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Eye care for ventilated patients
Michael Farrell and Fiona Wray
This literature survey identifies the importance of effective eye care technique, to prevent ocular complications in critically ill patients. The factors that lead to the development of such complications are outlined. Details are given of a survey of 20 intensive care units (ICUs), conducted to identify common eye care techniques. The conclusion from this review is that there is little which identifies the efficacy of current eye care techniques commonly used in ICUs. There is a need for research studies which demonstrate the best substance for maintaining eye lubrication and eyelid closure, in the care of critically ill patients.
Caring for a critically ill patient who requires
artificial respiratory support is a demanding medical and nursing challenge. Meticulous
nursing care is required to maintain optimal
body tissue integrity and organ function. Eye
care is one of the most important, yet simply
performed, nursing interventions included in
the care of ventilated patients. If effective, eye care can minim& and prevent the development
of potentially serious eye complications such as infection, cornea1 abrasions and possible cornea1
perforation, which if unresolved could result in serious visual impairment. Yet while eye care is a
simple technique it is often applied with con-
siderable variation from one medical centre to another. Therefore the aim of this review is to
identify the possible significance of these variations and comment on the processes involved in the development of eye compli- cations in ventilated patients.
Ml&eel FendI RGN, RSCN, Plans Wrey RGN, RSCN, Paediatric Intensive Care Unit (5A) Hospitals for Sick Children, Great Ormond Street, London, WC1 3JN. UK (Requests for offprints to MF) Manuscript accepted 10 February 7993
Paralysed patients are potentially exposed to a number of harmful eye insults. Eye compli-
cations can range from a mild conjunctival infection to serious cornea1 injury and cornea1
ulceration (Lloyd 1990). Although such patients are at risk of eye complications the frequency
with which these are seen in intensive care units
(ICUs) is uncertain. There are some case reports
of serious eye complications i.e. cornea1 ulcer- ation occurring in ventilated patients (Wincek &
Ruttum 1989, Ommeslag et al 1987). However it probable that the development of such serious complications is rare.
A number of factors can predispose to the onset of eye complications in a paralysed patient. These are now identified.
Infection
Potential causes of infection in the eyes of a ventilated patient include poor eye care tech- nique (i.e. poor handwashing), the use of conta- minated eye care materials and the presence of pathogenic organisms. Staph@coccus aurem, Haemophilus injknza and Strepococcus are the most common organisms implicated in mild eye
137
138 INTENSIVE AND CRITICAL CARE NURSING
infections (Fox 1989). Specifically in a paediatric intensive care unit ocular infections rates around
7% have been reported (Milliken et al 1988).
Bronchial toilet
Infection by respiratory tract pathogens, which
give rise to serious cornea1 injury, has been
reported (Hutton & Sexton 1972, Hilton, Uliss &
Samuels et al 1983, Ommeslaget al 1987). Hilton
et al (1983) and Ommeslaget al (1987) suggested that respiratory tract pathogens contaminated
the patients’ eyes, and that such nosocomial
contamination may have occured during routine
bronchial toilet of the ventilated patient. More investigation is required in order to confirm this.
Adverse, physiological effects of artificial ventilation
Serious eye complications may develop due to the adverse physiological effects of ventilation.
Ventilatory support leads to body fluid retention
and increased venous pressure which may result
in oedema sequestration (Chatburn 1990). The
process of intubation and the drugs used to facilitate this procedure can generate an acute
increase in intraocular pressure which may pre-
dispose to or exacerbate any ocular injury. This is of most concern in those patients who may
have open or penetrating eye wounds (Drenger, Pe’er 1987, Dear, Hammerton, Hatch, Taylor
1987). The method of securing a patient’s endo-
tracheal tube may be excessively tight, com-
promising venous return from the head thus leading to venous congestion and potential increases in intraocular pressure.
Vascular
Alterations in orbital flood flow and venous drainage can give rise to ocular insults. Orbital and lid oedema are early indicators of fluid retention or localised venous congestion. Asso- ciated with oedema there may be an increase in intraocular pressure which can result in sub- conjunctival haemorrhages (Monk 1990).
