increased risk of DRPUs because of their need for prolonged ventilatory support, especially when 'proning' Devices associated with DRPUs are often used to perform essential, life-saving functions. They include continuous positive airway pressure (CPAP) masks or endotracheal tubes. Minimising their use is clearly not an option, so practice innovation is needed Although the most common locations for DRPUs are the face, ears, lower legs and heels, any location where a device comes into close contact with the skin can be at risk. In the same vein, any device, whether needed for a medical purpose or not, has the capacity to cause injury if its use is not properly managed. Vigilance is needed for all patients. What can be done? The importance of routine risk assessment is covered in chapter 4. Although use of a validated risk assessment tool is the vital first step, this will not be enough on its own. Several steps can be taken to ensure the safe use of devices. These are described in chapter 5 and include device repositioning, cushioning with prophylactic dressings and moisture control (only where possible and clinically appropriate). Of key importance is the development of an institutional protocol and champions to ensure all necessary steps are adopted. For any of these changes to be put into practice, awareness of DRPUs needs to increase. A number of proposals are outlined in chapter 6. A change of focus among health professionals and policy makers, along with more investment in education and training, are needed. All patients being managed with a medical device must be considered as at high risk. The pandemic introduced the world to the problem of DRPUs in health professionals caused by the extended wear of personal protective equipment. Health professionals also have a right to expect institutional protocols and provision of devices that protect them from DRPUs. Cutting-edge ideas and technologies that may be available in the future are described in chapter 7. When designing new products, manufacturers of medical devices have a duty of care to investigate the risks of DRPUs associated with their products and mitigate them, wherever possible. Our developing understanding of how the design, structure and materials used in medical devices contribute to DRPUs will help us develop new solutions for tomorrow. The first step is for everyone involved to ask themselves, 'what can I do to help?' There is work to be done-your journey to reduce DRPUs starts here!.</p>

There is a significant focus on pressure injury prevention to promote better patient outcomes and control health care cost. In 2016, the institution's pressure injury quarterly prevalence survey showed that two-thirds of the patients surveyed who developed unit-acquired pressure injury stage 2 and greater were in the adult intensive care units. The quality improvement project used a pre- and postintervention design. The adult medical intensive care unit (MICU) executed a competency-based education project to increase staff implementation of pressure injury prevention. Following initiation of competency-based education, staff documentation of pressure injury prevention implementation increased, and unit-acquired pressure injury stage 2 and greater rates were reduced. The use of a competency-based education program may be effective in increasing pressure injury prevention in the intensive care unit.

Early in the coronavirus disease 2019 (COVID-19) pandemic, it was reported that prone position was beneficial for mechanically ventilated COVID-19 patients with acute respiratory distress syndrome (ARDS). However, for staff in some small and large hospitals, experience with this intervention was low. Select hospitals were able to assemble proning teams; but, as facilities began to experience staffing shortages, they found proning teams unsustainable, and less specialized staff needed to learn how to safely prone patients. Proning is a high-risk procedure-a lack of a standard approach can result in staff confusion and poor patient outcomes, including unintentional endotracheal tube (ET) loss, vascular access dislodgement, and skin breakdown. Given the acuity and high patient volume, translating a complex procedure into written policy may not be entirely effective. Critical care nurses, respiratory therapists, physical therapists, wound nurses, nurse practitioners, physician assistants, and medical doctors need to be prepared to safely perform this procedure for an acutely ill COVID-19 patient. Communication, teamwork, and multidisciplinary collaboration are critical for complication avoidance. Interventions to prevent tube and vascular access dislodgement, skin breakdown, and brachial plexus and soft tissue injury must be implemented during the procedure. Repositioning the patient in the prone position, as well as returning the patient to supine positioning, should be components of a comprehensive proning plan.

