MSc(Med), Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand / Introduction
Many patients that have suffered traumatic injuries require admission to Intensive Care Unit (ICU). Mechanical ventilation (MV) is deemed to be the defining event marking many ICU admissions. As many as 30% of admissions, and 90% of all critically ill patients will require at least a short period of MV. There are many risks and complications associated with prolonged MV, such as rate of pneumonia, morbidity and mortality, increased cost, hospital LOS, emotional distress and decreased bed availability. To minimize these risks and complications it is important that patients be weaned and extubated from MV at the earliest possible time. However, just as delayed weaning and extubation carries the risk of complications, premature extubation and subsequent re-intubation should be avoided where possible, as extubation failure leads to an eight-fold higher risk of infection and a twelve-fold increase in mortality. Weaning is the transition from ventilatory support to spontaneous breathing and can often be achieved easily, but may be difficult in up to 25% of patients. Numerous studies have shown the benefit of allied health care worker (nurses and physiotherapists) driven weaning protocols in decreasing MV days and costs.
Purpose
To determine if the use of a nurse and therapist-driven weaning protocol to wean and extubate long-term patients with trauma from MV in an open ICU results in decreased total MV days and ICU length of stay (LOS), and to determine time to spontaneous breathing trial (SBT) failure.
Methods
A weaning protocol was developed by the researcher using clinical guidelines compiled for the American Association for Respiratory Care, American College of Chest Physicians and American College of Critical Care Medicine. A total of 56 mechanically ventilated trauma patients were enrolled in two phases of the study. A prospective cohort of 28 patients (Phase I), weaned according to the protocol, was matched retrospectively with a historical cohort of 28 patients (Phase II), weaned according to physician preference. Pairs in the two groups were matched to be similar for gender, age, type and severity of injury. Data analyzed for both groups were number of MV days, number of ICU days, self-extubation and need for re-intubation. For Phase I patients, time to SBT failure and reason for failure was recorded.
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Results and Discussion
With respect to the mean MV days it was found that the two protocol groups did not differ significantly (p = 0.3 ; Phase I = 14.4 days vs Phase II = 16.3 days), although the two day reduction in MV was considered clinically significant in view of the complications associated with additional MV days. The difference of 0.25 days for length of ICU stay between the groups was not statistically significant (p = 0.9; Phase I = 20.8 days vs Phase II = 21 days), and demonstrates that a reduction in MV days may not necessarily result in a reduction of ICU LOS. Rate of re-intubation was similar in the two groups (Phase I = 3/28 vs Phase II = 4/28). Eleven patients (39%) in Phase I failed at least one SBT and four of these patients (36%) failed two SBTs prior to successful extubation. Failure of the first SBT occurred an average of 18 hours after onset of SBT. Injury severity scores for these patients were higher than the average for Phase I (16.1 vs 14.5). Mean MV time in this group was 20.5 days as opposed to 14.4 days in the total Phase I group. This indicates that these patients were more critically ill and that they may require longer SBTs than advocated in many studies. All patients failed SBT due to increased RR.
Conclusion
In this study of longer-term ventilated patients who had traumatic injury as reason for admission to ICU and mechanical ventilation, the use of a standardized protocol to assist with weaning and extubation from MV demonstrated a clinically significant reduction in total MV time, even though this did not reach statistical significance. The reduction in MV time did not lead to a reduction in ICU LOS, however it reduces the risks of ventilator-associated complications such as VAP. The use of a weaning and extubation protocol did not lead to a higher rate of re-intubation, demonstrating its safety for use in this patient population. This protocol was driven by nurses and physiotherapists, and the role of physiotherapists and nursing staff in weaning and extubation of patients from MV could be greatly expanded in the majority of ICUs in South Africa.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/8558 |
| Date | 26 August 2010 |
| Creators | Plani, Natascha |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
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