As a special service to our readers, International Hospital presents a few recent literature abstracts chosen by our editorial board as being particularly worthy of attention.
A review of oral preventative strategies to reduce ventilator-associated pneumonia.
Andrews T, Steen C. Nurs Crit Care 2013; May18(3):116-22. Epub 2013 Jan 30.
This article evaluates the evidence for and efficacy of the use of mechanical hygiene and chlorhexidine in the prevention of ventilator-associated pneumonia (VAP). Search strategies included primary research articles; randomized controlled trials; systematic reviews and excluded quasi-experimental trials and opinion articles. VAP is the commonest infection found in critically ill patients who are mechanically ventilated. It is associated with increased mortality, increased length of stay in intensive care and increased costs. VAP is a health care-associated infection consistent with the presence of an endotracheal tube and mechanical ventilation for greater than 48 h. Efforts aimed at reducing infection rates include oral decontamination and mechanical hygiene to control the bacteria responsible, since there is an association between changes in bacteria found in the oropharynx and its development. Tooth brushing and the use of an oral antiseptic such as chlorhexidine gluconate are increasingly recommended in ventilator care bundles.
While there have been a number of studies conducted evaluating the efficacy of both approaches, there is limited evidence to support their use. The frequency of oral decontamination and mechanical hygiene interventions have not been established and chlorhexidine 2% seems to be more effective compared to weaker concentrations, but data is mainly confined to patients following cardiothoracic surgery.
Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma.
Lim WJ, Mohammed Akram R, Carson KV, Mysore S, Labiszewski NA, Wedzicha JA, Rowe BH, Smith BJ. Cochrane Database Syst Rev. 2012; Dec 12:12:CD004360.
Because of sub-optimal long-term care and delays in obtaining help during acute exacerbations, the mortality and morbidity related to asthma is still a major health concern. There is reason to believe that non-invasive positive pressure ventilation (NPPV) could be beneficial to patients with severe acute asthma; however, the evidence surrounding the efficacy of NPPV is unclear, despite its common use in clinical practice.
The objectives were to determine the efficacy of NPPV in adults with severe acute asthma in comparison to usual medical care with respect to mortality, tracheal intubation, changes in blood gases and hospital length of stay.
The search method consisted of a search in the Cochrane Airways Group Specialized Register of trials (July 2012). Following this, the bibliographies of included studies and review articles were searched for additional studies (July 2012). Included were randomized controlled trials of adults with severe acute asthma as the primary reason for presentation to the emergency department or for admission to hospital. Asthma diagnosis was defined by internationally accepted criteria. Studies were included if the intervention was usual medical care for the management of severe acute asthma plus NPPV applied through a nasal or facemask compared to usual medical care alone. Studies including patients with features of chronic obstructive pulmonary disease (COPD) were excluded unless data were provided separately for patients with asthma in studies recruiting both COPD and asthmatic patients. Five studies on 206 participants contributed data, while one study was available in abstract form only and was not fully incorporated into this review. For the primary outcome of endotracheal intubation there were two studies that contributed data: two intubations were needed in 45 participants on NPPV and no intubations in 41 control patients (risk ratio 4.48; 95% CI 0.23 to 89.13). There were no deaths in either of these studies. Length of hospital stay was reported in two studies, though meta-analysis was not possible. Hospitalisation was reported in one small study, in which there were three admissions out of 17 on NPPV and 10 admissions out of 16 in control patients (RR 0.28, 95% CI 0.09, 0.84).
This review of studies has highlighted the paucity of data that exist to support the use of NPPV in patients in status asthmaticus. As such this course of treatment remains controversial despite its continued use in current clinical practice. Larger, prospective randomized controlled trials of rigorous methodological design are needed to determine the role of NPPV in patients with asthma.
A7 Anesthesia Global Launch
, /in Featured Articles /by 3wmediaRespiratory valves and other innovative respiratory products
, /in Featured Articles /by 3wmediaICIS (Imaging Clinical Information System) services platform
, /in Featured Articles /by 3wmediaMCS-8064 – GE Lightspeed VCT replacement tube
, /in Featured Articles /by 3wmediaTreating bladder cancer: is robotic-assisted surgery the answer?
