Does an evidence-based sedation protocol improve practice and patient outcomes in critical care?

Learning Objective 1: compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care.

Learning Objective 2: explain the contrasting international research findings on sedation protocol implementation.
Minimization of sedation in critical care patients has recently received widespread support. Professional organizations internationally have published sedation management guidelines for critically ill patients to improve the use of research in practice, decrease practice variability and shorten mechanical ventilation duration. Innovations in practice have included the introduction of decision making protocols, daily sedation interruptions and new drugs and monitoring technologies. The aim of this study was to compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care setting.

A randomized, controlled trial design was used to study 312 mechanically ventilated adult patients in a general critical care unit at an Australian metropolitan teaching hospital. Patients were randomly assigned to receive protocol directed sedation management developed from evidence based guidelines (n=153) or usual clinical practice (n=159).

The median (95% CI) duration of ventilation was 58 hrs (44–78 hrs) for patients in the non-protocol group and 79 hrs (56–93) for those patients in the protocol group (p=0.20). Results were not significant for length of stay in critical care or hospital, the frequency of tracheostomies, and unplanned extubations. A Cox proportional hazards model estimated that protocol directed sedation management was associated with a 22% decrease (95% CI: 40% decrease to 2% increase, p=0.07) in the occurrence of successful weaning from mechanical ventilation.

Few randomized controlled trials have evaluated the effectiveness of protocol-directed sedation outside of North America. This study highlights the lack of transferability between different settings and different models of care. Qualified, high intensity nursing in the Australian critical care setting facilitates rapid, responsive decisions for sedation management and an increased success rate for weaning from mechanical ventilation.

Tracheostomy decannulation failure rate following critical illness : a prospective descriptive study

Background : Tracheostomy is a well established and practical approach to airway management for patients requiring extended periods of mechanical ventilation or airway protection. Little evidence is available to guide the process of weaning and optimal timing of tracheostomy tube removal. Thus, decannulation decisions are based on clinical judgement. The aim of this study was to describe decannulation practice and failure rates in patients with tracheostomy following critical illness.

Methods : A prospective descriptive study was conducted of consecutive patients who received a tracheostomy at a tertiary metropolitan public hospital intensive care unit (ICU) between March 2002 and December 2006. Data were analysed using descriptive and inferential tests.

Results : Of the 823 decannulation decisions, there were 40 episodes of failed decannulation, a failure rate of 4.8%. These 40 episodes occurred in 35 patients: 31 patients failed once, 3 patients failed twice and 1 patient failed three times. There was no associated mortality. Simple stoma recannulation was required in 25 episodes, with none of these patients readmitted to ICU. Translaryngeal intubation and readmission to ICU took place for the remaining 15 episodes. The primary reason for decannulation failure was sputum retention. Twenty-four patients (60%) failed decannulation within 24 h, with 14 of these occurring within 4 h.

Conclusions : Clinical assessments coupled with professional judgement to decide the optimal time to remove tracheostomy tubes in patients following critical illness resulted in a failure rate comparable with published data. Although reintubation and readmission to ICU was required in just over one third of failed decannulation episodes, there was no associated mortality or other significant adverse events. Our data suggest nurses need to exercise high levels of clinical vigilance during the first 24 h following decannulation, particularly the first 4 h to detect early signs of respiratory compromise to avoid adverse outcomes.

Improving comfort levels in Darwin houses through passive design

Darwin`s climate is hot and humid and as a result the use of residential air-conditioners is high. Although this technology allows the occupant to achieve thermal comfort, its use contributes directly to an increase in the emission of greenhouse gases. More environmentally-friendly ways of achieving residential thermal comfort in this climate need to be investigated. One method is to improve the home`s passive design. The aim of this research was to increase the thermal comfort of typical Darwin homes without the use of air conditioning. Temperature data from two houses (lightweight elevated and concrete) was recorded over a nine-day period and used to validate a TRNSYS simulation model of each house. Simulations were run using these validated models and three months of climatic data (January—March) to evaluate various passive design strategies. The success of three strategies was analysed using PMV and PPD indicators. As a single strategy, it was found that ventilation and air velocity by far increased the level of thermal comfort for occupants of both houses. Although the passive design strategies of increased shading and insulation were beneficial, Darwin`s ovemight low temperature and humidity are still too high to reduce these levels within the house significantly without air conditioning.

