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Purpose: Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients. Methods: A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors. Results: A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI] 0.82 to 1.54; P = 0.46). Time to IVACs (adjusted hazard ratio [aHR], 1.06; 95% CI 0.44 to 2.57; P = 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23; P = 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10; P = 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17; P = 0.02) improved in the intervention period. Conclusion: Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health. [ABSTRACT FROM AUTHOR]

Introduction: In intensive care units, numerous geriatric patients are mechanically ventilated, and those with prolonged mechanical ventilation show high mortality. Such geriatric patients may greatly benefit from tracheotomy because it facilitates pulmonary care, increases patient comfort and helps wean them off mechanical ventilation. Materials and Method: A total of 70 mechanically ventilated geriatric patients were includ-ed. Patients’ electronic data, file records, age, sex, mechanical ventilation requirement, Acute Physiology and Chronic Health Evaluation II score, intubation and intensive care unit stay durations, discharge status and complications were examined. Results: The mean patient age was 78.6±7.4 years, and the mean Acute Physiology and Chronic Health Evaluation II score was 27.0±5.9. Tracheotomy was performed after a mean duration of 34.8±17 days, and the mean intensive care unit stay duration was 94±54 days. Major and minor haemorrhage were observed in 1 (1.4%) and 3 (4.2%) patients, respectively. Total 53 (76%) patients died, 8 (11%) patients were discharged and 9 (13%) patients are still hospitalized. Conclusion: The reluctance of geriatric patients’ relatives to perform tracheotomy affects the time of procedure and duration of intensive care unit stay. [ABSTRACT FROM AUTHOR]

Objective: Predictors of long-term functional impairment in acute respiratory failure of all causes are poorly understood. Our objective was to assess the frequency and predictors of long-term functional impairment or death after invasive mechanical ventilation for acute respiratory failure of all causes.Design: Population-based, observational cohort study.Setting: Eight adult ICUs of a single center.Patients: All adult patients from Olmsted County, Minnesota, without baseline functional impairment who received mechanical ventilation in ICUs for acute respiratory failure of all causes from 2005 through 2009.Interventions: None.Measurements and Main Results: In total, 743 patients without baseline functional impairment received mechanical ventilation in the ICU. At 1- and 5-year follow-up, the rates of survival with return to baseline functional ability were 61% (366/597) and 53% (356/669). Among 71 patients with new functional impairment at 1 year, 55% (39/71) had recovered and were alive without functional impairment at 5 years. Factors predictive of new functional impairment or death at 1 year were age, comorbidities, discharge to other than home, mechanical ventilation of 7 days or longer, and stroke. Of factors known at the time of intubation, the following are predictive of new functional impairment or death: age, comorbidities, nonsurgical condition, Acute Physiology and Chronic Health Evaluation III score, stroke, and sepsis. Post hoc sensitivity analyses revealed no significant change in predictor variables in patient populations when stroke was excluded or who received more than 48 hours of mechanical ventilation.Conclusions: At 1- and 5-year follow-up, many patients who received mechanical ventilation for acute respiratory failure from all causes are no longer alive or have new moderate-to-severe functional impairment. Functional recovery between year 1 and year 5 is possible and common. Sepsis, stroke, illness severity, age, and comorbidities predict long-term functional outcome at intubation. [ABSTRACT FROM AUTHOR]

Mobilization of critically ill patients admitted to intensive care units should be performed based on safety criteria. The aim of the present review was to establish which safety criteria are most often used to start early mobilization for patients under mechanical ventilation admitted to intensive care units. Articles were searched in the PubMed, PEDro, LILACS, Cochrane and CINAHL databases; randomized and quasirandomized clinical trials, cohort studies, comparative studies with or without simultaneous controls, case series with 10 or more consecutive cases and descriptive studies were included. The same was performed regarding prospective, retrospective or crosssectional studies where safety criteria to start early mobilization should be described in the Methods section. Two reviewers independently selected potentially eligible studies according to the established inclusion criteria, extracted data and assessed the studies' methodological quality. Narrative description was employed in data analysis to summarize the characteristics and results of the included studies; safety criteria were categorized as follows: cardiovascular, respiratory, neurological, orthopedic and other. A total of 37 articles were considered eligible. Cardiovascular safety criteria exhibited the largest number of variables. However, respiratory safety criteria exhibited higher concordance among studies. There was greater divergence among the authors regarding neurological criteria. There is a need to reinforce the recognition of the safety criteria used to start early mobilization for critically ill patients; the parameters and variables found might contribute to inclusion into service routines so as to start, make progress and guide clinical practice. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The aim of this study was to describe the frequency, physiologic effects, safety, and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation. Materials and Methods: Prospective observational report of consecutive patients ventilated 4 or more days and eligible for rehabilitation in a single medical intensive care unit (ICU) during a 13-week period was conducted. Results: Of the 32 patients who met the inclusion criteria, only 21 (66%) received physician orders for evaluation by rehabilitation services (physical and/or occupational therapy). Fifty rehabilitation treatments were provided to 19 patients on a median of 12% of medical ICU days per patient, with deep sedation and unavailability of rehabilitation staff representing major barriers to treatment. Physiologic changes during rehabilitation therapy were minimal. Joint contractures were frequent in the lower extremities and did not improve during hospitalization. In 53% and 79% of initial ICU assessments, muscle weakness was present in upper and lower extremities, respectively, with a decreased prevalence of 19% and 43% at hospital discharge, respectively. New impairments in physical function were common at hospital discharge. Conclusions: This pilot project illustrated important barriers to providing rehabilitation to mechanically ventilated patients in an ICU and impairments in strength, range of motion, and functional outcomes at hospital discharge. [Copyright &y& Elsevier]