Technique In Intensive Care Units Research Articles

Blood-sparing techniques prevalence in adult intensive care units: A multicentre survey study

IntroductionAnaemia is a common condition in patients admitted to intensive care units (ICUs). It is also well known that a significant amount of the carbon dioxide produced by health services is likely attributable to blood donation, testing, and the manufacture, storage, and distribution of blood components. To mitigate this, prevention strategies such as blood-sparing techniques are available. There is a lack of knowledge regarding the use of such techniques in ICUs in Spain and Latin America, healthcare systems with very different health expenditures per capita. The aim is to assess the degree of implementation of blood-sparing techniques in these regions. MethodsCross-sectional online multicentre survey. 251 ICUs in Spain and 53 in Latin America (20 in Argentina, 20 in Colombia, 13 in Ecuador) participated. A 20-item survey on the use of point-of-care, small-volume tubes (SVT), and closed-blood sampling devices (CBSD) was validated. Effect sizes were calculated using Phi (φ) or Cramer’s V (V). ResultsA response rate of 77% was obtained for Spain and 96% for Latin America. In Spain, the majority of ICUs were affiliated with public hospitals (88.1%, 171/194) while in Latin America, most were associated with private hospitals (56.9%, 29/51). Regarding the use of point-of-care testing, 67.5% of Spanish ICUs, compared to 35.3% of Latin Americans, reported frequent use (V=0.343). In 91.7% of Spanish ICUs and 58.9% of Latin Americans, SVTs were rarely or never used (V=0.380). The use of CBSD was significantly lower in Spain for both arterial and central venous catheters (V=0.336). Private hospitals used more CBSD in arterial catheter than public ones (27% vs 8.3%, V=0.278). ConclusionPoint-of-care testing can be improved in Latin America, while the use of CBSD and small-volume tubes can be enhanced in Spain. Private hospitals tend to implement blood-sparing techniques more effectively than public hospitals.

Verification of Nasogastric Tube Positioning Using Ultrasound by an Intensive Care Nurse: A Pilot Study.

Placing a nasogastric tube (NGT) is a frequent nursing technique in intensive care units. The gold standard for its correct positioning is the chest X-ray due to its high sensitivity, but it represents a radiation source for critically ill patients. Our study aims to analyze whether the ultrasound performed by an intensive care nurse is a valid method to verify the NGT's correct positioning and to evaluate the degree of interobserver agreement between this nurse and an intensive care physician in the NGT visualization using ultrasound. Its correct positioning was verified by direct visualization of the tube in the stomach and indirect visualization by injecting fluid and air through the tube ("dynamic fogging" technique). A total of 23 critically ill patients participated in the study. A sensitivity of 35% was achieved using direct visualization, increasing up to 85% using indirect visualization. The degree of interobserver agreement was 0.88. Therefore, the indirect visualization of the NGT by an intensive care nurse using ultrasound could be a valid method to check its positioning. However, the low sensitivity obtained by direct visualization suggests the need for further training of intensive care nurses in ultrasonography. According to the excellent degree of agreement obtained, ultrasound could be performed by both professionals.

Challenges of the Regional Anesthetic Techniques in Intensive Care Units - A Narrative Review.

