Neglected ocular surface care in critical care medicine: An observational study

Development and Validation of Eyes Care Bundle for Mechanically Ventilated Patients

Lack of proper eye care (EC) for mechanically ventilated patients can lead to serious ocular complications. Objective of this study is to develop and validate eyes care bundle for mechanically ventilated patients. A Delphi design study was conducted between March and May 2021. The Content Validity Index (CVI) was used to calculate the degree of agreement among the experts to analyze the bundle. Content validity was determined by 5 experts using a 4-point Likert scale. They evaluated the items in terms of the following: 1 = "irrelevant," 2 = "somewhat relevant if the phrasing is profoundly adjusted," 3 = "relevant with some adjustment," and 4 = "very relevant." The CVI was applied, and the accepted value was ≥0.50. The validation of EC bundle was conducted through 3 rounds after developed it based on the evaluated research evidence. The items were reviewed for content and face validity. The bundle was validated with 5 items with a total CVI of 0.96, a face validity of 1, and a Scale-Level Content Validity Index/Universal Agreement calculation method value of 0.8. This bundle can help critical care nurses, doctors, academics, and students assess and provide standard EC for mechanically ventilated patients.

Prevalence and risk factors of exposure keratopathy among critically ill patients: A systematic review and meta-analysis

AIMS

To identify the incidence, prevalence and risk factors of exposure keratopathy (EK) among critically ill patients.

DESIGN

Systematic review and meta-analysis, in accordance with the PRISMA 2020 Statement.

METHODS

The Cochrane Library, PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), China Knowledge Resource Integrated Database (CNKI), Chinese Biomedical Database (CBM), Weipu Database (VIP) and WanFang Database were systematically searched from inception to June 2022. Observational studies that reported EK among paediatric and adult critically ill patients were screened and included original articles based on the inclusion criteria. Two reviewers independently completed data extraction and quality assessments. Subgroup analysis investigated potential causes of heterogeneity.

RESULTS

Of the 4508 studies identified, 23 studies involving 3519 subjects were included. The pooled prevalence of EK was 34.0%, and the pooled incidence rate of EK was 23.0%. Risk factors associated with EK in critically ill patients included lagophthalmos, chemosis, eye blinks <5 times per minute, mechanical ventilation, sedation, lower Glasgow Coma Scale (GCS) score and higher Acute Physiology and Chronic Health Evaluation (APACHE) II score.

CONCLUSION

This review shows that EK rates are high in critically ill patients and are influenced by multiple factors. Medical staff should pay more attention to EK in critically ill patients, conduct professional evaluations and implement targeted eye care protocols to reduce its occurrence.

IMPLICATIONS FOR PRACTICE

This study shows the frequency of and multiple risk factors for EK in critically ill patients, which provides evidence-based guidance for nurses to evaluate the risk of EK in critically ill patients and take appropriate precautions to reduce the risk.

PROTOCOL REGISTRATION

The protocol was registered in PROSPERO (https://www.crd.york.ac.uk/prospero/) (CRD42022346964).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Causal validation of the risk for corneal injury in critically ill adults

BACKGROUND

The validity of a nursing diagnosis depends on a continuous investigation process in different populations to provide clinical evidence. The risk for corneal injury nursing diagnosis was approved in 2013 and only reviewed in 2017, demonstrating the need to perform a clinical validation to improve it.

AIM

To perform a causal validation of the risk for corneal injury nursing diagnosis in critically ill adults.

STUDY DESIGN

A prospective cohort study was performed in two intensive critical care units in Northern Brazil with adults aged over 18 years without corneal injury at admission. The patients were evaluated for 10 days, using a data collection tool composed of risk factors for the risk for corneal injury nursing diagnosis. The independent variables were described through absolute and relative frequency. The accuracy measures and risk factors were identified through Cox regression, considering a 95% confidence interval.

RESULTS

The nurses assessed 209 critically ill adults and identified that 76.0% of them presented the risk for corneal injury nursing diagnosis, with 16.3% developing a corneal injury, all having previously presented the risk for corneal injury nursing diagnosis. The risk factors identified were eyeball exposure (hazard ratio: 1.78; 95% CI: 1.27-2.51), Glasgow score < 6 (hazard ratio: 1.73; 95% CI: 1.15-2.60) and periorbital oedema (hazard ratio: 1.43; 95% CI: 1.03-1.99), with these factors showing high specificity, and the mechanical ventilation variable, showing high sensitivity, with ROC curve of .86.

CONCLUSION

Eyeball exposure, Glasgow score < 6 and periorbital oedema are the risk factors of the risk for corneal injury nursing diagnosis, in critically ill adults. These risk factors guide nursing interventions. This causal validation can improve the risk for corneal injury nursing diagnosis levels of evidence in the NANDA International Taxonomy.

RELEVANCE TO CLINICAL PRACTICE

It is necessary to guide nursing interventions for critically ill adults with lowered level of consciousness and corneal exposure for the prevention of corneal injury.

