الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Mechanical ventilator is a lifesaving therapy. Although, it can cause life threatening complications such as ventilator induced lung injury, ventilator associated pneumonia, deep venous thrombosis, gastrointestinal bleeding and psychological complications. Additionally prolonged mechanical ventilation increases morbidity, mortality and costs of care. So, patients should be weaned from the ventilator as early as possible. Protocol of weaning is series of systematically developed recommendations, interventions and practices for patient care which implemented in the three weaning phases (pre weaning phase, weaning phase and post weaning phase). Weaning protocol is designed for non-physician health care providers such as critical care nurses and respiratory therapists. Protocol of weaning can increase success of weaning trial, increase success of extubation, reduce the need for reintubation reduce the duration of mechanical ventilation before the first weaning trial, reduce total duration of mechanical ventilation, reduce length of ICU stay, reduce total period of hospitalization, reduce morbidity and mortality. Aim of the present study: was to evaluate the effect of implementing protocol of weaning on clinical outcomes among mechanically ventilated patients at intensive care units. Setting: This study was conducted at Surgical Intensive Care Unit of Emergency Tanta University Hospital. It was consisted of four units. The capacity of four units included 20 beds. Subjects: A purposive sample of 80 adult mechanically ventilated patients of both sexes was divided alternatively into two equals groups 40 patient in each based on the following criteria: • Adult patients of both sexes. • Using invasive mechanical ventilation via endotracheal tube or tracheostomy tube. • Patients need mechanical ventilation for more than 72 hours. • Patients on control mode of mechanical ventilation. • New admission during the first 24 hours of intubation. The exclusion criteria was as follow: • Patients with terminal respiratory failure. • Patients with a history of a neuromuscular disorder as multiple sclerosis, myasthenia gravis and muscular atrophy. • Patients diagnosed with brain death. • group 1 (Control group): they received their routine hospital care which included anesthesiologists wean patients by measuring number of parameters rather than using objective and systemic tool. Anesthesiologist alone has the decision to wean the patient and the nurse has a limited role in the weaning process. • group 2 (Study group): they received protocol of weaning which was implemented by the researcher during pre-weaning phase, weaning phase and post weaning phase with the routine hospital care. Data collection tools: Three tools were used to collect pertinent data related to the study purpose as follow (appendix II):- Tool (I) Mechanically Ventilated Patient Assessment Tool: This tool was developed by the researcher after extensive review of the related literature to gather baseline data except part d and e, this tool was consisted of 5 parts as follow: Part a: Patients’ Biosocio-demographic Data which included age, sex, marital status, educational level, occupation, body mass index, past medical history, past surgical history, current diagnosis, smoking history, current medication, date of admission, date of discharge and previous hospitalization. Part b: Ventilatory Assessment This part was developed by the researcher after extensive review of the related literature and it was consisted of ventilator mode, ventilator parameters and type of artificial airway. Part c: Baseline Patients’ Physiologic Parameters This part was developed by the researcher after extensive review of the related literature to assess baseline patient’s physiologic condition at admission and it was consisted Patient’s pulse, blood pressure, temperature, central venous pressure (CVP), saturation of peripheral oxygen (SPo2) and baseline arterial blood gases (ABG) on admission Part d: Glasgow Coma Scale (GCS): This scale was published since1974 and was modified by Graham Teasdale 2014 (166). This scale was consisted of three categories of patient’s response: eye opening included 4 points, verbal response included 5 points and motor response included 6 points. Part e: Riker- Sedation Agitation Scale (SAS): This scale was developed by Riker et al 1999 (167) and Mirzaei et al. 2014 (168) with the goal of clearly defining and providing more inclusive levels of sedation and agitation. It had symmetric range of levels for agitation and sedation. This scale was consisted of 7 elements (dangerously agitated, very agitated, agitated, calm and co-operative, sedated, very sedated and unarousable). Tool (II) Persian Weaning Tool (PWT) for Mechanically Ventilated Patients: This