Effective pain management is vital for critically ill patients, particularly post-surgery or trauma, as it can mitigate the stress response and positively influence morbidity and mortality rates. The suboptimal treatment of pain in Intensive Care Unit (ICU) patients is often due to a lack of education, apprehensions about side effects, and improper use of medications. Hence, the engagement of pain management and anesthesiology experts is often necessary. While opioids have been traditionally used in pain management, their side effects make them less appealing. Local anesthetics, typically used for anesthesia and analgesia in surgical procedures, have carved out a unique and crucial role in managing pain and other conditions in critically ill patients. This work aims to offer a comprehensive overview of the role, advantages, challenges, and evolving practices related to the use of local anesthetics in ICUs. The ability to administer local anesthetics continuously makes them a suitable choice for controlling pain in the upper and lower extremities, with fewer side effects. Epidural analgesia is likely the most used regional analgesic technique in the ICU setting. It is primarily indicated for major abdominal and thoracic surgeries, trauma, and oncology patients. However, it has contraindications and complications, so its use must be carefully weighed. Numerous challenges exist regarding critically ill patients, including renal and hepatic failure, sepsis, uremia, and the use of anticoagulation therapy, which affect the use of regional anesthesia for pain management. Appropriate timing and indication are crucial to maximizing the benefits of these methods. The advent of new technologies, such as ultrasonography, has improved the safety and effectiveness of neuraxial and peripheral nerve blocks, making them feasible options even for heavily sedated patients in ICUs.

The role of routine FIBERoptic bronchoscopy monitoring during percutaneous dilatational TRACHeostomy (FIBERTRACH): a study protocol for a randomized, controlled clinical trial

BackgroundTracheostomy is one of the most frequent techniques in intensive care units (ICU). Fiberoptic bronchoscopy (FB) is a safety measure when performing a percutaneous dilatational tracheostomy (PDT), but the controversy surrounding the routine use of FB as part of the procedure remains open. National surveys in some European countries showed that the use of FB is non-standardized. Retrospective studies have not shown a significant difference in complications between procedures performed with or without a bronchoscope. International guidelines have not been able to establish recommendations regarding the use of FB in PDT due to lack of evidence.DesignThis is a multicenter (three centers at the time of publishing this paper) randomized controlled clinical trial to examine the safety of percutaneous tracheostomy using FB. We will include all consecutive adult patients admitted to the ICU in whom percutaneous tracheostomy for prolonged mechanical ventilation is indicated and with no exclusion criteria for using FB. Eligible patients will be randomly assigned to receive blind PDT or PDT under endoscopic guidance. All procedures will be performed by experienced intensivists in PDT and FB. A Data Safety and Monitoring Board (DSMB) will monitor the trial. The primary outcome is the incidence of perioperative complications.DiscussionFB is a safe technique when performing PDT although its use is not universally accepted in all ICUs as a routine practice. Should PDT be monitored routinely with endoscopic guidance? This study will assess the role of FB monitoring during PDT.Trial registrationClinicalTrials.gov NCT04265625. Registered on February 11, 2020

Uso de ventilación mecánica no invasiva (VMNI) en la insuficiencia respiratoria aguda (IRA) en el servicio de urgencias: una revisión sistemática cualitativa

The aim of this study si to revise the use of non-invasive ventilation (NIV) in patients with acute respiratory failure in emergency departments. A systematized database review will be carried out by the search of articles attending the presented subject following a unique approach; restricting the results to findings in the last five years either in Spanish or English. A research performed in paediatric population concluded that the early management of acute respiratory failure and the use of high flow nasal cannulae reduced the hospitalization period and the referral to specialized hospitals, and gave more independence to regional hospitals in its management; reducing, therefore, the number of patients needing the implementation of invasive procedures. With respect to patients with exacerbations of the chronic obstructive pulmonary disease (COPD) and its early management in the prehospital care, an increase in the mortality in those patients who were exposed to high flow compared to the conventional oxygen therapy was observed. Following the results of a meta-analysis, no benefits were found in the use of high flow nasal cannulae opposed to the conventional therapy or NIV in the emergency departments, in terms of need for intubations, failures in the treatment, hospitalization and mortality.The data are inconclusive in all the studies analyzed and there is no agreement between the different authors. There is a scarce piece of bibliography regarding the use of NIV in the emergency departments due to the fact that the majority of the research are focused on the use of this techniques in intensive care units. In conclussion, there is a diversity in the results of the revised articles according to the use of NIV in the emergency departments.

Impact of Graded Passive Cycling on Hemodynamics, Cerebral Blood Flow, and Cardiac Function in Septic ICU Patients.

