Eyecare for the sedated patient undergoing mechanical ventilation: the use of evidence-based care

Synthetic rubber sheet to manage exposure keratopathy

Purpose

Exposure keratopathy often progresses even with conventional various treatments and needs plastic surgery. However, plastic surgery of eye lid is often difficult in cases with poor general condition by cerebrovascular disorders. We will propose a novel method using synthetic rubber sheet to manage the exposure keratopathy under poor general conditions.

Observations

We treated with synthetic rubber sheet on 9 eyes of 9 patients who suffered from refractory exposure keratopathy due to cerebrovascular disorders. Sheets cut from sterile surgical gloves made of synthetic rubber (SR sheets) were placed directly onto the ocular surface with antibiotic ointment and fixed with gauze and tape. Severity of the exposure keratopathy was scored before and after the application of SR sheet. Covered ocular surface with SR sheet could keep an adequate moist environment and exposure keratopathy was improved in all the cases with no adverse effects during an average observation period of 166.2 days.

Conclusions and importance

Sterile synthetic rubber sheet cut from surgical gloves is an effective, safe, easy, and economical material to maintain better condition of ocular surface and especially useful for refractory exposure keratopathy under poor general condition.

Efficacy of Simple Eye Ointment, Polyethylene Cover, and Eyelid Taping in Prevention of Ocular Surface Disorders in Critically Ill Patients: A Randomized Clinical Trial

Background

Under normal conditions, the cornea of the eye is protected from bacterial invasion, physical injury, and drying by the presence of tears, eyelids, and blinking reflex. However, patients admitted to the intensive care unit (ICU) for several reasons including loss of consciousness, receiving sedative and neuromuscular blocking agents, and mechanical ventilation may lose eye-protective mechanisms causing exposure keratopathy. Therefore, this study intended to compare three eye care methods to prevent ocular surface disorders (OSDs) in ICU patients.

Methods

This study was a double-blind clinical trial (IRCT: 201109225426N3, https://www.irct.ir/trial/5825), in which 152 patients were randomized into three groups and each group underwent a different eye care procedure. The eye care methods included simple eye ointment, polyethylene cover, and eyelid taping. The eligible patients received the care procedure for seven days, and their corneas were examined daily for OSD by a portable slit lamp with fluorescein staining. Descriptive and analytical tests (ANOVA, chi-square, logistic regression, and zero-inflated Poisson regression) were used for statistical analysis by STATA14.

Results

The odds of OSD (chances of getting an OSD grade between I and VI) in the ointment group were 0.19 (95% CI: 0.09, 0.41), and the odds of OSD in the polyethylene cover group were 0.06 (95% CI: 0.01, 0.20), showing a significant difference with the tape group (p=0.0001). Despite the lower odds of OSD in the cover group than in the ointment group, there was no significant between-group difference (p=0.08). However, the mean OSD scores in both the ointment and polyethylene cover groups were significantly lower than that in the tape group.

Conclusion

The results of this study showed that polyethylene cover followed by simple eye ointment and eyelid taping were the most effective methods in preventing OSD. Therefore, polyethylene cover and simple eye ointment are recommended as effective eye care methods in ICU.

Knowledge and practice patterns of Intensive Care Unit nurses towards eye care in Chhattisgarh state

Purpose

The aim of the study was to present the level of knowledge and practice patterns regarding exposure keratopathy in mechanically ventilated patients among Intensive Care Unit (ICU) nurses in Chhattisgarh state.

Methods

A previously validated semi-structured questionnaire was administered in the ICU of six multispecialty hospitals in Chhattisgarh in 2014-2015. Demography included age, gender, level of education, and months of working in ICU. Most of the questions dealt with frequency of eyelid closure assessment, frequency of cleaning of eyes with saline gauze, using a protocol-based approach for eye care, and documentation of ophthalmic complications. Common barriers to delivery of eye care such as shortage of time and too much writing tasks were also inquired.

Results

Our study included 120 nurses. They worked for mean 22.9 ± 17.8 months in ICU. Knowledge about high risk of exposure keratopathy in ventilated patient was present in 93% (78%; 95% confidence interval [CI]) nurses. Only six nurses (5%) followed a strict protocol for eye care, 52 nurses (43%) checked for eyelid closure in the ventilated patients, and 58 (48%) cleaned the eyes frequently. Those who were aware of exposure keratopathy checked eyelid closure (73% vs. 48%) and cleaned eyes with saline gauze more frequently (24% vs. 4%). Nurses in cardiac ICU were significantly lesser aware of exposure complications compared to medical ICU nurses (40% reduction in awareness, 95% CI = 0.37-0.98, P = 0.04).

Conclusion

Although there is high awareness, practice patterns of ICU nurses were less than desired. Educational initiatives should focus on weaknesses in knowledge and practice noted to improve eye care of patients in ICU.

Development and validation of an eye care educational programme for intensive care unit nurses

AIMS AND OBJECTIVES

To develop and validate an eye care educational programme for intensive care unit nurses.

BACKGROUND

Eye care guidelines and protocols have been developed for increasing eye care implementation in intensive care units. However, the guidelines lack consistency in assessment or intervention methodology.

DESIGN

This was a one-sample pre/postprogramme evaluation study design for testing the effects of the eye care educational programme, developed for and applied to intensive care unit nurses, on their levels of knowledge and awareness.

