RESUMEN
We prospectively investigated the large-scale implementation of a respiratory-therapist-driven protocol (TDP) that included 117 respiratory care practitioners (RCPs) managing 1,067 patients with respiratory failure over 9,048 patient days of mechanical ventilation. During a 12-mo period, we reintroduced a previously validated protocol that included a daily screen (DS) coupled with spontaneous breathing trials (SBTs) and physician prompt, as a TDP without daily input from a physician or "weaning team." With graded, staged educational interventions at 2-mo intervals, RCPs had a 97% completion rate and a 95% correct interpretation rate for the DS. The frequency with which patients who passed the DS underwent SBTs increased throughout the implementation process (p < 0.001). As the year progressed, RCPs more often considered SBTs once patients had passed a DS (p < 0.001), and physicians ordered more SBTs (46 versus 65%, p = 0.004). Overall, SBTs were ordered more often on the medicine than on the surgical services (81 versus 63%, p = 0.001), likely reflecting medical intensivists' prior use of this protocol. Important barriers to protocol compliance were identified through a questionnaire (89 respondents, 76%), and included: Physician unfamiliarity with the protocol, RCP inconsistency in seeking an order for an SBT from the physician, specific reasons cited by the physician for not advancing the patient to a SBT, and lack of stationary unit assignments by RCPs performing the protocol. We conclude that implementation of a validated weaning strategy is feasible as a TDP without daily supervision from a weaning physician or team. RCPs can appropriately perform and interpret DS data more than 95% of the time, but significant barriers to SBTs exist. Through a staged implementation process, using periodic reinforcement of all participants in ventilator management, improved compliance with this large-scale weaning protocol can be achieved.
Asunto(s)
Insuficiencia Respiratoria/terapia , Terapia Respiratoria/métodos , Desconexión del Ventilador , Protocolos Clínicos , Femenino , Estudios de Seguimiento , Humanos , Relaciones Interprofesionales , Masculino , Persona de Mediana Edad , Innovación Organizacional , Planificación de Atención al Paciente , Pautas de la Práctica en Medicina , Estudios Prospectivos , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
OBJECTIVE: To establish that female calves vaccinated with Brucella abortus strain RB51 at 3, 5, and 7 months of age are protected against infection and abortion when challenged exposed during their first pregnancy. ANIMALS: Polled Hereford heifer calves obtained from a brucellosis-free herd. PROCEDURE: Calves were inoculated SC at 3, 5, or 7 months of age with strain RB51 (n = 26), strain 19 (n = 16), or sterile saline solution (n = 15). Calves were bred at 16 to 17 months of age and challenged exposed during the first pregnancy with virulent B abortus strain 2308. RESULTS: After vaccination, none of the heifers given strain RB51 developed serum antibodies that reacted in the standard tube agglutination test, but reacted in a dot-blot assay, using RB51 antigen. B abortus was cultured from biopsy specimens of superficial cervical lymph nodes in the RB51 and S19 vaccinates at 10 weeks, but not at 12 weeks after vaccination. All 4 heifers that had been vaccinated with RB51 at 3 months of age were protected against infection and abortion when challenged exposed. Vaccination at 5 and 7 months of age gave equivalent protection. Heifers given strain 19 were 95% protected and controls (given saline solution) had a high influence of infection and abortion. CONCLUSIONS: Strain RB51 is protective at doses comparable to those of strain 19 in calves 3 to 10 months of age. CLINICAL RELEVANCE: Immunogenicity and failure to induce antibodies that interfere with the serologic diagnosis of field infections of B abortus make strain RB51 an effective vaccine.
Asunto(s)
Aborto Veterinario/prevención & control , Vacunas Bacterianas , Brucella abortus/inmunología , Brucelosis Bovina/prevención & control , Vacunación/veterinaria , Factores de Edad , Animales , Anticuerpos Antibacterianos/sangre , Formación de Anticuerpos , Biopsia , Brucella abortus/aislamiento & purificación , Brucelosis Bovina/inmunología , Bovinos , Femenino , Ganglios Linfáticos/microbiología , EmbarazoRESUMEN
To evaluate host responses, young goats were inoculated subcutaneously with a genetic deletion mutant (deltapurE201) of Brucella melitensis (n = 6), its virulent parental strain 16M (n = 6), or saline (n = 6). No clinical evidence of brucellosis was seen in any goat. Serum antibody titers peaked at postinoculation day (PID) 14. Bacteria in lymph nodes that drained sites of vaccination reached peak numbers of >10(6) CFU/g in both infected groups at PID 7 and progressively declined to PID 84. At necropsy, bacteria were present in mammary lymph nodes or spleen of 33% of goats given virulent 16M but in none of goats given the purE mutant. Lymphadenitis, most severe in goats given 16M, involved depletion of lymphocytes and germinal centers, proliferation of lymphoblasts, and vasculitis. By PID 28, lymph node architecture was restored; there was marked germinal center formation and medullary plasmacytosis. Brucellar antigens, detected with immunoperoxidase techniques, were prominent in capsular granulomas but not in lymph node cortices. Ultrastructurally, bacteria were found in macrophages (>97%) and small lymphocytes (<3%) but not in large lymphocytes. Bacteria were intact in small lymphocytes but in macrophages were in various stages of degradation. The deltapurE phenotype of deltapurE201 was preserved during infection of goat lymph nodes. Unlike Salmonella spp. purE mutants, strain deltapurE201 may be a candidate for efficacy testing; it produced immune responses, was cleared from visceral tissues, and produced less severe pathologic changes than its wild-type parent.