Background: In-bed passive cycling is considered a safe and feasible early mobilization technique in intensive care unit (ICU) patients who are unable to exercise actively. However, the impact of varying intensity of passive cycling on perfusion and function of ischemia-prone organs is unknown. In this study, we assessed the impact of a graded passive cycling protocol on hemodynamics, cerebral blood flow, and cardiac function in a cohort of septic ICU patients.Methods: In consecutive patients presenting with sepsis, we measured global hemodynamic indices, middle cerebral artery velocity (MCAv), and cardiac function in response to a graded increase in passive cycling cadence. Using 5-min stages, we increased cadence from 5 to 55 RPM in increments of 10 RPM, preceded and followed by 5 min baseline and recovery periods at 0 RPM. The mean values obtained during the last 2 min of each stage were compared within and between subjects for all metrics using repeated-measures ANOVA.Results: Ten septic patients (six males) completed the protocol. Across patients, there was a 5.2% reduction in MCAv from baseline at cycling cadences of 25–45 RPM with a dose-dependent decrease of MCAv of > 10% in four of the 10 patients enrolled. There was a 16% increase in total peripheral resistance from baseline at peak cadence of 55 RPMs and no changes in any other measured hemodynamic parameters. Patient responses to passive cycling varied between patients in terms of magnitude, direction of change, and the cycling cadence at which these changes occurred.Conclusions: In septic patients, graded passive cycling is associated with dose-dependent decreases in cerebral blood flow, increases in total peripheral resistance, and either improvement or worsening of left ventricular function. The magnitude and cadence threshold of these responses vary between patients. Future studies should establish whether these changes are associated with clinical outcomes, including cognitive impairment, vasopressor use, and functional outcomes.

Role of regional analgesic techniques in ICU

Pain is a major problem in patients admitted in the Intensive Care Units (ICU). Untreated pain has significant impact on the outcome of these patients, especially surgical patients. There is enough evidence in the literature which has demonstrated that inadequately treated pain in ICU leads to prolonged ventilation, longer ICU stay, morbidity and other issues like development of post-traumatic stress disorder (PTSD) and chronic post-surgical pain (CPSP). Regional anesthesia and analgesia (RA) techniques like epidural analgesia, paravertebral blocks, and other peripheral nerve blocks (PNB) play a great role in providing significant pain relief, thus, limiting the use of opioids. They facilitate in earlier weaning from ventilation, reducing respiratory morbidity, and faster rehabilitation. These RA techniques are most useful in polytrauma patients, major thoracoabdominal and orthopedic surgeries, as many of them require post-surgical ICU care. However, these RA techniques are underutilised in many ICUs. Many a times, ICU physicians are not well versed with these RA techniques, and sometimes have fixed misconceptions with regards to these blocks. In this review, we will discuss on the need of these RA techniques and make a quick presentation on the technical aspect of frequently used blocks. The review will only focus on Ultrasound-guided regional analgesia (USRA) techniques as USG is commonly available in ICUs.Abbreviations: PTSD (Post-traumatic stress disorder), CPSP (Chronic post-surgical pain), RA (Regional anesthesia and analgesia), USRA Ultrasound-guided regional analgesia), PNB (Peripheral nerve block), IFPB (Interfascial plane blocks), ASRA (American Society of Regional Anesthesia and Pain Medicine) Citation: Sahoo RK, Nair AS, Badole UR, Kar R, Jadon A. Role of regional analgesic techniques in ICU. Anaesth Pain & Intensiv Care 2018;22 Suppl 1:S73-S82

The use of ECMO in ICU. Recommendations of the Spanish Society of Critical Care Medicine and Coronary Units