Orbital oedema may prevent the complete closure of the eyelids. This causes cornea1 drying
which is the most common predisposing cause of cornea1 ulceration in the ventilated patient (Wincek et al 1989).
Loss of protective eye mechanisms
Due to the effects of paralysing and sedating pharmacological agents, important physio-
logical eye protection mechanisms are inhibited.
For example, an effective blink reflex is neces-
sary for adequate tear spread over the eye, which is important in maintaining lubrication of the
cornea and cleansing the eye of any debris and bacteria (O’Callaghan 1983). Tears also kill
bacteria by distributing lysozyme; they also dis- tribute water and nutrients to the cornea and
help maintain its structural integrity (Carola, Harley & Noback 1992). With the effects of
muscle relaxant drugs used to maintain ad-
equate ventilatory support, the patient’s blink reflex is lost, thus leading to the loss of an
important protective mechanism.
Normally complete closure of the eylids occurs due to contraction of the obricularis oculi muscle
which is also maintained during sleep (Moses
1975). When muscle relaxant drugs are adminis- tered the closure of the eyelids is determined by passive forces only. The inability to completely
close the eyelids leads to exposure of the cornea1 structures and cornea1 drying.
EYE CARE PROCEDURES
A small survey was conducted by the authors to gain information about eye care procedures
commonly used in ICUs.
Sample
Twenty ICUs were contacted by telephone and asked four prepared questions about eye care management, as used within that unit, in the care of ventilated patients. The ICUs were chosen at random but included both adult and paediatric critical care units.
si I Ri
fig. 1 Frequency of eye care management.
Results
In this sample, 12 units reported that eye care was performed at 2 h intervals (Fig. 1). Saline
solution (0.9%) was the most commonly used cleaning agent in eye care in 15 units (Fig. 2).
Following cleansing of the eyes a fluid/substance
which maintains lubrication is used. Six units
reported the use of hypermellose drops and 1 unit simple eye ointment. In 6 of the units
contacted eye lubrication was maintained by placing a lubricating substance over the closed eye. In 7 units eye lubricants were not routinely
used as part of the patient eye care management (Fig. 3).
Seventeen units utilised some method of maintaining eyelid closure in ventilated and
paralysed patients. The most common method
of maintaining eye closure, stated by 12 of the
ICUs contacted was with the application of gel- like substance, known as Geliperm (Fig. 4).
DISCUSSION
The small sample size limits the generalisability to these results. Responses were given by a senior member of each unit’s staff, but it cannot be assumed that this fully reflects all possible indi- vidual eye care practices within that unit. However, the results are useful in giving some indication as to the variations in eye care man-
INTENSIVE AND CRITICAL CARE NURSING 139
The survey results indicate the common use of
eye lubricating substances. These solutions are
applied in order to maintain adequate lubri- cation of the eye and prevent crust formation on the cornea (British National Formulary 1992).
While this method of eye care has long been practised, it appears that there is no evidence for its efficacy.
From the survey results it is evident that saline
is the most common solution used in eye care
management. Yet Lloyd (1990) states that an
increase in tear production is evident when the eyes have been cleansed with saline and that tear production increases from a normal 6l.t.l to
lOOu1 an hour. While tear production has pro-
tective effects on the eye this probably indicates
an eye irritation response. Lloyd (1990) there-
fore recommends that the use of saline, as an eye cleansing agent, should be reserved for those eye
conditions where actual eye irrigation is
required. Trees and Tomlinson (1990) in a small study comparing the effects of artificial tears and
saline solutions on tear evaporation rates (TER)
found that all solutions increased tear evapo-
ration. This may potentiate a reduction in the
protective effects associated with tear produc-
tion. However they suggest that with the use of artificial tears a return to a more normal baseline
TER is seen when compared with saline lubri-
cants. In a study comparing four eye irrigation solutions, for treatment of patients who sustained chemical injuries, it was found that
more patient discomfort was seen in those
..........