Oxygen delivery to patients after cardiac surgery : a medical record audit

OBJECTIVE: To describe how intensive care nurses manage the administration of supplemental oxygen to patients during the first 24 hours after cardiac surgery.
METHODS: A retrospective audit was conducted of the medical records of 245 adult patients who underwent cardiac surgery between 1 January 2005 and 31 May 2008 in an Australian metropolitan hospital. Physiological data (oxygen saturation measured by pulse oximetry and respiratory rate) and intensive care unit management data (oxygen delivery device, oxygen flow rate and duration of mechanical ventilation) were collected at hourly intervals over the first 24 hours of ICU care.
RESULTS: Of the 245 patients whose records were audited, 185 were male; mean age was 70 years (SD, 10), and mean APACHE II score was 17.5 (SD, 5.14). Almost half the patients (122, 49.8%) were extubated within 8 hours of ICU admission. The most common oxygen delivery device used immediately after extubation was the simple face mask (214 patients, 87%). Following extubation, patients received supplemental oxygen via, on average, two different delivery devices (range, 1-3), and had the delivery device changed an average of 1.38 times (range, 0-6) during the 24 hours studied. Twenty-two patients (9%) received non-invasive ventilation or high-flow oxygen therapy, and 16 (7%) experienced one or more episode of hypoxaemia during mechanical ventilation. A total of 148 patients (60%) experienced one or more episodes of low oxygenation or abnormal respiratory rate during the first 24 hours of ICU care despite receiving supplemental oxygen.
CONCLUSION: These findings suggest that the ICU environment does not protect cardiac surgical patients from suboptimal oxygen delivery, and highlights the need for strategies to prompt the early initiation of interventions aimed at optimising blood oxygen levels in cardiac surgical patients in the ICU.

Patients and nurses' perspective on oxygen therapy : a qualitative study

Aim. This paper is a report of a study to describe patients' and nurses' perspectives on oxygen therapy.
Background. Failure to correct significant hypoxaemia may result in cardiac arrest, need for mechanical ventilation or death. Nurses frequently make clinical decisions about the selection and management of low-flow oxygen therapy devices. Better understanding of patients' and nurses' experiences of oxygen therapy could inform clinical decisions about oxygen administration using low-flow devices.
Methods. Face-to-face interviews with a convenience sample of 37 adult patients (17 cardio-thoracic: 20 medical surgical) and 25 intensive care unit nurses were conducted from February 2007 to September 2007. Interviews were audio-taped, transcribed verbatim and then analysed using a thematic analysis approach.
Findings. The patients identified three key factors that underpinned their compliance with oxygen therapy: (i) device comfort; (ii) ability to maintain activities of daily living; and (iii) therapeutic effect. The nurses identified factors, such as: (i) therapeutic effect, (ii) issues associated with compliance, (iii) strategies to optimize compliance, (iv) familiarity with device, (v) triggers for changing oxygen therapy devices, as being key to the effective management of oxygen therapy.
Conclusion. Differences between the patients' and nurses' perspective of oxygen therapy illustrate the variety of factors that impact on effective oxygen administration. Further research should seek to provide a further in-depth understanding of the current oxygen administration practices of nurses and the patient factors that enhance or hinder effectiveness of oxygen therapy. Detailed information about nurse and patient factors that influence oxygen therapy will inform a sound evidence base for nurses' oxygen administration decisions.

Exposure to fumes and gases during welding operations

The exposure to fumes and gases is one of the hazards associated with welding operations. Apart from research conducted on the mechanism of fume and gas formation and the relationship between fume formation rates and common welding parameters, little is known about the exposure process during welding. This research project aimed to identify the factors that influence exposure, develop an understanding of their role in the exposure process and through this understanding formulate strategies for the effective control of exposure during welding. To address these aims a literature review and an experimental program was conducted The literature review surveyed epidemiological, toxicological and exposure data. The experimental program involved three approaches, the first, an evaluation of the factors that influence exposure by assessing a metal inert gas/mild steel welding process in a workshop setting. The second approach involved the study of exposure in a controlled environment provided by a wind tunnel and simulated welding process. The final approach was to investigate workplace conditions through an assessment of exposure and control strategies in industry. The exposure to fumes and gases during welding is highly variable and frequently in excess of the health based exposure standards. Exposure is influenced by a number of a factors including the welding process, base material, arc time, electrode, arc current, arc voltage, arc length, electrode polarity, shield gas, wire-to-metal-work distance (metal inert gas), metal transfer mode, intensity of the UV radiation (ozone), the frequency of arc ignitions (ozone), thermal buoyancy generated by the arc process, ventilation (natural and mechanical), the welding environment, the position of the welder, the welders stance, helmet type, and helmet position. Exposure occurs as a result of three processes: the formation of contaminants at or around the arc region; their transport from the arc region, as influenced by the entry and thermal expansion of shield gases, the vigorous production of contaminants, thermal air currents produced by the heat of the arc process, and ventilation; and finally the entry of contaminants into the breathing zone of the welder, as influenced by the position of the welder, the welders stance, helmet type, and the helmet position. The control of exposure during welding can be achieved by several means: through the selection of welding parameters that generate low contaminant formation rates; through the limitation of arc time; and by isolating the breathing zone of the welder from the contaminant plume through the use of ventilation, welder position or the welding helmet as a physical barrier. Effective control is achieved by careful examination of the workplace, the selection of the most appropriate control option, and motivation of the workforce.