The use of extracorporeal membrane oxygenation systems has increased significantly in recent years; given this reality, the Spanish Society of Critical Intensive Care Medicine and Coronary Units (SEMICYUC) has decided to draw up a series of recommendations that serve as a framework for the use of this technique in intensive care units. The three most frequent areas of extracorporeal membrane oxygenation systems use in our setting are: as a cardiocirculatory support, as a respiratory support and for the maintenance of the abdominal organs in donors. The SEMICYUC appointed a series of experts belonging to the three working groups involved (Cardiological Intensive Care and CPR, Acute Respiratory Failure and Transplant work group) that, after reviewing the existing literature until March 2018, developed a series of recommendations. These recommendations were posted on the SEMICYUC website to receive suggestions from the intensivists and finally approved by the Scientific Committee of the Society. The recommendations, based on current knowledge, are about which patients may be candidates for the technique, when to start it and the necessary infrastructure conditions of the hospital centers or, the conditions for transfer to centers with experience.Although from a physiopathological point of view, there are clear arguments for the use of extracorporeal membrane oxygenation systems, the current scientific evidence is weak, so studies are needed that define more precisely which patients benefit most from the technique and when they should start.

A study of hand hygiene technique in intensive care unit of a tertiary care hospital

Introduction: Hand hygiene (HH) has been characterized as the keystone and starting point in all infection control programs, with the hands of health-care faculty being the handler and advocates of infection in critically ill patients. Materials and Methods: This was a cross-sectional observational study using direct observation technique. A single observer collected all HH data. This single-observer study was conducted in the 45-bedded intensive care unit (ICU) of Mahatma Gandhi Hospital. HH compliance was monitored using the hand hygiene observation form developed by the World Health Organization. A nonidentified observer was used for monitoring compliance with HH. Results and Discussion: A total of 900 observations were recorded from health-care personnel in ICU. With respect to the personnel, the nursing department had the highest number of observations as 400 circulating nurses were sampled. There were also 110 senior consultants, 250 resident doctors, and 140 paramedical staffs. Of the total opportunities, nurses had the highest number of contacts (67%), followed by allied health-care workers (82.94%). The average compliance was about 75%, which differed significantly among health-care workers, with higher compliance among the nursing staff (82.9%) followed by allied staff (67%). Of the average overall compliance of 75%, maximum compliance was seen for moment 3, that is, the staffs were very careful after body fluid contact as it was perceived important for self-protection. The HH instances after patient contact (86.29%) also suggested similarly. The nurses' compliance was 64.40% before patient contact and 68.35% after touching surroundings. Conclusion: The observance of HH is still low in our local environment. Handwashing practices in our study show that health-care workers pay attention to HH, when it appears, there is a direct observable threat to their well-being. Educational programs need to be developed to address the issue of poor HH.

Aseptic technique in intensive care unit

Maintaining asepsis is main component of intensive care. Adopting simple measures help in survival, decreasing morbidity, preventing hospital burden and economy health of family and nation. Various simple measures are hand washing, use of personnel protective devices, aseptic technique during procedures, and environmental cleanliness.

Effects of Vibrax (Mechanical Vibrations) on the Arterial Blood Gases of Patients in the Intensive Care Unit after Cardiac Surgery

Respiratory physiotherapy is an integral part of the care of patients in intensive care units (ICU) after cardiac surgery. One of the most commonly used techniques in ICU to prevent pulmonary complications are mechanical vibrations, which can be applied with a tool called Vibrax.The aim of this study was to investigate the effects of Vibrax (mechanical vibrations) on the arterial blood gases of patients in ICU during the 1. or 2.day after cardiac surgery. A randomized controlled pilot study was conducted with 23 patients. The participants of the control group (CG) received a cardiovascular training with mobilization to the edge of the bed and active breathing exercises. On the patients of the intervention group (IG) additionally Vibrax was applied for 5 minutes. As primary outcome parameter the PaO2/FiO2 ratio was measured. In the CG no significant changes over time were observed (p ≥ 0.06). The IG showed a significant (p = 0.009) increase in the PaO2/FiO2 ratio from before the physiotherapy intervention (M = 296.52, SE = 34.94 mmHg) to 60 minutes after completion of the physiotherapy intervention (M = 331.39, SE = 48.14 mmHg). There was no significant difference between the CG and IG at any measuring time (p ≥ 0.09). The results of this pilot study indicate that the application of Vibrax has positive effects on the arterial blood gases of patients in ICU on the 1. or 2.day after cardiac surgery. But whether the effects are clinically relevant could not be clarified.