, /in Featured Articles /by 3wmediaBladder cancer is a significant cause of morbidity and mortality worldwide, but with the exception of countries where schistosomiasis is prevalent, such as Egypt, the disease most commonly affects older men in developed countries. In EU residents it is the fourth most frequent cancer among men, accounting for around 7% of total cancers and 6% of cancer deaths; in women it is the tenth most frequent cancer accounting for 2% of cancer deaths.
Surgery is involved in the management of most bladder cancers, with transurethral resection being the usual approach to facilitate diagnosis and staging, and to remove small superficial tumours, but for areas of the bladder that are not easily accessible, manipulation of the endoscope and other instruments may injure healthy tissues. For the approximately 30% of tumours that are muscle-invasive, open radical cystectomy (ORC) is the normal standard of care. This procedure is medically challenging for the patient, and because of the duration of the surgery together with the inevitable loss of blood and other fluids, it is contraindicated for many elderly patients.
The answer to these problems is robotic-assisted surgery. An innovative telerobotic system, which is under development at Vanderbilt and Colombia universities, USA, incorporates a segmented working arm of only 5.5 mm diameter for viewing as well as supporting micro-instruments. The inherent flexibility of the device should eventually allow micrometer-resolution images of the entire bladder wall and removal of all superficial tumour cells.
A recently published pilot trial in the US involving 47 randomized patients with invasive bladder cancer compared ORC with robotic-assisted laparoscopic radical cystectomy (RARC). While there was no reported difference in treatment outcomes, the latter group lost less blood and needed fewer transfusions, experienced a quicker return of bowel function and had shorter hospital stays. A larger scale trial involving several healthcare centres is now ongoing, which will also follow long-term outcomes.
Robotic-assisted surgery is expensive, though. Already in terms of average healthcare costs per patient, bladder cancer is the most expensive adult cancer in the West, mainly due to the high rate of recurrence. But telerobots could actually go a long way towards preventing recurrence and thus reducing costs, and while the actual procedure of RARC is currently more expensive than ORC, shorter hospital stays with fewer interventions should help balance the books.
eHealth in Europe – a status check
, /in Featured Articles /by 3wmediaThe emerging European eHealth system depends on an asynchronous cocktail of technology development cycles, vendor push to adopt new products and solutions, as well as growing patient demands for less anonymous, personalized health intervention. Other factors making an impact are the often-significant divergences in hospital/healthcare cultures across EU Member States, coupled to significant differences in health and technology spending. This has been emphasized by new pressures on budgets and spending, after the end-2008 financial crisis.
The EU Commission has sought to bridge and buffer this array of cross-currents, while seeking to resolutely promote a common but effective eHealth agenda. It has sought to establish enabling rules and guidelines in order to level the playing field and provide transparent incentives for implementing eHealth projects, across the EU
Reaching for the skies: Healthcare and cloud computing
, /in Featured Articles /by 3wmediaHealthcare has traditionally been a late entrant in adopting new information technology innovation, and the Cloud is no exception. In terms of markets, the US has been a first mover in healthcare Cloud applications. The EU has spent a great deal of time and effort assessing its implications, above all on data privacy. Britain, however, may have taken the most significant steps to begin endorsing use of the Cloud in its healthcare system.
Cloud computing comprises platforms and applications (online operating systems, file and data sharing), as well as infrastructure (Web-based data storage and access). Service providers bill users on the basis of subscriptions or pay-as-you-go. The latter is a key incentive for growing interest in the Cloud, given that it allows businesses to reduce upfront investments and scale up on the basis of real requirements rather than anticipated ones. The Cloud
Tele-anesthesia ? a new field of telemedicine
, /in Featured Articles /by 3wmediaTelemedicine has been around for many years, evolving in tandem with technological change and improvements. In essence, telemedicine delivers healthcare services by means of technology, in cases where the healthcare professional cannot attend to the patient physically. Tele-anesthesia takes it a step further by doing pre-operative consultations by means of telemedicine systems. In this article, the authors report of the growing use of tele-anesthesia.
by Dr Nora Terrasini, Dr Erik Arbeid, Dr Riccardo Taddei, Dr Cedrick Zaouter, Dr Shantale Cyr and Dr Thomas M Hemmerling
What is telemedicine?