In intensive care units (ICUs), endotracheal tubes (ETTs) cause injury to the oral mucosa through friction and pressure. The incidence and risk factors of oral mucosal pressure injuries (PIs) have gained increasing attention in recent years. The study aimed to identify risk factors for oral mucosal PIs associated with ETTs. This was a single-centre brief follow-up longitudinal study conducted from January to May 2022. It recruited 250 patients without oral mucosal PIs who received mechanical ventilation support via ETT and were hospitalized in the ICU of a teaching and research hospital in Turkey. Receiver operating characteristic (ROC) analysis was performed to estimate the onset time of oral mucosal PI using the ETT repositioning time as an independent variable. Oral mucosal PIs associated with ETT developed in 41.6% of patients. Of the 250 endotracheally intubated patients, the mean Acute Physiology and Chronic Health Evaluation (APACHE-II) score was 27.5 (min/max: 18/42), the mean length of stay (LOS) in the ICU was 24 days (min/max: 13/80). The median body mass index (BMI) of patients with oral mucosal PIs was (24.59 [IQR = 3.81] kg/m2), significantly lower than the median BMI of patients without oral mucosal PIs (26.62 [IQR = 5.93] kg/m2) (Z = 4.200; p < .001). The earliest onset of oral mucosal PIs was noted at 16 h after the start of follow-up, and the latest was 208 h after the start of follow-up, with a median of 160 (IQR = 48) h (approximately 6.7 days). Patients whose ETT was repositioned after 10.5 h had a higher risk of developing oral mucosal PIs (OR = 3.77; 95% CI: 2.65-5.37; p < .001). The decision tree (CHAID) method was applied to determine the time required to reposition the ETT to prevent oral mucosal PIs. The decision tree correctly classified the occurrence of oral mucosal PIs by 60.6% and the non-occurrence of oral mucosal PIs by 97.9%. Patients with parenteral nutrition and a low frequency of ETT repositioning time had a higher risk of oral mucosal PIs (p < .001). Parenteral nutrition support and ETT repositioning timing were the primary risk factors for developing oral mucosal PIs. Close monitoring of endotracheally intubated patients receiving parenteral nutrition is essential, with particular attention to forming oral mucosal PIs. Additionally, repositioning the ETT at intervals of no more than 8 h may help reduce the risk of oral mucosal PI development. As ICU patients are particularly vulnerable to mucosal membrane PIs, recognizing the associated risk factors is crucial for early detection and prevention. This study highlights the specific risk factors for oral mucosal PIs, equipping nurses with the knowledge to develop targeted interventions to prevent these injuries.

Background:Data describing an endotracheal tube holder both for securing an endotracheal tube (ETT) and reducing skin breakdown compared to cloth tape or other methods of securing the ETT in adult intensive care units (ICU) are limited. Pressure injuries associated with ETTs are concerning due to increased morbidity, treatment cost, and reduced reimbursement. Having a device specific to secure an ETT may reduce variation and improve outcomes. We have used cloth tape to secure ETTs for many years at our hospital. We hypothesize that using a device designed to secure the ETT would reduce hospital-acquired pressure injuries to the mouth and face and secure the airway better than tape. Methods:The Hollister AnchorFast ETT holder was initiated on all intubated patients that met criteria in our adult intensive care units starting in August 2017. Data was retrospectively collected on number of skin injuries to the mouth/face and unplanned extubations compared to ETTs secured with 1 inch cloth adhesive tape. We collaborated with the ICU nurses to ensure that the ETT holder would be repositioned as recommended every two hours. Two data periods were analyzed, PRE - January 2016 to August 2017, POST - August 2017 to present. Results:7,614 patients received mechanical ventilation in the adult ICU's since January of 2016, 5,286 patients in the prior to the ETT holder (PRE) and 2328 patients during use of the ETT holder (POST). See data table for incidence of injury and unplanned extubations. Conclusions:Pressure injuries associated with the ETT had a significant decrease from 2.93% (PRE) to 1.97% (POST). Along with the reduction in skin breakdown, the number of unplanned extubations was unchanged. Future studies should investigate the quality of mouth care given when using an ETT holder versus cloth tape.Facial Injuries and Unplanned Extubations PRE and POST Implementation of an Endotracheal Tube HolderData ElementPREPOSTp valueVentilator Patients52862328 # Facial Injury/Ulcerations15546 % with Facial Injury/Ulceration2.93%1.97%0.015# Unplanned Extubations11257 % With Unplanned Extubation2.11%2.44%0.315

To assess the impact of delay in emergency department (ED) on outcome of critically ill patients admitted to the medical intensive care unit (MICU). Outcome was defined as hospital mortality and as health-related quality of life (HRQoL) at 6 months after intensive care assessed by the 15D measure. The 15D is a generic, 15-dimensional, standardized measure of HRQoL. We hypothesized that prolonged stay in the ED is related to worse outcome. A prospective follow-up cohort study in university hospital. All consecutive 1675 patients admitted to the MICU between July 2002 and June 2004. The 15D questionnaire was mailed to all patients alive at 6 months after admission. Of all MICU patients, 64% were admitted from ED. The mean length of stay in the ED was 6.2 h (95%CI 5.9-6.5 h). The hospital mortality rate was 24.4% (20.0% in the ED vs. 33.0% in the non-ED cohort, P < 0.001) and it was associated with higher age and degree of physiological derangement at admission. Neither the length of ED stay was associated with hospital mortality (P = 0.82) nor with HRQoL at 6 months after MICU admission (P = 0.34). Altogether, HRQoL at 6 months was significantly lower compared with the age- and sex-matched general population (P < 0.001). In a university hospital, the length of ED stay was not associated with the outcome of critically ill medical patients. However, we feel that the effect of ED treatment and delay on outcome and outcome prediction in the critically ill patients deserves further evaluation.