Ensayo clínico aleatorizado para la comparación de dos métodos de cura de traqueotomía en una Unidad de Cuidados Intensivos

IntroductionTracheotomy is a common technique in Intensive Care Units (ICU). It is known that nursing care during and after that procedure is directly related to its success, by reducing the possible complications to a minimum, such as the stoma infection, and contributing to a favourable outcome in critical patients. ObjectivesTo compare the use of polyhexanide (PLX) versus saline+povidone iodine (PY) as antiseptics and infection incidence in tracheostomies performed in Intensive Care Units. Material and methodA 2-year, experimental, randomised, open-label trial carried out in a multidiscipline ICU with 32 beds. The study was approved by the Research Ethics Committee of Principality of Asturias. ResultsThe overall infection rate observed for every hundred patients was 1.34 (95% CI; 0.81-2.01), with 1.46 when using PLX and 1.21 for PY (P=.685). ConclusionsIn spite of the experimental treatment (PLX) was shown to be effective in other types of wounds in our study. No significant differences were found between this technique and the standard one. Since there is no national registry of tracheotomy- associated infections, it is not possible to know whether the rate observed is within the usual parameters.

Endotracheal tube securements: Effectiveness of three techniques among orally intubated patients

BackgroundInvasive ventilation is a common practice in intensive care units (ICUs). Once a patient is intubated, maintenance of the endotracheal tube placement is essential. When the ETT is not secured effectively, even basic nursing management can cause tube slippage which is a major factor in causing airway trauma. Aim of the studyThis study was aimed at comparing the effectiveness of three endotracheal tube securement techniques (Twill, Adhesive and Simple bow) on endotracheal tube slippage, external jugular venous pressure measurement, oral mucosa and facial skin integrity, pain intensity and on patient satisfaction after the fixation method. Subjects and methodsA randomized clinical trial was conducted at the intensive care units in Ain Shams University Specialized Hospital. It included a sample of 90 patients, randomly allocated to the three equal groups: Twill, Adhesive and Simple bow groups, 30 subjects for each. The tools used for data collection included demographic and clinical data sheet, the time profile of ETT fixation method sheet and scales for endotracheal tube (ETT) slippage, external jugular venous pressure (EJVP) measurement, oral assessment guide (OAG) for oral mucosa, Facial Skin Integrity, pain intensity and patient satisfaction procedure scale. The study maneuvers were applied according to the group. ResultsBoth ETT slippage and EJVP were measured at 15, 30, 60 and 120min post fixation method. At 120min, 73% of patients in the Twill group had no slippage compared to Simple bow (50%) and (36%) in Adhesive groups. However, at 30min post fixation method 90% of patients in the Twill group had normal EJVP measurement compared to Simple bow and Adhesive groups (70% and 57%, respectively), with a statistically significant difference between the three groups. At 60min, only 10% of patients in the Twill group had high EJVP compared to Simple bow (37%) and Adhesive groups (47%) with a statistically significant difference among them. As well, at 120min post fixation method, most patients in the Twill group (97%) had normal EJVP measurement, compared to the Adhesive (60%) and Simple bow (57%) groups. Oral mucosa and facial skin integrity assessment was done for all patients in the three study groups at 2, 6, 12, and at 24h post fixation method. For oral mucosa at 24h post fixation method, 80% of patients in the Twill group had healthy oral mucosa compared to Simple bow and Adhesive groups (47% and 37%, respectively), with a statistically significant difference between the three groups (P=0.07). For facial skin integrity, at 6h, no one of patients in the Twill and Simple bow groups had severe facial skin reaction compared to patients in the Adhesive group (7%) and the difference was statistically significant, (P=0.01). As well, a statistically significant difference was revealed among the three groups, at 12 and 24h post fixation method, (P=0.04 and 0.02, respectively). The Twill technique had the shortest time taken for application and removal of securement method than other groups. Additionally, the Twill group had the lowest scores of pain at all three assessment times (5, 10 and 20min), whereas those in the Adhesive group had the highest scores. All these differences were statistically significant, (P<0.001). Overall, 80% of patients in the Twill group were satisfied, compared to 57% in the Simple bow group, and 37% only in the Adhesive group. ConclusionIt is concluded that Twill technique is an ETT securement technique in ICUs for orally intubated patients. RecommendationsIt is recommended to use this method, with development of strategies to prevent slippage aiming at increasing patient safety after securement technique intervention.

