Orozco-Levi M, Torres A, Ferrer M, et al. Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. American Journal of Respiratory Critical Care Medicine. 1995;152(4 Pt 1):1387-1390.

The authors instilled a radioactive substance (Tc⁹⁹ sulphur colloid) into the stomachs of 15 patients receiving mechanical ventilation who also had a nasogastric tube in place.  Scintigraphic radioactivity counting was performed hourly to identify the presence of gastric contents in oropharyngeal and bronchial secretions.  Patients were studied in two positions: supine and semirecumbent (head of bed elevated 45 degrees).  At five hours gastric contents were present in the oropharynx of patients in both groups.  However, gastric contents were present in the bronchial secretions of only those patients who were in the supine position.

Kollef MH. Ventilator-associated pneumonia. A multivariate analysis. Journal of the American Medical Association. 1993;270(16):1965-1970.

This paper describes a cohort study of patients admitted to any of three ICUs in an academic tertiary care center who required mechanical ventilation for longer than 24 hours.  Stepwise logistic regression analysis identified four factors that were independently associated with risk of VAP: organ system failure, patient age > 60 years, impaired functional status prior to hospitalization, and supine head positioning (<30 degrees of elevation) during the first 24 hours of mechanical ventilation.

Fernandez-Crehuet R, Diaz-Molina C, de Irala J, Martinez-Concha D, Salcedo-Leal I, Masa-Calles J. Nosocomial infection in an intensive-care unit: Identification of risk factors. Infection Control and Hospital Epidemiology. 1997;18(12):825-830.

The authors describe a cohort study identifying risk factors for nosocomial infection among patients admitted to the ICU of a tertiary-level hospital for at least 24 hours.  Two factors were associated with an increased risk of nosocomial infection: head of the bed in a horizontal (<30 degrees) position and use of sedative medication.

Cook D, Guyatt G, Marshall J, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. New England Journal of Medicine. 1998;338(12):791-797.

The authors describe a multicenter, randomized, blinded, placebo-controlled trial, comparing sucralfate with the H₂-receptor antagonist ranitidine for the prevention of upper GI bleeding in 1,200 patients who required mechanical ventilation.  Patients receiving ranitidine had a significantly lower rate of clinically important GI bleeding than those treated with sucralfate.  There were no significant differences in the rates of ventilator-associated pneumonia, the duration of the stay in the ICU, or mortality.

Cook DJ, Reeve BK, Guyatt GH, et al. Stress ulcer prophylaxis in critically ill patients: Resolving discordant meta-analyses. Journal of the American Medical Association. 1996;275(4):308-314.

The authors report a meta-analysis of 63 randomized trials of stress ulcer prophylaxis in critically ill patients.  They find “strong evidence” of a reduction in clinically important GI bleeding with H₂-receptor antagonists.  They also find that sucralfate may be as effective in reducing bleeding as pH-altering drugs and is associated with lower rates of pneumonia and mortality.  However, they note that the data are insufficient to determine the net effect of sucralfate compared with no prophylaxis.

Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. New England Journal of Medicine. 1994;330:377-381.

The authors describe a prospective multicenter cohort study evaluating risk factors for the development of stress ulceration among patients admitted to ICUs.  They also document the incidence of  “clinically important” gastrointestinal (GI) bleeding.  Both respiratory failure (odds ratio (OR) 15.6) and coagulopathy (OR 4.3) were associated with clinically important GI bleeding.  The authors conclude that prophylaxis against stress ulcers can safely be withheld from critically ill patients unless they have coagulopathy or require mechanical ventilation.

Attia J, Ray JG, Cook DJ, Douketis J, Ginsberg JS, Geerts WH. Deep vein thrombosis and its prevention in critically ill adults. Archives of Internal Medicine. 2001;161:1268-1279.

The authors conducted a systematic review of studies referenced in MEDLINE, EMBASE, abstract databases, and the Cochrane database, to determine the incidence of deep venous thrombosis (DVT) and the efficacy of prophylaxis in critically ill adults, including patients admitted to ICUs and following trauma, neurosurgery, or spinal cord injury.  They found that 1) 10-30 percent of medical and surgical ICU patients develop DVT within the first week of ICU admission and 2) the use of subcutaneous low-dose heparin reduces the rate by 50 percent compared with no prophylaxis.

Wright MM, Stenhouse CW, Morgan RJ. Early detection of patients at risk. Anaesthesia. 2000;55(4):391-392.

This letter comments on the publication by Goldhill et al. describing experience with a “patient-at-risk team” (PART) (Anaesthesia 1999;54:853-860).  The authors suggest that their own Early Warning Scoring System (EWSS) might be a useful tool for the detection of patients with impending critical illness who might benefit from evaluation by a PART.  The EWSS is based on five parameters: pulse, systolic blood pressure, respiratory rate, temperature, and response to stimulus.

Subbe CP, Davies RG, Williams E, Rutherford P, Gemmell L. Effect of introducing the Modified Early Warning score on clinical outcomes, cardio-pulmonary arrests and intensive care utilization in acute medical admissions. Anaesthesia. 2003;58(8):797-802.

Patients with a Modified Early Warning Score >4 were referred for urgent medical and critical care outreach team review. Data analysis confirmed respiratory rate as the best discriminator in identifying high-risk patient groups. Further study recommended. 

Sharpley JT, Holden JC. Introducing an early warning scoring system in a district general hospital. Nursing in Critical Care. 2004;9(3):98-103.

The informal and gradual approach used to optimize the effectiveness of introducing the early warning scoring system is highlighted and explanations given of the training processes undertaken, the pilot evaluation, and lessons learned from the process.