tool is a specific protocol designed to assess patients’ readiness for weaning from mechanical ventilation. This tool had three areas which included respiration status (9 items), cardiovascular status (4 items) and general status (13 items) of the patients. Tool (III): The Clinical Outcome Assessment Tool This tool was used to assess the effect of implementing protocol of weaning on success of weaning, it was used to assess the patients during weaning and post weaning phases and it was consisted of 3 parts as follow: Part a: Weaning Flow Sheet This part was developed by the researcher after extensive review of relevant literature to assess patient’s progress during the weaning process and it reported data about weaning trial number, method of weaning, rapid shallow breathing index (RSBI), Ventilator parameters during weaning trial, patient’s arterial blood gases (ABGs) during the weaning trial, patient’s hemodynamic parameters, patient’s respiratory parameters, weaning trial success and causes of weaning trial failure. Part b: Respiratory Distress Observation Scale (RDOS): It was also used to assess respiratory distress during the weaning from mechanical ventilation. This scale had eight observer-rated parameters: heart rate, respiratory rate, accessory muscle use, paradoxical breathing pattern, restlessness, grunting at end-expiration, nasal flaring, and a fearful facial expression. Part c: Weaning Outcomes Assessment: This part was developed by the researcher after extensive review of the relevant literature to assess outcomes of weaning and it was consisted of duration of mechanical ventilation before first weaning trial, total duration of mechanical ventilation, total number of weaning trials, extubation success/ failure, weaning Success/ failure, need for reintubation, length of ICU stay and total period of hospitalization. Materials and method 1. Assessment phase:- • Immediately upon admission initial assessment was carried out by the researcher for all study subjects in both control and study groups to assess the patients who met the inclusive and exclusive criteria of the study. • Assessment was done by using tool (I) part (a, b, c) to collect baseline data. • Assessment was done by using tool I part (d, e) to assess level of consciousness and sedation agitation status, respectively and tool (II) to assess patient’s readiness for weaning. 2. Planning Phase: • This phase was formulated based on assessment phase and literature review (187). Priorities and expected outcome criteria were put when planning patient care. Expected outcome criteria included reduced duration of mechanical ventilation before first weaning trial, reduced weaning duration, increased success of weaning trial, reduced total duration of mechanical ventilation, no need for reintubation, reduced duration of ICU stay and reduced duration of total period of hospitalization. 3. Implementation phase:- In this phase, study group was received weaning protocol (implemented by the researcher) as agreed by the treating physicians in the intensive care unit. The researcher provided care to the patient throughout the three weaning stages; pre-weaning (assessment) phase, weaning phase and the post-weaning (outcome) phase as the following: • Nursing intervention in the pre weaning (assessment) phase which included: achieving requisites of weaning, determines the patient’s ability to breathe spontaneously, assessment of patient’s readiness for weaning. • Nursing intervention during the weaning phase which included: providing physical and psychological preparations for weaning from the ventilator and starting the weaning trial • Nursing intervention during the post weaning phase which included: assessment of extubation readiness, using noninvasive ventilation immediately after extubation, promoting spontaneous breathing through the use of inspiratory muscle training, and early ambulation for fully conscious and stable patients. • Providing general nursing care for mechanically ventilated patient which included: effective respiratory management, cardiovascular assessment, neurologic assessment, maintain adequate nutritional status, fluid and electrolyte management, prevention of pressure ulcer, prevention of DVT, promoting safety, prevention of infection, providing psychological care for the mechanically ventilated patients which includes (prevention of sleep deprivation, facilitating communication, managing anxiety, controlling pain and caring for the family) and managing ventilator system. 