Semirecumbent Positioning in Ventilator-Dependent Patients: A Multicenter, Observational Study

Abstract

Background Positioning of patients is a modifiable risk factor for ventilator-associated pneumonia. Current guidelines for prevention of ventilator-associated pneumonia recommend semirecumbency at 30º, with 45º preferable unless contraindicated. Objective To assess the use of semirecumbency for ventilator patients in Australian and New Zealand intensive care units. Methods In a multicenter, observational study, backrest elevation, mean arterial pressure, use of inotropic agents, enteral feeding, and weaning status were recorded 3 times per day by using a predetermined randomization schedule for 7 consecutive days (maximum 21 observation episodes). Severity of illness was recorded daily by using the Sepsis-Related Organ Failure Assessment (SOFA) score. Results Measurements (n = 2112) were recorded for 371 ventilator patients in 32 intensive care units. Backrest elevation at ≥45º was noted for 112 of 2112 (5.3%; 95% confidence interval [CI], 4.3-6.3) measurements; elevation ≥30º but <45º for 472 of 2112 (22.3%; 95% CI, 20.6-24.1). Contraindications to semirecumbency were noted during 447 measurements. Increased backrest elevation occurred during enteral feeding (2.2º, P < .001) and weaning (3.1º, P < .001). Decreased backrest elevation was associated with inotropic support (2.8º, P < .001), decreased mean arterial pressure (0.7º/10 mm Hg, P < .001), and organ failure (0.5º/1-point increment in SOFA max score, P < .001). For measurements recorded with no contraindication to semirecumbency, weaning status (P = .003) and SOFA max score (P = .008) remained associated with the degree of backrest elevation. Conclusions The findings of this multicenter, observational study suggest that backrest elevation was less than recommended and was influenced by clinical practices and patient condition.

The Comparison of the Effect of the Head of Bed Elevation to 30 and 45 Degreess on the Incidence of Ventilator Associated Pneumonia and the Risk for Pressure Ulcers: A Controlled Randomized Clinical Trial

“…Performing nursing procedures in critical conditions and carrying out nursing interventions in the lateral position hindered the elevation of the HOB. Other factors are a lack of patient comfort, fear of pressure ulcers, and insufficient information regarding raising the HOB for the prevention of VAP (33).…”

Behavioral Pain Assessment Tool for Critically Ill Adults Unable to Self-Report Pain

“…Numerous observational studies [24][25][26] have indicated poor compliance with various evidence-based practice recommendations, indicating that implementation of the recommendations remains a challenge in the ICU. Assessment of the need for medication and of the effect of the medication is a central tenet of medication administration that guides initiation, escalation, and discontinuation of therapy.…”

Evaluación del cumplimiento de un protocolo de prevención de Neumonía asociada a Ventilación mecánica en una UCI polivalente

“…Existe un estudio prospectivo que concluye que si el volumen es alto (>10 ml) aspiración c\2 horas o más a menudo (20) . Respecto a los sistemas de drenajes de secreciones se ha demostrado que disminuye la incidencia de NAVM de comienzo precoz en pacientes con una duración de la ventilación mecánica > 72 horas, pero no hay disminución de la mortalidad, de la estancia en UCI ni de los días de ventilación mecánica (3,5,6,8,9,10,(16)(17)(18)20) . En cuanto a la utilización de sistemas cerrados o abiertos no encuentran diferencias en relación a NAVM pero sí se habla de ventajas e inconvenientes como que el abierto está asociado a desaturación arterial e inestabilidad hemodinámica y el cerrado mayor colonización y es más caro (21)(22)(23) .…”

“…9. Se recomienda la desinfección con antiséptico como la clorhexidina 0.12-2% cada 8 horas (8)(9)(10)(11)(12)(13)16,18,26) .…”

“…Se recomienda elevación de la cabecera de la cama entre 30-40º (siempre que no exista contraindicación). A pesar de ser una medida fácil en un estudio observacional se detectó que solo el 85% de los pacientes mantenían la elevación a 45º (18) .Respecto a las camas cinéticas, aunque la medida es eficaz, no se puede recomendar por falta de datos sobre el riesgo-beneficio (3,5,6,9,10,19) Esta medida es especialmente importante en pacientes que reciban nutrición enteral ya que se ha considerado un factor de riesgo por la posibilidad de aspiración del contenido gástrico (2,3,5,6,(8)(9)(10)(11)(12)(13)16,17) . De ahí la recomendación de realizar una comprobación del volumen gástrico…”