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Oral Care Protocols With Specialty Training Lead to Safe Oral Care Practices and Reduce Iatrogenic Bleeding in Extracorporeal Membrane Oxygenation Patients

Lucchini, Alberto, RN; Bambi, Stefano, PhD, MSN, RN, CCN; de Felippis, Christian, RN; Galazzi, Alessandro, MSN, RN, CCN; Addis, Grazia, RN, CCN; Rona, Roberto, MD; Grasselli, Giacomo, MD; Pesenti, Antonio, MD; Fumagalli, Roberto, MD; Foti, Giuseppe, MD

doi: 10.1097/DCC.0000000000000321
Clinical DIMENSION

Introduction Oral care, using either a mouth rinse, gel, toothbrush, or combination of them, together with aspiration of secretions, may reduce the risk of ventilator-acquired pneumonia in intubated patents. Oral care procedure in patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) may cause bleeding due to the systemic anticoagulation required.

Purpose The aim of this study was to investigate the rate of bleeding episodes during oral care in patients supported by VV-ECMO.

Methods A retrospective observational study was performed. All patients admitted to an Italian ECMO center during 2014 were included in the study.

Results Data from 14 patients were analyzed. The median intensive care unit length of stay was 39.0 days (interquartile range, 27.3-83.3 days), and median days on VV-ECMO was 19.5 (10.3-46.0). There were 440 ECMO days, with 1320 oral care maneuvers. In 7 patients, bleeding episodes occurred: 2 with orotracheal intubation and 5 initially managed with orotracheal intubation, thereafter via Translaryngeal tracheostomy tube (according to Fantoni’s technique). In 61 oral care procedures (4.6%), bleeding was detected during or after the maneuver, whereas the total numbers of days with at least 1 bleeding episode were 35 (8%).

The presence or absence of bleeding during ECMO days was statistically significant for international normalized ratio (1.01 [0.95-1.11] vs 1.13 [1.03-1.25], P < .0001), platelets (163 000 [93 500-229 000] vs 61 000 [91 00–100 000], P < .0001), and mouth care score (6 [5-7] vs 8 [7-9], P < .001).

Conclusion Oral care can cause bleeding in patients on VV-ECMO. Implementation of protocols for daily oral care in patients on ECMO may reduce risks. As recommended by the literature, this category of patients should be treated in selected centers distinguished by a regular volume of ECMO activity and the presence of dedicated ECMO specialist nurses.

Alberto Lucchini, RN, is head nurse at the General Intensive Care Unit, ASST Monza, San Gerardo Hospital, Italy. He is the coordinator of the master’s degree program in intensive and critical care nursing at Milano-Bicocca University, Italy. His main publications concern the nursing workload in intensive care, nursing care of ECMO patients, invasive and non-invasive mechanical ventilation, endotracheal suctioning.

Stefano Bambi, PhD, MSN, RN, CCN, is staff nurse at the Emergency & Trauma Intensive Care Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.

Christian de Felippis, RN, is staff nurse at the Adult Intensive Care Unit, Glenfield Hospital, University Hospital of Leicester–NHS Trust, Leicester, United Kingdom.

Alessandro Galazzi, MSN, RN, CCN, is staff nurse at General Intensive Care Unit, Department of Anesthesia and Intensive Care Medicine, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy.

Grazia Addis, RN, CCN, is staff nurse at Hematology Department, Niguarda Ca’ Granda Hospital, Milan, Italy.

Roberto Rona, MD, is head at General Intensive Care Unit, ASST Monza, San Gerardo Hospital, Italy.

Giacomo Grasselli, MD, is associate professor at General Intensive Care Unit, Department of Anesthesia and Intensive Care Medicine, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy.

Antonio Pesenti, MD, is full professor at General Intensive Care Unit, Department of Anesthesia and Intensive Care Medicine, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy.

Roberto Fumagalli, MD, is director and full professor at the Department of Anesthesia and Intensive Care Medicine, Niguarda Ca’ Granda Hospital University of Milan-Bicocca, Milan, Italy.

Giuseppe Foti, MD, is director and associate professor, Emergency Department, ASST Monza, San Gerardo Hospital, Italy.

The present study was performed at the General Intensive care Unit, Emergency Department and Intensive Care, San Gerardo Hospital–ASST Monza, Milan-Bicocca University, Monza, Monza and Brianza, Italy.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Authors Contributions: A.L., C.D., A.G., G.A., S.B., R.R., G.G., G.F., A.P., and R.F.: conception and design of the study, manuscript writing, and final approval. A.L. and G.A.: data collection and analysis. A.L., C.D., and S.B.: statistical analysis, manuscript writing, and final approval of the manuscript. All authors have read and approved the final manuscript.

Address correspondence and reprint requests to: Alberto Lucchini, RN, General Intensive Care Unit, San Gerardo Hospital, ASST Monza, Via Pergolesi 33, Monza, Monza and Brianza, Italy (alberto.lucchini@unimib.it; a.lucchini@asst-monza.it).

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