4. Evaluation phase: • Evaluation was done for both study and control groups using Tool III part a (Weaning Flow Sheet) to evaluate patient’s progress during weaning, part b (Respiratory Distress Observational Scale) to evaluate development of dyspnea and respiratory distress during weaning trial and part c to evaluate the effect of implementing weaning protocol on clinical outcomes of mechanically ventilated patients. • Evaluation was done daily during the morning, afternoon and night shifts for 2 weeks. The main results of this study were as follow: 1. It was noticed that the patient’s age ranged from 21 to 57 years, 57.5% of the study sample were males, 58.8% were married and 30% had secondary education while 53.8% were manual workers. 2. It was found that 43.75% were smokers, average duration of smoking was 3-20 years and 31.42% of the subjects stopped smoking. 3. Regarding past medical history, it was found that 15% of the control group and 25% of the study group had respiratory disorders, while 12.5% and 35% of the control and the study group had diabetes mellitus, respectively. 4. Regarding current diagnosis, it was found that an equal proportion (25%), (22.5%), (20%) and (7.5%) of the control and the study group had respiratory disorders, neurologic disorders, polytrauma and renal failure respectively. 5. It was observed that mean±SD of persian weaning tool was 56.87±4.97, 58.43±5.19 and 59.78±4.51 for the control group during first, second and third weaning trials, respectively. While it was 65.25±7.88, 67.52±5.87 and 67 .00±6.36 for the study group during first, second and third weaning trials, respectively and this indicated that the study group was highly ready for weaning more than the control group. 6. Statiscal significant differences were found between the two groups regarding mean±SD of rapid shallow breathing index during first and second weaning trials while p= 0.001 and 0.008, respectively and this indicated that the study group were more ready for weaning than the control group. 7. The results of the present study revealed that protocol of weaning reduced the use of sedatives and muscle relaxants. 8. The results of the present study revealed that implementation of protocol of weaning improved values of Glasgow coma scale and riker sedation agitation scale during days of follow up. 9. It was noticed that 75% of the study group compared to 42.5% of the control group were extubated. 10. The results of the current study concluded that 10% of the control group and 7.5% of the study group needed reintubation. 11. It was observed that 42.5% of the control group and 27.5% of the study group died on mechanical ventilation. 12. Duration of mechanical ventilation before the first weaning trial was longer (4-10 days) in the control group compared to 1-6 days in the study group. 13. Total duration of mechanical ventilation was longer (10-40 days) in the control group compared to (2-24 days) in the study group. 14. It was found that duration of ICU was longer in the control group (20-45days) while it was 10-28 days in the study group. 15. The result of the current study reported that total period of hospitalization was longer in the control group (20-48 days) while it was (15-30 days) in the study group. 16. No statiscal significant differences were found between the two groups regarding PH, Paco2, Hco3 during any weaning trial. The main recommendations of the study were as follow: (I) For patients: 1. Mechanically ventilated patients should be assessed routinely for weaning using objective weaning tools such as persian weaning tool to determine patient’s readiness for weaning. 2. Patients should redomenstrate inspiratory muscle training immediately after extubation which improved spontaneous breathing and prevented the need for reintubation. (II) For nurses: 1. In-service training programs should be conducted periodically for the nurses in the intensive care unit to improve and update their knowledge and practices about weaning the mechanically ventilated patients. 2. Protocol of weaning should be used as a routine nursing intervention for all mechanically ventilated patients. 3. A simple illustrated booklet regarding protocol of weaning should be given to all critical care nurses. (III) For administration: 1. Objective and comprehensive tools for assessment of patient’s readiness for weaning should be available in intensive care units. 2. Written polices for practicing protocol of weaning to all mechanically ventilated patients should be available to all health care providers in intensive care units. 3. Protocol of weaning should be included in the basic nursing education and should be learned to all nursing students. (IV) For future research (studies): 1. Replication of the study on a larger sample size and with long term follow up can validate and help generalizing the results. 2. Further research is needed in this area for nursing staff to provide more information about the additional benefits of protocol of weaning. 3. Further research is needed to evaluate the clinical effects of protocol of weaning on difficult to wean patients from mechanical ventilator.