METHODS

The eye care educational programme was developed based on literature review and survey of educational needs. Thirty intensive care unit nurses served as subjects for the study.

RESULTS

The levels of eye care-related knowledge, awareness and practice were enhanced following the implementation of the educational programme. Moreover, satisfaction with the educational programme was high.

CONCLUSION

It is necessary to intensify eye care education aimed at new nurses who are inexperienced in intensive care unit nursing and provide continuing education on the latest eye care methods and information to experienced nurses.

RELEVANCE TO CLINICAL PRACTICE

The eye care educational programme developed in this study can be used as a strategy to periodically assess the eye status of patients and facilitate the appropriate eye care.

Making a Difference in Eye Care of the Critically Ill Patients

Ocular surface disorders are frequently encountered in patients under sedation and paralyzed patients in intensive care units (ICUs). In the ICUs, treatment is usually focused on the management of organ failures, and eye care becomes a side issue. As a result, ophthalmological complications do occur (incidence ranges from 3.6% to 60%) and are frequently overlooked in this setting. To identify the best available evidence in providing the best eye care to prevent exposure keratopathy, a literature review was performed. The databases of PUBMED, COCHRAN, and EMBASE library were searched. We only looked at higher quality articles. Among various eye care measures that have been advocated to prevent exposure keratopathy, the most effective is the application of polyethylene covers. Early diagnosis and effective treatment will help prevent microbial keratitis and visual loss.

[Knowledge and application level of the Ramsay Scale by Mexican nurses specialized in intensive care]

INTRODUCTION

Among the intensive care specialized nursing staff, knowing the sedation level of the patient under their responsibility is of crucial importance. The present study evaluated the knowledge that nurses specialized in intensive care (NSIC) have on the Ramsay Scale (RS) and the way in which they apply it.

MATERIAL AND METHODS

Those personnel who were developing their activity in the intensive care units (ICU) of four public hospitals of the cities of Merida, Yucatan, Mexico were enrolled during May 2003. The information was obtained by applying an expressly designed questionnaire that contained both demographic endpoints (age, years of experience as NSIC and type of ICU) and those related with the RS (clinical components that it evaluates, operative definitions, frequency of use per week or day). 95% (95% CI) confidence intervals were applied and odds ratio (OR) was used to determined the likelihood of the event.

RESULTS

Of the 60 nurses interviewed, 75% did not know the RS. Age was a significant factor associated with its knowledge, since 11 of 23 with an age equal to or less than 38 years (47.8%) and 4 of 37 over 38 years (10.8%) knew what it evaluated (OR of 4 for the group of lower age, 95% CI 1.5 to 12.3, p = 0.002). Of 15 NSIC who knew what it evaluated, 9 (60%) also knew its operative definitions, and stated that they applied it adequately per day.

CONCLUSIONS

In this sample, there is an elevated percentage of NSIC who did not know the RS. Age was the factor associated with lack of knowledge.

A randomised controlled study of the efficacy of hypromellose and Lacri-Lube combination versus polyethylene/Cling wrap to prevent corneal epithelial breakdown in the semiconscious intensive care patient

OBJECTIVE

To compare the efficacy of two forms of eye care (hypromellose and Lacri-Lube combination vs polyethylene/Cling wrap covers) for intensive care patients.

DESIGN

Randomised-controlled trial.

SETTING

University affiliated, tertiary referral hospital.

PATIENTS AND PARTICIPANTS

One hundred ten patients with a reduced or absent blink reflex were followed through until they regained consciousness, were discharged from the facility during study enrolment, died or developed a positive corneal ulcer or eye infection.

INTERVENTIONS

All patients received standard eye cleansing every 2 h. In addition to this, group one ( n=60) received a treatment combining hypromellose drops and Lacri-Lube (HL) to each eye every 2 h. Group two ( n=50) had polyethylene covers only placed over the eye to create a moisture chamber.

MEASUREMENTS AND RESULTS

Corneal ulceration was determined using corneal fluorescein stains and mobile slit lamp evaluation, performed daily. No patients had corneal ulceration in the polyethylene cover group, but 4 patients had corneal ulceration in the HL group.

CONCLUSIONS

Polyethylene covers are as effective as HL in reducing the incidence of corneal damage in intensive care patients.

Building a framework for getting evidence into critical care education and practice

One challenge for nurse educators is how best to enhance the integration of theory and practice elements in relation to critical care nursing. Practice should be evidence-based, i.e. the best available empirical evidence, including recent research findings, should be applied in practice in order to aid clinical decision-making. Barriers to the implementation of research exist at many levels including the individual practitioner, the clinical team, the practice setting and wider organizational factors. The authors propose that clinical guidelines can provide a vital link between theory and practice. At varying levels the use of care protocols, clinical pathways and algorithmic guidelines (provided they are rigorously reviewed and evidence-based) can help infuse research into practice, thereby promoting quality and standardization of care. The purpose of this paper is to discuss the value and use of these frameworks in promoting and raising awareness of the need for and use of evidence-based approaches to critical care education and practice. In this paper, we present outline information relating to an assessment method, adopted for continuing education courses in critical care within our department. This approach is designed to combine the best available evidence with reflective practice through the assessment process.