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SYtYr sYllr ksx . . . * . . . . . .
ctLr
agement within differing critical care units. Fig. 2 Most common solution used in eye care.
140 INTENSIVE AND CRITICAL CARE NURSING
i
. . ..a....,
. . . . . . . . . . . . . . . . . . . ..,... “.
. . . . . . . . . . . . . . . ..* . . . . . . . . . . . . .
. . . . , . . . , . ::::::::::1---’ . . . . . . . . . . . . ::::~:~:
. . . . * . . . . . :::::::::::::::::::::
K m .::::: . . . * . . . . . . . . , , . . , .
q::::::;:;:::;:::: ::.:::::::::::‘::::::
4 .:. .:::
. . . . * . . . . . :::::::::::::::::::::
. . . . . . . . . . . . . .
.::::: . . . * * . . . . .
::::::::jjjjl.ljjjjjj
rm .....* . ..* . . . . . .
::::ii+::;:-.:;; . . ..a . . . . . . . ..,.. “..
Jolort Cslilirn Ib# llYrroncll#s,
Fig. 3 Substances used for eye lubriciation in the KU.
patients whose eyes were irrigated with normal
saline solution than those whose eyes were irri-
gated with a solution known as balanced saline
solution plus (Herr et al 199 1). This suggests that
for regular use in eye care management normal
saline solution may not be the most suitable eye cleaning agent.
Various methods of maintaining eyelid
closure, in the critically ill patient, have been
identified. The use of such methods has been
confirmed within the literature (Lloyd 1990, Wincek & Ruttum 1989). While all methods
probably afford some degree of eyelid closure,
closing the eyelids and placing securing tape in a
horizontal position may be most effective
(Wincek & Ruttum 1989). However due to the need for frequent pupillary observation and eye
care procedures frequent removal of any
securing tape may lead to a degree of eyelid and facial skin trauma. Securing eyelids with tape
may also be a source of distress to critically ill patients’ relatives.
Twelve of the ICUs contacted indicated the use of Geliperm as part of critically ill patients’ eye care management. The use of polyacryl- amide gels has been a recent innovation in maintaining adequate eye care for such patients. Geliperm is a transparent, soft, non allergenic highly water based gel-like material. This gel- like substance is commonly used in wound care management where its therapeutic properties may optimise cellular growth and inhibit the development of secondary infections (Geistlich
1990). In relation to eye care management for
critically ill patients the makers of Geliperm suggest that the use of this substance has a
number of advantages. It is suggested that due to its high water content drying in the eyes is
prevented; it acts as a bacterial barrier to prevent infection; it is non adherent and thus facilitates
eye care management and that the substance is sufficiently heavy enough to maintain closure of
the eyelid. It is further suggested that because of Geliperm’s transparency qualities, observation
of the eyes is facilitated. While it is probable that
the use of this type of gel-like substance has
potential beneficial applications in eye care man- agement of critically ill patients, there is at present no published research evidence to con-
firm these benefits.
CONCLUSION
Within this review the processes that lead to
ocular complications have been outlined.
Various approaches to eye care management for
critically ill patients have been identified.
Reviewing the literature has proved beneficial in enhancing our understanding of the importance
of an effective eye care technique. Yet, we have discovered little which identifies the most suit-
able eye care technique in ICU. It is apparent that investigation into various aspects of eye care
management of critically ill patients is required.
Fig. 4 Method of maintaining eyelid closure in the KU.
INTENSIVE AND CRITICAL CARE NURSING 141
Research studies are needed to identify the most
appropriate cleansing agent for eye care and the best method for maintaining complete eyelid closure. It is important that a comparative study between the use of traditional and newer eye lubricating maintaining substances should be undertaken. Only when such studies have been undertaken and the results presented will it be possible to make a conclusion as to the most suitable and appropriate eye care technique for critically ill patients.
Acknowledgements
The authors would like to thank Dr R. Tasker, Dr K. Wilkinson, Dr D Taylor and Rosemary Castle (Staff Nurse) for reviewing this manuscript and giving helpful comments.
References
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