Purpose: A retrospective descriptive study was performed to develop strategies to manage or prevent pressure ulcers in patients with severe trauma being cared for in the trauma intensive care unit (TICU).Methods: Study data was compiled from 315 patients with severe trauma (injury severity score ≥ 15) who were admitted to a general hospital from January 1, 2020, to February 28, 2021 and were being cared for in the TICU. For patients with pressure ulcers, the characteristics and associated factors of pressure ulcers were examined.Results: There were 42 severe trauma patients (13.3%) with pressure ulcers, of which, 50.0% of cases occurred at the site of the coccyx. In 50% of patients, Stage 2 pressure ulcers were observed. The mean onset day of pressure ulcers was 9.74 days after admission. The occurrence of diabetes, critical care triage score, length of stay in intensive care, death, shock, dialysis, ventilator application, endotracheal intubation, peripheral insertion central catheter insertion, A-line insertion, body protector application, sedatives, blood pressure boosters, nasal cannula, high-flow oxygenators, oxygen tip application, drainage insertion, nasogastric tube nutrition, and ventilator application period were investigated. Logistic regression analysis revealed that the influencing factors for the development of pressure ulcers were endotracheal intubation, length of stay in the TICU, and age, in that order.Conclusion: By identifying the characteristics and risk factors associated with pressure ulcers in patients with severe trauma, strategies can be developed to better prevent or manage pressure ulcers in the future.

Background Negative pressure wound therapy (NPWT) includes closed vacuum drainage (VSD) technology and vacuum assisted closure (VAC) technology, which have been used as the new treatments to promote acute and chronic wound healing for nearly 20 years. Currently, the Medline database has collectively referred to these techniques as the negative pressure wound therapy (NPWT) . Among them, VAC is a medical foam material with pore spaces (commonly using hydrophobic polyurethane foam dressing) to cover the wound after debridement, and is sealed with a transparent film to form a confined space. Then it is connected with a dedicated negative pressure pump for continuous or discontinuous negative pressure suction, so as to fully drain wound exudate and infectious substances, reduce edema, increase local blood flow, reduce the number of bacteria on the wound, and accelerate the growth rate of granulation tissue, thereby effectively promoting of secondary or tertiary (delayed) wound healing. In recent years, VAC has been widely used in trauma orthopedics, mainly for acute and chronic wounds, soft tissue infections, ulcers (such as diabetic ulcers or pressure sores) , and wounds before and after flap transplantation. Due to the complexity of the VAC tubing connection, the lack of preventive measures against unplanned extubation during clinical care can result in wound exposure, increase the incidence of complications, and lead to adverse care events. Different methods of tubing fixation have various effects in preventing unplanned extubation. Therefore, the innovative fixation of the VAC tubing fixation method ensures safe and effective treatment while also reducing unplanned accidental extubation. Methods 1. General information: From July 2016 to June 2018, our department treated 77 patients with upper extremity trauma and infection, including 43 males and 34 females. Their ages ranged from 12 to 79 years. The reasons for VAC included 1 case of compartment syndrome, 28 cases of dog bite, 25 cases of open injury, 9 cases of soft tissue infection, 3 cases of postoperative wound nonunion, and 11 cases of postoperative wound infection. Forty-one patients received VAC tubing fixation with conventional methods, including 23 males and 18 females, and their ages ranged from 12 to 71 years (48.32±17.36) years; 36 patients received VAC tubing fixation with sandwich method, including 20 males and 16 females, and their ages ranged from 22 to79 years (55.19±14.27) years. 2. Intervention methods: (1) Conventional tube fixation group. The hydrophobic polyurethane foam dressing was cut during surgery to fit the wound size, including the fistula and ulcer; the sealing membrane was trimmed to completely cover the dressing and the area beyond the edge of the wound 3-5 cm. The operator used the index finger and thumb to pinch the sealing film, cut a small hole in the film to allow the wound to seep through (without opening the dressing) , opened the suction cup, and fixed the suction cup on the sealing film. Finally, the treatment host was connected, and the pressure was set by touching the screen of VAC negative pressure wound therapy device. (2) Sandwich method fixation group. On the basis of the last step of the conventional tubing fixation method, the film was covered on the fixed suction cup and the proximal end of the VAC tube, and the VAC tube was fixed on the corresponding limb with the high lift method. If the suction cup was fixed near the joint, it should be protected by a brace to prevent from falling off due to repeated movement of the joint. 3. Statistical methods: SPSS23.0 statistical software was used to analyze and process the data. The measurement data was expressed as±s; the count data was described by the number of cases and percentage, and the chi-square test was used. A value of P<0.05 was considered significant difference. Results There were no significant differences in gender and age between the two groups (P>0.05) . In the conventional tube fixation group, there were 8 cases of dissociations, 3 cases of sudden position change, 4 cases of postoperative delirium with postoperative sputum self-extraction, and 1 case of patient consciously uncomfortable to pull the tube accidentally. In the sandwich method group, 1 case of unplanned extubation occurred due to the reason of postoperative delirium and inability to corporate with care. There was a statistically significant difference in the unplanned extubation of the two tube fixation methods (P=0.032) . Conclusions The use of the sandwich method to fix the upper limb VAC vacuum suction tube can reduce the incidence of unplanned extubation to a certain extent, and help to reduce the incidence of negative clinical care events, which is worth promoting. Key words: Sandwich method; Vacuum assisted closure; Unplanned extubation; Care

