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Essential Nursing Care of the Critically Ill Patient 127

Case study, Continued
dialysis continued to be required up until day 34 when urine Summary
output was consistently effective. Kevin was able to sit out of bed Kevin had a very complicated and serious illness requiring man-
daily with the assistance of initially a lifting machine and then a agement of many critical conditions. Essential nursing care, com-
standing device. munication and psychological support were vital components of
Day 38 his care while in ICU. In addition his haemodynamic and respiratory
Kevin was able to have his tracheostomy decannulated. instability along with his initial size and then the development of
critical illness polyneuropathy limited the ICU team’s options for
Day 40 early mobility and potentially impacted on Kevin’s need for signifi-
Kevin was transferred from ICU to the respiratory unit and then cant rehabilitation before he was able to return home to indepen-
discharged from hospital to a rehabilitation unit on day 53. dent living.

Research vignette

Munroe CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlor- Conclusions
hexidine, toothbrushing, and preventing ventilator-associated Chlorhexidine, but not toothbrushing, reduced early ventilator-
pneumonia in critically ill adults. American Journal of Critical Care associated pneumonia in patients without pneumonia at
2009; 18(5): 428-38. baseline.
Abstract Critique
Background The factorial RCT is a powerful design to test hypotheses of cause
Ventilator-associated pneumonia is associated with increased mor- and effect as was tested in this study. It is interesting to note that
bidity and mortality. a total of 10,910 patients were screened for eligibility, only 13%
(n = 1416) met the eligibility criteria and only 5% (n = 547) were
Objective consented and subsequently enrolled in the study. Consent was
To examine the effects of mechanical (toothbrushing), pharmaco- unable to be obtained for 61% (n = 869) of those eligible. This
logical (topical oral chlorhexidine), and combination (toothbrush- points to a real difficulty in conducting trials in the ICU setting;
ing plus chlorhexidine) oral care on the development of large numbers of patients may have to be screened with many of
ventilator-associated pneumonia in critically ill patients receiving those eligible not subsequently participating due to consent
mechanical ventilation.
issues. A clear description of the interventions were described. For
Methods example, the toothbrushing protocol was described in detail and
Critically ill adults in 3 intensive care units were enrolled within 24 involved dividing the mouth into quadrants and brushing each
hours of intubation in a randomised controlled clinical trial tooth for five strokes using Biotene toothpaste, which was based
with a 2 x 2 factorial design. Patients with a clinical diagnosis on the American Dental Association’s recommendations. The
of pneumonia at the time of intubation and edentulous details about the interventions allow others to replicate them in
patients were excluded. Patients (n = 547) were randomly future research, however, the researchers did not mention collect-
assigned to 1 of 4 treatments: 0.12% solution chlorhexidine oral ing data on intervention fidelity, or the extent to which the tooth-
swab twice daily, toothbrushing thrice daily, both toothbrushing brushing and chlorhexidine swabbing were actually performed as
and chlorhexidine, or control (usual care). Ventilator-associated was planned. Further, it is not clear what ‘usual care’ was in the
pneumonia was determined by using the Clinical Pulmonary Infec- study sites.
tion Score (CPIS).
Two issues are important to consider when examining the findings.
Results First, complete data was only available for 192 of the 547 patients
The four groups did not differ significantly in clinical characteristics. randomised, which represents a 35% retention rate (i.e. 65 % loss
At day 3 analysis, 249 patients remained in the study. Among to follow up). Second, 54% (105 of 192) patients recruited to the
patients without pneumonia at baseline, pneumonia developed in study did not meet the eligibility requirement because they already
24% (CPIS ≥6) by day 3 in those treated with chlorhexidine. When had pneumonia, yet they were randomised. Both issues may com-
data on all patients were analyzed together, mixed models analysis promise the randomisation process. Specifically, randomisation is
indicated no effect of either chlorhexidine (P = 0.29) or toothbrush- a method to try to ensure the groups are similar in all known and
ing (P = 0.95). However, chlorhexidine significantly reduced the unknown characteristics, which is important in that this will control
incidence of pneumonia on day 3 (CPIS ≥ 6) among patients who for the effect of potential confounders. While the researchers
had CPIS <6 at baseline (P = 0.006). Toothbrushing had no effect present the subgroup analysis of those without pneumonia, this
on CPIS and did not enhance the effect of chlorhexidine. analysis may not represent ‘random’ allocation to the various