Nursing interventions to prevent corneal injury in critically ill sedated and mechanically ventilated patients: A systematic review of interventions

OBJECTIVE

To identify the effectiveness of interventions to prevent corneal injury in critically ill, sedated, and mechanically ventilated patients.

RESEARCH METHODOLOGY

A systematic review of intervention studies was conducted in the following electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Literature in Health Sciences, LIVIVO, PubMed, Scopus and Web of Science, and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Study selection and data extraction were performed by two independent reviewers. Quality assessment of the randomized and non-randomized studies was performed using the Risk of Bias (RoB 2.0) and ROBINS-I Cochrane tools, respectively, and the Newcastle-Ottawa Scale for cohort studies. The certainty of the evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

15 studies were included. Meta-analysis showed that the risk of corneal injury in the lubricants group was 66% lower (RR = 0.34; 95 %CI: 0.13-0.92) than in the eye-taping group. The risk of corneal injury in the polyethylene chamber was 68% lower than in the eye ointment group (RR = 0.32; 95 %CI 0.07-1.44). The risk of bias was low in most of the studies included and the certainty of the evidence was evaluated.

CONCLUSIONS

The most effective interventions to prevent corneal injury in critically ill sedated mechanically ventilated, who have compromised blinking and eyelid closing mechanisms, are ocular lubrication, preferably gel or ointment, and protection of the corneas with a polyethylene chamber.

IMPLICATIONS FOR CLINICAL PRACTICE

Critically ill, sedated, and mechanically ventilated patients who have compromised blinking and eyelid closing mechanisms must receive interventions to prevent corneal injury. Ocular lubrication, preferably gel or ointment, and protection of the corneas with a polyethylene chamber were the most effective interventions to prevent corneal injury in critically ill, sedated, and mechanically ventilated patients. A polyethylene chamber must be made commercially available for critically ill, sedated, and mechanically ventilated patients.

Risk Factors of Eye Complications in Patients Treated in the Intensive Care Unit

In critically ill patients, normal eye protection mechanisms, such as tear production, blinking, and keeping the eye closed, are impaired. In addition, many other factors related to patients' severe condition and treatment contribute to ocular surface disease. Reducing risk factors and proper eye care can have a significant impact on incidences of eye complications and patient quality of life after discharge from the intensive care unit (ICU). The aim of the study was to determine risk factors for ocular complication, especially those related to nursing care. The study was conducted in the ICU of a university hospital. Methods for estimating and analyzing medical records were used. The patient's evaluation sheet covering 12 categories of risk factors for eye complications was worked out. The study group included 76 patients (34 patients with injuries and 42 without injuries). The Shapiro-Wilk test, the Spearman's rank correlation test, the Mann-Whitney U test and the Friedman's ANOVA test were used. The level of significance was set at α = 0.05. The most important risk factors for eye complications in the study group were: lagophthalmos (p < 0.001), sedation (p < 0.01), use of some cardiological drugs and antibiotics (p < 0.01), mechanical ventilation (p < 0.05), use of an open suctioning system (p < 0.01), presence of injuries (p < 0.01) including craniofacial trauma (p < 0.001), high level of care intensity (p < 0.01), failure to follow eye care protocol (p < 0.001), length of hospitalization at the ICU (p < 0.001), and the frequency of ophthalmological consultations (p < 0.001). There was no correlation between the incidence of these complications and the age and gender of the patients. The exposure of critically ill patients to eye complications was high. It is necessary to disseminate protocols and guidelines for eye care in ICU patients to reduce the risk factors.

Risk for corneal injury in intensive care unit patients: A cohort study

AIM

To identify the incidence and risk factors for corneal injury amongst critically ill patients.

METHOD

A prospective cohort study with adult patients from one intensive care unit in Northern Brazil. Logistic regression was performed to predict the risk factors associated with corneal injury.

RESULTS

Data from 149 patients revealed 18.8% (28/149) corneal injuries. Factors independently associated with corneal injury were patients with eyeball exposure (OR: 27.31; 95% CI: 3.50-212.78); lagophthalmos (OR: 17.15; 95% CI: 5.78-50.85); chemosis (OR: 7.39; 95% CI: 2.28-23.97), periorbital oedema (OR: 7.99; 95% CI: 2.19-29.13) and hospitalisation >7-days (OR: 11.96; 95% CI: 3.27-43.66) had a significantly higher risk of developing corneal injury in this ICU.

CONCLUSION

Corneal injury was a common complication amongst critically ill patients and was associated with altered physiological function of the eyes such as exposure, lagophthalmos, chemosis and periorbital oedema. This study suggests introduction of a corneal injury prevention protocol for nursing and adding lagophthalmos and chemosis to the NANDA-I Taxonomy, thus contributing to the assessment and monitoring for the risk for corneal injury in critically ill patients.