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November 15th, 2011
Have you had your daily feeding of evidence
Years ago, to get the latest findings in your field, you needed to travel to your hospital... »
November 14th, 2011
Incentive Spirometry or Cough
Coughing and deep breathing is equally effective as incentive spirometry according to... »
November 13th, 2011
Depression screening for HIV/AIDS patients
Depression screening can be a challenging process with HIV/AIDS patients...»

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Letters on Evidence Archive

View Current Letters on Evidence

Dear Colleagues in evidence-based care,
Comfort in terminal extubation: Minimal evidence, maximal need

Studying  the dying process and terminal extubation in particular, is clearly a challenge.  Are the measures we choose even relevant to the person in the bed?  We may never know.  Nevertheless, some brave souls have attempted to offer their best effort on it.  What they mostly do is retrospectively review the chart for processes of care and trends of results.  This amounts to little more than consensus of expert opinion but is the best most have been able to achieve to date.

A few trends became obvious as one team reviewed this literature and offered their own local experience.  Some of this is just plain common sense.  For example, if you don’t need to use devices to maintain patient comfort or resting safety, then don’t.  If you don’t need to start an intravenous to give medications, then don’t.  Use alternate routes.  We have oral morphine (Roxanol) and we can use atropine eye drops under the tongue for secretions.  Never stop comfort measures already in place, such as benzodiazepines (Kompanje, 2008).  Truog et al. (2008) reminded us all that the goal is to support dignity and comfort, providing quiet, comfortable spaces for the patient and family, absent the trappings of technology, full of human caring.  Turn off the alarms and monitors.

Experts argue about the speed of withdrawal of the endo-tracheal tube, but are clear that there are circumstances where it is not appropriate to remove it:  large volume of secretions and swollen tongue , for example (Campbell, 2007).  Truog et al. (2008) cited the absence of evidence governing this subject.  They further noted that rapid withdrawal may cause dyspnea and related discomfort.

Fear of causing a premature death via opioids paralyzes some.  Mazer et al. (2011) found  that the mean dose of morphine just before death was about 10 mg.  During the last hour of life each 1 mg /hour increment of morphine infused was associated with a delay of death by 7.9 minutes.  The authors encouraged practitioners to reduce their concern for premature death and act purely on the patient’s assessed needs for comfort.

Truog and colleagues (2008) did their best to summarize care recommendations in a consensus statement by the American College of Critical Care Medicine.  This was published in Critical Care Medicine, in 2008.  Authors included nurses and physicians knowledgeable in the field.  Although many hope this will change as time goes on, around 20% of all deaths in the United States occur in ICUs.  Clinicians need to apply the same vigor to dignity and comfort preservation as they do to life saving.

Kompanje, E.O., Van der Hoven, B., & Bakker, J. (2008) Anticipation of distress after discontinuation of mechanical ventilation in the ICU at end of life. Intensive Care Medicine, 34, 1593-1599.

Mazer, M. A. (2011).  The infusion of opioids during terminal withdrawal of mechanical ventilation in the medical intensive care unit.  Journal of Pain and Symptom Management, 42(1), 44-51.

Truog, RD et. al. (2008) Recommendations for end-of-life care in the intensive care unit: a consensus statement by the american academy of critical care medicine. Critical Care Medicine. 36(3): 953-961.

***
Dear Colleagues in evidence-based care,
Hope for Resistant C. difficile patients?

Earlier this year, an Ocean Medical Center physician approached hospital leadership with a request to try a novel procedure to assist a patient suffering from resistant C. difficile. The physician was familiar with the work of Lawrence Brandt, M. D., a gastroenterology physician at Montefiore Medical Center. Dr. Brandt shared his work of administering screened donated stool to patients with recurrent C. difficile related diarrhea at a conference. The Institute for Evidence-Based Care was asked to review the additional evidence of this procedure. The literature available to date was found to be based on case series. Just under ninety case reports were published in ten articles. As some of these were only available as abstracts, only those available as full reports will be shared here. The fecal transplant was accomplished through colonocope, enema or even naso-gastric tube. Of 61 patients reported, all but five recovered post treatment. A systematic review by Barody et al. (2004) reported an 86% success rate in the 84 cases reviewed for treatment of C. diff by this procedure. Of note, this procedure was first documented in 1958 by Eiseman. Literature throughout the ensuing decades reported no adverse effects. While a randomized controlled trial is in process, the best available evidence is currently a substantial number of case reports. The conclusion is that when all standard current treatments have failed and no other options exist, this procedure merits strong consideration.

When is enough evidence present to determine acceptability for practice is a frequently asked question. Claxton, Cohen and Neumann (2005) entered this argument by stating that it goes against common sense to ignore existing evidence of various sources. They said, “For example, suppose an observation al study suggested a treatment for a terminal illness is effective. Does it makes sense to withhold this treatment from the population until a “proper” RCT can be conducted?” (p. 94). They advocated consideration of potential benefits and consequences. In fact, evidence-based care should always be based on a consideration of the combination of evidence, practitioner judgment and patient preferences.

