1.
Effect of oropharyngeal povidone-iodine preventive oral care on ventilator-associated pneumonia in severely brain-injured or cerebral hemorrhage patients: a multicenter, randomized controlled trial.
Seguin, P, Laviolle, B, Dahyot-Fizelier, C, Dumont, R, Veber, B, Gergaud, S, Asehnoune, K, Mimoz, O, Donnio, PY, Bellissant, E, et al
Critical care medicine. 2014;(1):1-8
Abstract
OBJECTIVE To evaluate the efficacy and safety of oral care with povidone-iodine on the occurrence of ventilator-associated pneumonia in a high-risk population. DESIGN A multicenter, placebo-controlled, randomized, double-blind, two-parallel-group trial performed between May 2008 and May 2011. SETTING Six ICUs in France. PATIENTS One hundred seventy-nine severely brain-injured patients (Glasgow Coma Scale ≤ 8) or cerebral hemorrhage expected to be mechanically ventilated for more than 24 hours. INTERVENTIONS Participants were randomly assigned to receive oropharyngeal care with povidone-iodine (n = 91) or placebo (n = 88) six times daily until mechanical ventilation withdrawal. MEASUREMENTS AND MAIN RESULTS Primary endpoint was the rate of ventilator-associated pneumonia. Secondary endpoint included the rates of ventilator-associated tracheobronchitis and acute respiratory distress syndrome and patient's outcome. The number of patients evaluable for the primary endpoint (preplanned modified intention-to-treat population) was 150 (78 in the povidone-iodine group, 72 in the placebo group). Ventilator-associated pneumonia occurred in 24 patients (31%) in the povidone-iodine group and 20 (28%) in the placebo group (relative risk, 1.11 [95% CI, 0.67-1.82]; p = 0.69). There was no significant difference between the two groups for ventilator-associated tracheobronchitis: eight patients (10%) in the povidone-iodine group and five patients (7%) in the placebo group (relative risk, 1.48 [95% CI, 0.51-4.31]; p = 0.47). Acute respiratory distress syndrome occurred in five patients in the povidone-iodine group but not in the placebo group (p = 0.06). There was no difference between groups for ICU and hospital lengths of stay, as well as ICU and 90-day mortality. CONCLUSIONS There is no evidence to recommend oral care with povidone-iodine to prevent ventilator-associated pneumonia in high-risk patients. Furthermore, this strategy seems to increase the rate of acute respiratory distress syndrome.
2.
Clinicians' perceptions of factors contributing to complexity and intensity of care of outpatients with traumatic brain injury.
Jeyaraj, JA, Clendenning, A, Bellemare-Lapierre, V, Iqbal, S, Lemoine, MC, Edwards, D, Korner-Bitensky, N
Brain injury. 2013;(12):1338-47
Abstract
PRIMARY OBJECTIVE This study investigated clinicians' perceptions on factors linked to patient complexity in traumatic brain injury (TBI) outpatient rehabilitation. METHOD Twelve clinicians from various disciplines, working in TBI outpatient programmes from three rehabilitation institutions in Montreal, Quebec, were recruited using convenience and snowball sampling. Data was collected through focus groups and individual interviews and thematic analysis was used to identify themes. MAIN OUTCOMES AND RESULTS Participants identified complexity factors falling under the following themes: sequelae of TBI (cognitive/behavioural/psychological impacts), personal factors (personality traits, pre-medical state, lifestyle and age), patients' environment (architectural, social, language, cultural and financial) and therapeutic relationship (mismatch, misunderstanding and personality clashes). Clinicians also reported facilitators to optimal treatment delivery such as quality of services and working in an interdisciplinary team. Limited time, training and resources were identified as barriers to treatment. CONCLUSION A substantial proportion of patients in outpatient TBI programmes seem to follow an atypical evolution and exhibit added complexity. In order to optimize quality of care, clinicians recommended increased community awareness about TBI, increased resources for rehabilitation clinicians and specialized services post-discharge. These findings are insightful for stakeholders; providing a basis for discussions on policy changes that can better meet this population's needs.