Telemedicine is defined as the delivery of healthcare and sharing of medical knowledge over a distance, using telecommunications systems [1]. The World Health Organization gives a more extensive definition of what should be considered as telemedicine and describes it as
A new safety kit helps to raise anesthesia safety standards across Europe
, /in Featured Articles /by 3wmediaThe European Society of Anaesthesiology (ESA) is to launch a safety starter kit containing a wide variety of essential resources to help raise safety standards in anesthesiology across Europe. The kit will be distributed on a memory stick at this year
Scientific literature: mechanical ventilation
, /in Featured Articles /by 3wmediaAs a special service to our readers, International Hospital presents a few recent literature abstracts chosen by our editorial board as being particularly worthy of attention.
A review of oral preventative strategies to reduce ventilator-associated pneumonia.
Andrews T, Steen C. Nurs Crit Care 2013; May18(3):116-22. Epub 2013 Jan 30.
This article evaluates the evidence for and efficacy of the use of mechanical hygiene and chlorhexidine in the prevention of ventilator-associated pneumonia (VAP). Search strategies included primary research articles; randomized controlled trials; systematic reviews and excluded quasi-experimental trials and opinion articles. VAP is the commonest infection found in critically ill patients who are mechanically ventilated. It is associated with increased mortality, increased length of stay in intensive care and increased costs. VAP is a health care-associated infection consistent with the presence of an endotracheal tube and mechanical ventilation for greater than 48 h. Efforts aimed at reducing infection rates include oral decontamination and mechanical hygiene to control the bacteria responsible, since there is an association between changes in bacteria found in the oropharynx and its development. Tooth brushing and the use of an oral antiseptic such as chlorhexidine gluconate are increasingly recommended in ventilator care bundles.
While there have been a number of studies conducted evaluating the efficacy of both approaches, there is limited evidence to support their use. The frequency of oral decontamination and mechanical hygiene interventions have not been established and chlorhexidine 2% seems to be more effective compared to weaker concentrations, but data is mainly confined to patients following cardiothoracic surgery.
Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma.
Lim WJ, Mohammed Akram R, Carson KV, Mysore S, Labiszewski NA, Wedzicha JA, Rowe BH, Smith BJ. Cochrane Database Syst Rev. 2012; Dec 12:12:CD004360.
Because of sub-optimal long-term care and delays in obtaining help during acute exacerbations, the mortality and morbidity related to asthma is still a major health concern. There is reason to believe that non-invasive positive pressure ventilation (NPPV) could be beneficial to patients with severe acute asthma; however, the evidence surrounding the efficacy of NPPV is unclear, despite its common use in clinical practice.
The objectives were to determine the efficacy of NPPV in adults with severe acute asthma in comparison to usual medical care with respect to mortality, tracheal intubation, changes in blood gases and hospital length of stay.
The search method consisted of a search in the Cochrane Airways Group Specialized Register of trials (July 2012). Following this, the bibliographies of included studies and review articles were searched for additional studies (July 2012). Included were randomized controlled trials of adults with severe acute asthma as the primary reason for presentation to the emergency department or for admission to hospital. Asthma diagnosis was defined by internationally accepted criteria. Studies were included if the intervention was usual medical care for the management of severe acute asthma plus NPPV applied through a nasal or facemask compared to usual medical care alone. Studies including patients with features of chronic obstructive pulmonary disease (COPD) were excluded unless data were provided separately for patients with asthma in studies recruiting both COPD and asthmatic patients. Five studies on 206 participants contributed data, while one study was available in abstract form only and was not fully incorporated into this review. For the primary outcome of endotracheal intubation there were two studies that contributed data: two intubations were needed in 45 participants on NPPV and no intubations in 41 control patients (risk ratio 4.48; 95% CI 0.23 to 89.13). There were no deaths in either of these studies. Length of hospital stay was reported in two studies, though meta-analysis was not possible. Hospitalisation was reported in one small study, in which there were three admissions out of 17 on NPPV and 10 admissions out of 16 in control patients (RR 0.28, 95% CI 0.09, 0.84).
This review of studies has highlighted the paucity of data that exist to support the use of NPPV in patients in status asthmaticus. As such this course of treatment remains controversial despite its continued use in current clinical practice. Larger, prospective randomized controlled trials of rigorous methodological design are needed to determine the role of NPPV in patients with asthma.