Clinical, ethical and legal considerations in the treatment of newborns with non-ketotic hyperglycinaemia

Non-ketotic hyperglycinaemia (NKH) is a devastating neurometabolic disorder leading, in its classical form, to early death or severe disability and poor quality of life in survivors. Affected neonates may need ventilatory support during a short period of respiratory depression. The transient dependence on ventilation dictates urgency in decision-making regarding withdrawal of therapy. The occurrence of patients with apparent transient forms of the disease, albeit rare, adds uncertainty to the prediction of clinical outcome and dictates that the current practice of withholding or withdrawing therapy in these neonates be reviewed. Both bioethics and law take the view that treatment decisions should be based on the best interests of the patient. The medical-ethics approach is based on the principles of non-maleficence, beneficence, autonomy and justice. The law relating to withholding or withdrawing life-sustaining treatment is complex and varies between jurisdictions. Physicians treating newborns with NKH need to provide families with accurate and complete information regarding the disease and the relative probability of possible outcomes of the neonatal presentation and to explore the extent to which family members are willing to take part in the decision making process. Cultural and religious attitudes, which may potentially clash with bioethical and juridical principles, need to be considered.

Urban sustainability and market typologies : lessons from Tabriz Bazaar

The market is an essential component of urban form. Contemporary shopping malls can benefit from the inherent efficiencies of traditional markets. This paper addresses the development of sustainable models of market typologies based on a specific case study, the Bazaar of Tabriz in Iran.

As one of the biggest historical covered markets in the world (Moradi and Nassabi 2007), it remains an effective trading centre in the city. What are the lessons that make Tabriz a sustainable urban typology and what lessons can we draw from its spatial and operational structure?

To address this question, the paper presents two analytical studies of the urban and building morphology of Tabriz. First, the paper presents an analysis of the urban and social structure of the market based on Lynchian analysis. Second, it provides an analysis of the thermal, ventilation and lighting principles used in the buildings of the market and how they respond to the extreme climatic conditions of north-west Iran.

Rainfall and snow in one side and hot summers in the other, give the buildings in the city really critical performance in terms of life span during the years of operation.

The main target in this case study, is to illuminate the urban typological clarifications in the Bazaar of Tabriz, which wilt elucidate how parallel links between urban morphology (land cover) and urban typology (land use) in a defined urban planning can form a sustainable urban space. Moreover, how the case of this study can be an energy efficient complex with its own urban morphology.

The lessons of Tabriz for the development of contemporary markets are summarised in the paper and need to be addressed at two scales, namely the urban scale and the scale of the building.

Implementation of a management guideline aimed at minimizing the severity of primary graft dysfunction after lung transplant

Objective
Primary graft dysfunction, a severe form of lung injury that occurs in the first 72 hours after lung transplant, is associated with morbidity and mortality. We sought to assess the impact of an evidence-based guideline as a protocol for respiratory and hemodynamic management.

Methods
Preoperative and postoperative data for patients treated per the guideline (n = 56) were compared with those of a historical control group (n = 53). Patient data such as ratio of arterial Po2 to inspired oxygen fraction, central venous pressure, cumulative fluid balance, vasopressor dose, and serum urea and creatinine were measured and documented at specific times. Primary outcome was severity of primary graft dysfunction within the first 72 hours.

Results
Primary graft dysfunction grade was progressively lower in patients treated after introduction of the guideline (P = .01). Lower postoperative fluid balances (P = .01) and vasopressor doses (P = .007) were seen, with no associated renal dysfunction. There were no differences in duration of mechanical ventilation or mortality. Nonadherence to the guideline occurred in 10 cases (18%).

Conclusions
Implementation of an evidence-based guideline for managing respiratory and hemodynamic status is feasible and safe and was associated with reduction in severity of primary graft dysfunction. Further studies are required to determine whether such a guideline would lead to a consistent reduction in severity of primary graft dysfunction at other institutions. Creation of a protocol for postoperative care provides a template for further studies of novel therapies or management strategies for primary graft dysfunction.