Jejunal Feeding Tubes Can Be Efficiently and Independently Placed by Intensive Care Unit Teams

Nutrition support is an important therapeutic measure in critically ill patients. Several studies have shown that the enteral route is preferable to the parenteral route. Insertion of a feeding tube beyond the ligament of Treitz combined with continuous gastric drainage will reduce regurgitation and probably also the rate of nosocomial pneumonia. This study was conducted to assess the safety, success rate, and time required to establish jejunal nutrition by the fluoroscopy-guided technique in intensive care unit (ICU) patients. This was a prospective observational study in the ICUs of a 300-bed and a 600-bed community hospital. Indications were large gastric residuals during attempted gastric feeding, severe acute pancreatitis, or recurrent aspiration. Feeding tubes were introduced by the ICU staff at bedside under fluoroscopic guidance (a senior ICU physician and a resident or a registered ICU nurse). The correct jejunal position was documented by the application of a radiopaque contrast medium through the tube. After confirmation of the correct position, jejunal tube feeding was immediately started. The insertion procedure in 38 patients lasted a median of 17 minutes. The median time from decision to place the tube until start of enteral feeding was 141 minutes. The success rate was 84.2%. No adverse events were observed. Fluoroscopic placement of a jejunal feeding tube at the bedside is fast, is safe, and has a high success rate when performed by well-trained ICU staff. Using this method makes the ICU team more self-sufficient when critically ill patients require enteral nutrition and no gastroenterologist is available.

Echocardiographic measurement of ventricular function

We review new findings concerning ventricular function in patients in intensive care units with shock or unexplained respiratory distress syndrome analyzed using echocardiography. Bedside echocardiography is not only an imaging technique but should be considered as a hemodynamic method. Left-ventricular systolic function can be assessed in daily clinical practice by measuring shortening fraction, fraction area change and ejection fraction. But these indices are dependent on load conditions. Index of myocardial performance can be also used. Rate of left-ventricular pressure increase may be measured from mitral regurgitation. Other indices such a maximal elastance and preload-adjusted maximal power were developed to evaluate myocardial systolic function but are not still used in clinical practice in patients in intensive care. Cardiac output measurement can be calculated easily from aortic annulus diameter and the velocity time integral of aortic blood flow. To complete the assessment of ventricular function, left-ventricular diastolic function and pressure as well as right ventricular size, septal movement and right pressures should be analyzed. Using echocardiography the intensivist can examine both the mechanism and the cause of shock or pulmonary edema. It is time to increase the use of this technique in intensive care units.

Use of percutaneous tracheostomy in intensive care units in Spain. Results of a national survey.

