Paired Spontaneous Awakening Trial and Spontaneous Breathing Trial Protocol Implementation
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Spontaneous Awakening and Breathing TrialAbstract
Problem & Purpose: Mechanical ventilation (MV) is a commonly used life-saving modality in the intensive care unit (ICU) patients. Sedation is widely used for improved patient MV tolerance. However, evidence shows a link between sedation use and increased MV duration and risk for MV-associated complications. This quality improvement (QI) project aimed to implement a paired Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT) protocol in the ICU to promote early extubation and endorse a practice change that includes sedation guidelines and safety screening to identify appropriate candidates for extubation with a goal to reduce MV days. Methods: The QI project was implemented over a three months period on all intubated, MV adult ICU patients aged 18 years and older. Data was collected on monthly MV days, and Standardized Utilization Ratio (SUR) obtained from the infection prevention department as reported to the National Healthcare Safety Network (NHSN), and the percentage of mean staff compliance with the protocol implementation using a manual audit. Results: During the implementation period, the SUR decreased from 0.99 to 0.89, while the MV days increased from 154 to 162, and the percentage of mean staff compliance increased from 3% to 82%. Conclusion: The staff compliance goal was met, but the MV data is inconclusive. Data from the past 24 months have shown a seasonal variance pattern in the MV days and SUR, and there is insufficient data to analyze the impact of the protocol implementation on the clinical site. Barriers that affected the project implementation includes the synchronous merging of the Neuro and the Cardiothoracic ICUs with the hospital relocation during the implementation month.Identifier to cite or link to this item
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Properties of individual hippocampal synapses influencing NMDA-receptor activation by spontaneous neurotransmissionNMDA receptor (NMDAR) activation is critical for maintenance and modification of synapse strength. Specifically, NMDAR activation by spontaneous glutamate release has been shown to mediate some forms of synaptic plasticity as well as synaptic development. Interestingly, there is evidence that within individual synapses each release mode may be segregated such that postsynaptically there are distinct pools of responsive receptors. To examine potential regulators of NMDAR activation because of spontaneous glutamate release in cultured hippocampal neurons, we used GCaMP6f imaging at single synapses in concert with confocal and super-resolution imaging. Using these single-spine approaches, we found that Ca2+ entry activated by spontaneous release tends to be carried by GluN2B-NMDARs. Additionally, the amount of NMDAR activation varies greatly both between synapses and within synapses, and is unrelated to spine and synapse size, but does correlate loosely with synapse distance from the soma. Despite the critical role of spontaneous activation of NMDARs in maintaining synaptic function, their activation seems to be controlled factors other than synapse size or synapse distance from the soma. It is most likely that NMDAR activation by spontaneous release influenced variability in subsynaptic receptor position, release site position, vesicle content, and channel properties. Therefore, spontaneous activation of NMDARs appears to be regulated distinctly from other receptor types, notably AMPARs, within individual synapses. Copyright 2019 Metzbower et al.