In our index case, the patient favored the new procedure and the practitioner had weighed his options for benefits and risks carefully. Organizational leadership accepted the findings of the Institute for Evidence-Based Care. A procedure has been developed and privileging issues addressed. It is not available for patients suffering from debilitating resistant disease.

***
Dear Colleagues in evidence-based care,
Naso/orogastric Tube Placement Confirmation

One of the worst case scenarios in naso/orogastric tube management is misplaced tubes in the lungs. Pulmonary damage varies depending upon the amount, osmolality and pH of the aspirated material, but can be severe. A case report from the literature described the example of a 70-year-old woman who died after an enteral feeding infused into her right lower lung. The tube placement had been assumed to be confirmed by air insufflation (Metheny 2006).

Over twenty years have passed since Metheny and colleagues (1990) produced the first research identifying that the ability to distinguish the location of a nasogastric tube through auscultation was limited.  Nearly as long has passed since her team shared their findings regarding the inability to distinguish varying types of aspirate by source (Metheny, Reed, Berglund & Wehrle, 1994).

The medical executive committees of Jersey Shore University Medical Center, Ocean Medical Center and Riverview Medical Center have approved the following for adult patients:

Metheny, M. (2006). Preventing respiratory complications of tube feedings: Evidence-based practice.American Journal of Critical Care, 15 (4), 360-369.

Metheny, M. Reed, L. Berglund, B. & Wehrle, M. A. (1994). Visual characteristics of aspirates from feeding tubes as a method for predicting tube location. Nursing Research, 43 (5), 282-87.

Metheny, M., McSweeney, M. Wehrle, M. A. & Wiersema, L. (1990). Effectiveness of the ausculatory method in predicting feeding tube location. Nursing Research, 39 (5), 262-267.

***
Dear Colleagues in evidence-based care,
Obstructive Sleep Apnea Screening

An evidence review team for COPD recently endorsed the STOP BANG tool for use in screening for obstructive sleep apnea (OSA). OSA is a risk factor for hypertension and cardiovascular disease. It also may have deleterious effects on quality of life.

A systematic review (Brishami, Khajehdehi and Chung, 2008) compared the use of the Berlin questionnaire, the STOP BANG questionnaire, the Wisconsin question and the Sleep Apnea of Sleep Disorders tool.  Validation of the tools was achieved through the gold standard of laboratory polysomnography.  Prevalence of OSA in patients with no previous sleep disorders ranged from 21-69%. 

Sensitivity “refers to the proportion of people who have a positive test result and who really have the disease” and specificity “refers to the people who do not have the disease and whose test results are negative (Melnyk, B. & Fineout-Overholt, 2005).
Brishami and colleagues pooled all data as well as presented individual tool data.  In patients without history of sleep disorders, the sensitivity of the tools varied depending upon the degree of OSA (presence with AHI ≥5 to moderate AHI ≥15) and ranged from 66-95%.  The Wisconsin and the STOP BANG showed the highest sensitivity for the two populations.  The Wisconsin tool was better at prediction in lower risk patients and the STOP BANG was better at prediction in higher risk populations.  Specificity ranged lower and pooled estimates were at 51%. 

The Wisconsin tool studies may have been subject to bias through a prescreening process.  The authors found the STOP BANG tool had the highest scientific rigor and was free of bias.  It is also easy to use, containing only eight simple questions. 

Overall, STOP BANG is recommended for screening of OSA in chronic disease patients.  The review teams for COPD, diabetes and heart failure have all endorsed its use. 

Abrishami, A., Khajehdehi, A., Chung, F.  (2010).  A systematic review of screening questionnaires for obstructive sleep apnea.  Canadian Journal of Anesthesiology.  57, 423-438. 

STOP BANG Screening for Obstructive Sleep Apnea.

Answer the following questions to find out if you are at risk for Obstructive Sleep apnea

STOP

 
S (snore) Have you been told that you snore?
YES / NO
T (tired) Are you often tired during the day?
YES
/ NO
O (obstruction) Do you know if you stop breathing or has anyone witnessed you stop breathing while you are asleep?
YES
/ NO
P (pressure) Do you have high blood pressure or on medication to control high blood pressure?
YES
/ NO

If you answered YES to two or more questions on the STOP portion you are at risk for Obstructive Sleep Apnea. It is recommended that you contact your primary care provider to discuss a possible sleep disorder.

To find out if you are at moderate to severe risk of Obstructive Sleep Apnea, complete the BANG questions below.

BANG

 
B (bmi) Is your body mass index greater than 28?
YES / NO
A (age) Are you 50 years old or older?
YES / NO
N (neck) Are you a male with a neck circumference greater than 17 inches, or a female with a neck circumference greater than 16 inches.
YES
/ NO
G (gender) Are you a male?
YES
/ NO
The more questions you answer YES to on the BANG portion, the greater your risk of having moderate to severe Obstructive Sleep Apnea.

***