Monday, February 7, 2011

ICU Rounds Report - Nicotine patches and 24-hr staffing

From Daniel:
Nicotine Patches for the Perioperative Smoker?
Nicotine replacement therapy (NRT) has been used in the inpatient setting to decrease cravings and lower psychological stress, but does it work perioperatively?  David Warner and friends performed a double-blind placebo controlled trial of 121 smokers undergoing elective surgical procedures and found no benefit whatsoever.  They measured Nicotine Withdrawal Scores and the Perceived Stress Scores for patients perioperatively receiving placebo vs. nicotine patches (all P > 0.19).  This contrasts to a much smaller study in healthy non-surgical volunteers where the patch was shown to reduce cravings.

Acutely, nicotine is known to have adverse effects on wound healing, lung function, immunity and may increase cardiovascular events. No perioperative studies have been done looking at NRT and these relevant outcomes- infections, healing, MI's, pulmonary complications, etc. (Although it should be noted that NRT appears safe for outpatients with known cardiovascular disease).That said, the theoretic potential for harm is real while the available data suggest that if you're jonesing for a light after surgery, the patch probably isn't going to help anyway. Further, at least 2 additional studies have found the NRT has no meaningful effect on post-operative pain scores. So, why not then just avoid them?
Joseph et al.  The safety of the transdermal nicotine as an aid to smoking cessation in patients with cardiac disease.  1996.  N. Engl. J. Med.; 335: 1792.
Teneggi et al.  Smokers deprived of cigarettes for 72 h: effect of nicotine patches on craving and withdrawal.  2002.  Psychopharmacology; 164(2): 177-87.
Warner et al.  Effect of nicotine replacement therapy on stress and smoking behaviour in surgical patients.  2005.  Anesthesiology; 102(6): 1138-46.

Is 24-hour staffing worth the trouble? It's been known for a long time that outcomes vary widely by ICU. Admission to a high quality ICU can lower your risk of death by 40%. So, what makes a good ICU? That's the subject of intense research and debate, but adherence to evidence-based national guidelines, wide-spread use of protocols, adequate multidisciplinary staffing and 24-hour in-house intensivist staffing are generally acknowledged as the benchmarks that make a high quality ICU.

Just up the Mason-Dixon line, the University of Maryland (UM) recently completed a large hospital renovation that included a brand new, larger MICU (from 10 to 29 beds). But in addition to the new facilities, they started 24-hour in-house attending coverage (previously a fellow and 2 residents were on overnight), added a pharmacist on rounds and changed RT staffing ratios from 1:24 to 1:10. Prior to the change, the UM MICU was considered "high quality" and in fact had been honored by the Leapfrog Group for superior outcomes.

The results were big. Relative ICU mortality dropped by 19% (18.4% to 14.9%, p<.006) meaning one in five deaths were prevented. Patients were vent free longer and received less fentanyl and versed. Is this intervention feasible? Who knows, they didn't do a cost analysis. Is it generalizable? Probably not, many of the interventions were specific to UM and all done at the same time. Does it show that thoughtful attention to ICU organization can make as big a difference in outcome as many of our equally costly clinical interventions? Absolutely.
Kahn JM, Goss CH, Heagerty PJ, et al: Hospital volume and the outcomes of mechanical ventilation. N Engl J Med 2006; 355: 41–50
Netzer G, et al. Decreased mortality resulting from a multicomponent intervention in a tertiary care medical intensive care unit Crit Care Med Feb 2011 39(2):284-293,.
Jordan Hackworth, M.D.
Fellow, Critical Care Medicine
Department of Anesthesiology
University of Virginia
PO Box 800710
Charlottesville, VA 22908-0710
T (434) 924-2283
F (434) 982-0019


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