Evidence-Based Practice in Critical Care
Critically ill patients are susceptible to the development of dry eye. Few studies have been conducted on how to best prevent and treat this condition. Objective To compare the effectiveness of 2 nursing inter- ventions in preventing dry eye in adult intensive care unit patients: liquid artificial tears (Lacribell; Latinofarma) and artificial tears gel (Vidisic Gel; Bausch and Lomb). Methods In this randomized controlled trial, 140 partici- pants were randomly assigned to 1 of 2 treatment groups: a liquid artificial tears group (n = 70) and an artificial tears gel group (n = 70). The study inclusion criteria were as follows: admission to the intensive care unit, age of 18 years or older, no diagnosis of dry eye at admission, receipt of mechanical ventilation, blink rate of less than 5 times per minute, and a score of 7 or less on the Glasgow Coma Scale. Evidence-Based Practice in Critical Care On 5 consecutive days, a single researcher who was unaware of the treatment assign- ment assessed the participants’ eyes using the fluores- cein eye stain test and the Schirmer test for dry eye. Results Dry eye developed in 21% of participants who received liquid artificial tears versus 9% of participants who received artificial tears gel (P = .04). Conclusions In this study, artificial tears gel was superior to liquid artificial tears in preventing the development of dry eye. These results may help nurses deliver evidence- based eye care aimed at reducing the risk of dry eye in critically ill patients. (American Journal of Critical Care. 2019;28:299-306) Evidence-Based Practice in Critical Care
EFFECTIVENESS OF NURSING INTERVENTIONS TO PREVENT DRY EYE IN CRITICALLY ILL PATIENTS By Diego Dias de Araujo, PhD, MSN, RN, Daniel Vinicius Alves Silva, Carolina Amaral Oliveira Rodrigues, Patricia Oliveira Silva, Tamara Goncalves Rezende Macieira, BSN, and Tania Couto Machado Chianca, PhD, MSN, RN
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Intensive care unit (ICU) patients often have conditions leading to compromised physio- logical mechanisms of eye protection. These conditions include being unconscious or comatose; taking several medications such as diuretics, sedatives, and -blockers; receiv- ing mechanical ventilation; and being exposed to air conditioning and low air humid- ity.1-4 Consequently, these patients are susceptible to the development of dry eye and other ocular surface disorders.4-7 Evidence-Based Practice in Critical Care
Clinical guidelines that have been developed for eye care in the ICU refer to a variety of interventions designed to reduce the prevalence and incidence of ocular surface alterations in critically ill patients, such as corneal ulcerations and keratitis. These inter- ventions include ointments, liquid eyewashes, gels, moist gauze, paraffin gauze, hydrogel, and polyeth- ylene film.6-8
Dry eye has been defined as a multifactorial change in tears and the ocular surface that results
in discomfort, visual distur- bances, and tear film instabil- ity, with potential damage of the ocular surface.9 In nurs- ing, the diagnosis of “risk for dry eye” is applied to patients who are “vulnerable to eye discomfort or damage to the cornea and conjunctiva due Evidence-Based Practice in Critical Care
to reduced quantity or quality of tears to moisten the eye, which may compromise health.”10(p387)
A recent study in Brazil showed that dry eye is a common problem in patients admitted to ICUs, with an incidence of 53%.5 Intensive care unit patients have a higher probability of dry eye developing than do other hospitalized patients because of a variety of internal and external risk factors.1-3,5 Dry eye can be chronic and progressive, imposing limitations on patients’ ability to perform activities of daily living and negatively affecting their quality of life. There- fore, a preventive approach that includes appropri- ate eye care is crucial to minimize the risk of dry eye and avert possible complications. Evidence-Based Practice in Critical Care
Because nurses are the frontline health care pro- viders in hospitals, they have an important role to play in reducing the risk of dry eye in critically ill patients through effective nursing interventions. A study reported in 2011 compared the effectiveness of 2 nursing interventions—polyethylene film and carbomer drops—in the prevention of dry eye among 18 adult ICU patients.2 The polyethylene film was found to prevent dry eye in all of the cases, while the carbomer drops were effective in only 17% of the patients (P < .001).2 However, large studies of polyethylene film for the prevention of dry eye have not yet been conducted. Moreover, more research is needed on evidence-based nursing interventions that result in less discomfort for patients and can be more easily applied by nurses than polyethylene film. There- fore, this study was conducted to compare the effec- tiveness of 2 nursing interventions in preventing dry eye in adult patients admitted to an ICU: liquid arti- ficial tears (Lacribell; Latinofarma) and artificial tears gel (Vidisic Gel; Bausch and Lomb).