Introduction and aims Accidental extubations (AE) are significant risk to patient safety and can be associated with serious complications and mortality. We introduced a quality improvement programme in our tertiary...

Introduction: Ventilator-associated pneumonia (VAP) is a hospital acquired nosocomial infection that is commonly found in patients receiving mechanical ventilation. Continuous aspiration of subglottic secretions (CASS) is found to lower the incidence of VAP. The aim of this study was to assess respiratory therapists and nurses’ awareness and experiences about the Endotracheal Tubes (ETT) with CASS. Methodology: This is a cross-sectional study. Purposive sampling of 51 respiratory therapists and 51 nurses who were involved in taking care of critically ill patients in adult ICUs at King Abdul-Aziz Medical City, Riyadh were used. The questionnaire was related to the knowledge and experiences of respiratory therapists and nurses about the proper use of ETT with CASS. Results: The results suggest that the respiratory therapists were more knowledgeable in the use of ETT-CASS. However, both respiratory therapists and nurses had problems related to ETT design and materials. Most of these problems were related to cuff materials and its design, suctioning system and tubes, in addition to the availability of the equipment. Conclusion: This study presents a unique contribution to knowledge about the experiences of respiratory therapists and nurses who work in KAMC about the proper use of ETT-CASS. The results of this study showed that the use of ETT-CASS is yet to be popularly recognized. Thus, it should be acclaimed by further studies and promotion through formulation of updated protocols and educational programs.

A multi-center evaluation of a disposable catheter to aid in correct positioning of the endotracheal tube after intubation in critically ill patients

Objective To investigate the effect of 工 type adhesive tape fixation method on tracheal tube fixation in children′s adenoids and tonsils surgery. Methods Eighty children who underwent selective adenoids and tonsils surgery from January to June 2019 in Shengjing Hospital of China Medical University were selected. The children were divided into control group and experimental group by random digits table method with 40 cases each. The tracheal tube of control group was fixed by traditional double-adhesive tape fixation method, and the tracheal tube of experimental group was fixed by 工 type adhesive tape fixation method. The distance between tracheal tube and right corner of mouth at the time of tracheal tube fixation, mouth opener insertion and the end of surgery by a soft ruler were recorded as an index of tracheal tube displacement. The detubation and skin damage were also recorded. Results The displacement distances of tracheal tube from tracheal tube fixation to mouth opener insertion and from tracheal tube fixation to the end of surgery in experimental group were significantly smaller than those in control group: (0.38 ± 0.16) cm vs. (0.74 ± 0.25) cm and (0.51 ± 0.20) cm vs. (1.69 ± 0.51) cm, and there were statistical differences (t = 7.67 and 13.62, P 0.05). The pressure ulcers did not occur in 2 groups; there was no statistical difference in the incidence of breakage between 2 groups (P>0.05); the incidences of redness and total skin damage in experimental group were significantly lower than those in control group: 20.0% (8/40) vs. 55.0% (22/40) and 20.0% (8/40) vs. 62.5% (25/40), and there were statistical differences (χ2 = 13.07 and 14.90, P<0.01). Conclusions The 工 type adhesive tape fixation method is used for the fixation of tracheal tube in adenoids and tonsils surgery in children, which is easy to operate and fixes firmly, and can effectively reduce the displacement of tracheal tube and reduce the degree of skin damage. It is worthy of clinical application. Key words: Tonsillectomy; Adenoidectomy; Intubation, intratracheal; Anesthesia; 工 type adhesive tape