To assess the use of percutaneous tracheostomy in Intensive Care Units (ICU) in Spain, its practice, and current opinions on the technique. An e-mail or post survey was sent to 239 Spanish ICU directors. Pediatric ICUs and coronary units were excluded. One hundred ICUs (41.8%) replied. The 44% ( n=44) of the ICUs that answered belonged to university hospitals and 53% ( n=53) had postgraduate teaching. Eighty-two percent ( n=82) used percutaneous tracheostomy. Griggs' Guide Wire Dilating Forceps and Ciaglia Blue Rhino were the most frequent techniques employed. In 30.5% of ICUs ( n=25) endoscopic guidance was used, in 15.7% ( n= 13) it was routine. In 24.4% ( n=20) some kind of long-term follow-up was carried out, but only in 12.2% ( n=10) was follow-up done routinely. In 58.5% of ICUs ( n=48) in which percutaneous tracheostomy is performed is this technique considered safer than surgical tracheostomy and in 86.4% ( n=70) percutaneous tracheostomy is the first choice for tracheostomy in the critically ill patient. Percutaneous tracheostomy is a well-established technique in ICUs in Spain, and is considered the technique of choice for tracheostomy in critically ill patients. It is mainly performed without endoscopic guidance and follow-up is not usually carried out.

Late outcome of percutaneous dilatational tracheostomy in intensive care patients.

Percutaneous dilatational tracheostomy is increasingly practiced in intensive care units and has a low incidence of early complications. The late effects of this procedure are still poorly known and were the focus of this study. Prospective descriptive clinical study. Interdisciplinary intensive care unit in a 300-bed teaching hospital. A consecutive group of critically ill patients who underwent percutaneous tracheostomy between Nov. 90 and March 93, surviving at least 2 months after decannulation. There were 17 patients fulfilling the inclusion criteria and 16 of them were seen and examined. The follow-up protocol required a formal standardized patient interview, a physical examination of the stoma site and a fiberoptic laryngotracheoscopy. Results of these sub-tests and overall outcome rating were standardized and expressed as good, moderate or poor. Subjective rating was good in all patients. All denied suffering from any side effects of their tracheostomy. Clinical examination revealed neither stridor nor hoarseness in any of the patients. Most of the scars were whitish and less than 1 cm in length, a few were sunken in, none had adhesions. In 15 patients the clinical result was good and in one, moderate (whitish, sunken-in scar, longer than 2 cm). Ten patients underwent tracheoscopy, while 6 did not. There were no signs of significant stenosis or tracheomalacia. In 8 patients with minor findings results were scored as good, while 2 were classified as moderate (combination of swelling and scar formation of a string-like membrane). The overall rating was good in 13 patients (81%) and moderate in 3 patients (19%). There were no poor outcomes. Late outcome of percutaneous dilatational tracheostomy in critically ill patients is mostly good. Pending further studies, the use of this technique in intensive care units appears justified.

A Survey on Manual Hyperinflation as a Physiotherapy Technique in Intensive Care Units

Summary There is minimal documented evidence about the commonly performed physiotherapy technique, manual hyperinflation (MH). This paper presents the findings of a literature review on MH and the analysis of a questionnaire sent in September 1991 to 176 senior respiratory physiotherapists working in NHS hospitals throughout Britain. The questionnaire aimed to ascertain the practice of MH by physiotherapists in an intensive care unit (ICU). Twelve questions were asked about technique, indications, benefits of treatment, and precautions, with particular regard to high peak airway pressures (PAP). It is recommended that a manometer (pressure measuring device) is included in the inflation circuit when performing MH to reduce the risk of barotrauma. Clearly, more research needs to be carried out to ascertain the effectiveness of MH as a technique.

Failure of infection control in intensive care units: Can sucralfate improve the situation?

Conventional infection control measures in intensive care units (ICUs) are aimed primarily at stemming cross-infections. The role of patients' endogenous flora in the pathogenesis of nosocomial infection and occasional lapses in aseptic technique in ICUs help to explain the frequent failure of the conventional approaches. Newer control strategies include avoiding gastric and oropharyngeal overgrowth of gram-negative bacilli by using sucralfate to avoid gastric alkalinization and/or suppressing nosocomial flora by use of topical antimicrobials.

Useful and useless hygienic techniques in intensive care units.

Useful and useless hygienic techniques in intensive care units.