Methods This study was registered in ClinicalTrials.gov Evidence-Based Practice in Critical Care
(Identifier: NCT02767258) and in the Brazilian Clinical Trials Registry (ReBec) (Identifier: RBR- 5r8syp). Ethical approval was obtained from the institutional review board of the Universidade Fed- eral de Minas Gerais before the study was begun. We followed the Consolidated Standards of Report- ing Trials (CONSORT) guidelines for nonpharmaco- logical interventions.11 Written informed consent was obtained from each patient’s family member or next of kin before recruitment.
Design This was a double-blind (patients, outcome asses-
sor) randomized controlled trial with 2 parallel groups. The data reported here were collected between Janu- ary 14, 2016, and March 14, 2017, in a 10-bed ICU at a large tertiary care, nonprofit hospital in Brazil.
Patients recruited for the study met the follow- ing inclusion criteria: age of 18 years or older, no diagnosis of dry eye at ICU admission, receipt of mechanical ventilation, blink rate of less than 5
About the Authors Diego Dias de Araujo is assistant professor and Daniel Vinicius Alves Silva, Carolina Amaral Oliveira Rodrigues, and Patricia Oliveira Silva are undergraduate students, Department of Nursing, Universidade Estadual de Montes Claros, Montes Claros, Brazil. Tamara Goncalves Rezende Macieira is a PhD candidate, College of Nursing, Univer- sity of Florida, Gainesville, Florida. Tania Couto Machado Chianca is professor, School of Nursing, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
Corresponding author: Diego Dias de Araujo, PhD, MSN, RN, Av Ruy Braga, Predio 6 (CCBS), Montes Claros, Minas Gerais, Brazil 39401-089 (email: email@example.com). Evidence-Based Practice in Critical Care
Fifty-three percent of adult patients admitted to intensive care units
have dry eye.
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times per minute, and a Glasgow Coma Scale score of 7 or lower.2 Patients were excluded if they had an ICU stay of less than 48 hours or were admitted to the unit with a diagnosis of brain death. Failure to document the delivery of nursing interventions (liq- uid artificial tears or artificial tears gel) at the correct time resulted in the participant’s exclusion from the study and discontinuation of treatment. Evidence-Based Practice in Critical Care
Sample Size and Randomization We performed a pilot study involving 30 patients
between November and December 2015, with 10 patients allocated to each of 3 groups (liquid artifi- cial tears, artificial tears gel, and 0.9% sodium chlo- ride solution), to estimate sample size. In the pilot study, 40% of the patients treated with liquid artifi- cial tears had dry eye develop, compared with 10% of those treated with artificial tears gel (P = .01).
Power analysis using the proportion of unfavorable results in the pilot study (40%), a significance level of .05, power of 80%, and a relative risk (RR) of 0.5 in favor of artificial tears gel (or RR reduction of 20%) resulted in an estimated sample size of 134 patients: 67 patients for each of the 2 intervention groups. If any participants were lost during the study, more would be recruited until at least 67 patients were allocated to each group. Evidence-Based Practice in Critical Care
The initial study population consisted of 546 medical or surgical patients who had been admitted to the ICU of the target hospital. Of the 546 patients assessed for eligibility, 406 were excluded according to the inclusion and exclusion criteria. The resulting final sample consisted of 140 patients, 70 in each group (see Figure).
Despite allocation to a third group in the pilot study, we decided not to treat patients with 0.9%
Figure Flowchart illustrating the 4 phases of the study, following the Consolidated Standards of Reporting Trials (CONSORT) recommendations for nonpharmacological interventions Evidence-Based Practice in Critical Care