Context dependency of comfort and energy performance in mixed mode offices

This article investigates the context dependency of comfort and energy performance in mixed-mode offices in the climate of Athens, Greece. It is based on a parametric study using the simulation software EnergyPlus. Context refers to different building design priorities on the real estate market (prestige, low cost and green), occupant behaviour scenarios (ideal and worst case) and cooling strategies (fixed and adaptive set points). Results are evaluated according to energy consumption and related greenhouse gas emissions, daylight autonomy, view and percentage of working time when heating and cooling are operating. The results indicate that a holistic approach to comfort and energy performance evaluation focused on the specific context of a building and its occupants is necessary to develop appropriate optimization strategies. In early design stages, such specific information is not yet available and ideal/worst-case scenarios can indicate the magnitude of influence of occupants compared to building design.

Review : nurses can improve patient nutrition in intensive care

Aims and objectives. To review the literature and identify opportunities for nutritional practice improvement in the critically ill and opportunities to improve nurses’ knowledge relating to enteral feeding.

Background. The literature reports varying nutritional practices in intensive care.

Design. Systematic review.

Methods. A systematic search, selection, analysis and review of nursing, medical and dietetic primary research articles was undertaken. Fifteen studies met the selection criteria.

Results. Delivery of nutrition to the critically ill varied widely. Patients were frequently underfed and less frequently, overfed. Both under- and overfeeding have been linked with unacceptable consequences including infections, extended weaning from mechanical ventilation, increased length of stay and increased mortality. Underfeeding was related to slow initiation and advancement of nutrition support and avoidable feed interruptions. The most common reasons for interrupting feeds were gastrointestinal intolerance and fasting for procedures. Certain nursing practices contributed to underfeeding such as the management of gastric residual volumes.

Conclusions. Consistent and reliable nutrition support in intensive care units is hampered by a lack of evidence leading to varying nutrition practices. Factors impeding delivery of enteral nutrition were considered avoidable. A new concept of a therapeutic range of energy delivery in the critically ill has emerged implying the need for re-evaluation of energy recommendations and improved delivery of enteral nutrition.

Relevance to clinical practice. This review supports the multi-disciplinary development and implementation of an evidence-based enteral feeding protocol in intensive care units as a strategy to improve adequacy of nutritional intake. Critical care nurses are well placed to improve this process.

Ten years of environmental university building

The authors have been involved in over ten years of environmental consulting and research on university buildings. Numerous simulations and measurement studies have occurred over this period of time. The intentions have always been to improve and optimise the environmental performing aspects of a building. This paper is a reporting of the implemented strategies, their pre-building research investigation as well as their operational outcomes. Their successes and failures are discussed here. This research is intended as a feedback loop to future design specification, commissioning and maintenance improvements. In hindsight many of the environmental concepts, when executed as planned, were successful. However, often those requiring extensive control, such as lighting, ventilation and mechanical air-conditioning were a failure. The observations between simulation and actual performance are also noted. The paper includes discussion about some of the obstacles in building procurement which can hinder the result of a good environmental performing building.

Pneumatic vehicle

A pneumatic vehicle is provided with a first sub-assembly with a chassis, part of the vehicle body, a pair of B-pillars, a pair of rear rails, wheels, an elongate aluminum compressed load bearing air tank oriented longitudinally in the chassis, side panels connected to the tank and the wheels, a heat exchanger to heat the compressed air, and an air motor driven by the heated, compressed air and connected to a wheel. A ventilation system has a restrictive solenoid valve for directing air to the heat exchanger. The air tank is provided with a carbon filament reinforced plastic layer, and a fiberglass and aramid-fiber layer. A second sub-assembly includes part of the vehicle body bonded to the first-sub-assembly using a structural adhesive, a pair of A-pillars, and a pair of roof rails. Seating includes inflatable components for adjustment.

CHASSIS FOR PNEUMATIC VEHICLE

A pneumatic vehicle is provided with a first sub-assembly with a chassis, part of the vehicle body, a pair of B-pillars, a pair of rear rails, wheels, an elongate aluminum compressed load bearing air tank oriented longitudinally in the chassis, side panels connected to the tank and the wheels, a heat exchanger to heat the compressed air, and an air motor driven by the heated, compressed air and connected to a wheel. A ventilation system has a restrictive solenoid valve for directing air to the heat exchanger. The air tank is provided with a carbon filament reinforced plastic layer, and a fiberglass and aramid-fiber layer. A second sub-assembly includes part of the vehicle body bonded to the first-sub-assembly using a structural adhesive, a pair of A-pillars, and a pair of roof rails. Seating includes inflatable components for adjustment.