Study of Body Positions in Unconsciousness

Coma Clinical Trial

Official title:

A Randomised Controlled Study of the Use of Recovery Positions for Comatose Patients in a Resource Limited Setting

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02427633
• Other study ID #: BAKMAL1405
• Status: Completed
• Phase: N/A
• Start date: August 23, 2014
• Est. completion date: March 21, 2020

Study information

• Verified date: October 2020
• Source: University of Oxford
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

In resource limited settings, access to one-on-one nursing care and airway protection by intubation may be unavailable. Patients with coma but adequate oxygenation are frequently cared for on medical wards, and nursed by their family members. The investigators previously audited the use of the recovery position in patients with cerebral malaria and found that its usage was greatly increased by an educational intervention aimed at patient's caregivers. A trend to reduction in coma duration and aspiration pneumonia was also found. Since there is no evidence that placing comatose, non-intubated patients in a recovery position improves outcome, the investigators plan to conduct a randomised controlled study comparing standard care with an educational intervention targeting patients' relatives, teaching them to maintain their relative in one of two different recovery positions. With the preliminary efficacy and safety data and feedback that this study will provide, the investigators would then move to conduct a large multicenter study powered to detect a difference in mortality.

Description:

Methods:

In this prospective, three-armed randomised controlled study, patients admitted to the adult medical wards of Chittagong Medical College Hospital with acute onset of reduced consciousness (Glasgow Coma Scale (GCS) <12 for less than 5 days) will be randomised 1:1:1 to one of three arms; standard care (no intervention) or an educational intervention directing placement into one of two recovery positions.

The educational intervention will occur following randomisation and on daily follow-up until recovery from deep coma or death. For patients in the intervention arms, the patients' relatives will be instructed on how to maintain their patient in the recovery position, and an educational poster will be attached to their bed.

Enrolled subjects will be observed 3 times a day until discharge for body position and vital signs including GCS, heart rate, respiratory rate and oxygen saturation.

The primary outcome will be the risk of (hazard ratio) aspiration pneumonia and pneumonitis. The secondary outcome measures will include time to hypoxia, death and coma recovery time. Pulmonary complications will be defined clinically and radiologically. The primary comparison between groups will be the standard care group versus both recovery positions combined. Analysis will be by intention to treat.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 1540
• Est. completion date: March 21, 2020
• Est. primary completion date: March 21, 2020
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Male or female admitted to the medical wards at CMCH

• Current GCS < 12

• Less than 5 day history of reduced consciousness

• Written informed consent obtained through an adult (=18 years) relative or parent/guardian

Exclusion Criteria:

• Suspected head or spinal injury/trauma requiring appropriate immobilisation and stabilization

• Patient physically restrained by ward staff due to agitation

• Unsuitability for lateral positioning e.g. due to burns on lateral aspects, femoral vascular catheter

• Requirement for nursing in an upright position e.g. due to respiratory insufficiency

• Known or suspected pregnancy

• Intubation

• Patient or family member previously enrolled in this study.

• Consent refused, or no adult (=18 years) relative or parent/guardian present to give consent

Related Conditions & MeSH terms

• Coma

Intervention

Other:
• Educational Intervention UKRC 1997
Educational poster intervention indicating the modified UKRC 1997 recovery position
• Educational Intervention UKRC 2010
Educational poster intervention indicating the modified UKRC 2010 recovery position

Locations

Country	Name	City	State
Bangladesh	Chittagong Medical College Hospital	Chittagong

Sponsors (2)

Lead Sponsor	Collaborator
University of Oxford	Chittagong Medical College and Hospital

Country where clinical trial is conducted

Bangladesh, 

References & Publications (25)

Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia. Lancet. 1996 Jul 13;348(9020):123-4. — View Citation

Adnet F, Borron SW, Finot MA, Minadeo J, Baud FJ. Relation of body position at the time of discovery with suspected aspiration pneumonia in poisoned comatose patients. Crit Care Med. 1999 Apr;27(4):745-8. — View Citation

American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416. — View Citation

Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM, Hazinski MF, Lerner EB, Rea TD, Sayre MR, Swor RA. Part 5: adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S685-705. doi: 10.1161/CIRCULATIONAHA.110.970939. Review. Erratum in: Circulation. 2011 Oct 11;124(15):e402. — View Citation

Bollig G, Wahl HA, Svendsen MV. Primary school children are able to perform basic life-saving first aid measures. Resuscitation. 2009 Jun;80(6):689-92. doi: 10.1016/j.resuscitation.2009.03.012. Epub 2009 Apr 21. — View Citation

Dalhoff K, Ewig S; Gideline Development Group, Abele-Horn M, Andreas S, Bauer TT, von Baum H, Deja M, Gastmeier P, Gatermann S, Gerlach H, Grabein B, Höffken G, Kern W, Kramme E, Lange C, Lorenz J, Mayer K, Nachtigall I, Pletz M, Rohde G, Rosseau S, Schaaf B, Schaumann R, Schreiter D, Schütte H, Seifert H, Sitter H, Spies C, Welte T. Adult patients with nosocomial pneumonia: epidemiology, diagnosis, and treatment. Dtsch Arztebl Int. 2013 Sep;110(38):634-40. doi: 10.3238/arztebl.2013.0634. Epub 2013 Sep 20. — View Citation

Doxey J. Comparing 1997 Resuscitation Council (UK) recovery position with recovery position of 1992 European Resuscitation Council guidelines: a user's perspective. Resuscitation. 1998 Dec;39(3):161-9. — View Citation

Fulstow R, Smith GB. The new recovery position, a cautionary tale. Resuscitation. 1993 Aug;26(1):89-91. — View Citation

Guidelines for the treatment of malaria. World Health Organisation 2010. 2nd edition.

Handley AJ, Becker LB, Allen M, van Drenth A, Kramer EB, Montgomery WH. Single rescuer adult basic life support. An advisory statement from the Basic Life Support Working Group of the International Liaison Committee on Resuscitation (ILCOR). Resuscitation. 1997 Apr;34(2):101-8. — View Citation

Handley AJ. Resuscitation. Resuscitation Council (UK) wants everyone who uses new recovery position to report experiences. BMJ. 1997 Nov 15;315(7118):1308. — View Citation

Huxley EJ, Viroslav J, Gray WR, Pierce AK. Pharyngeal aspiration in normal adults and patients with depressed consciousness. Am J Med. 1978 Apr;64(4):564-8. — View Citation

Koster RW, Baubin MA, Bossaert LL, Caballero A, Cassan P, Castrén M, Granja C, Handley AJ, Monsieurs KG, Perkins GD, Raffay V, Sandroni C. European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation. 2010 Oct;81(10):1277-92. doi: 10.1016/j.resuscitation.2010.08.009. — View Citation

Kumar P, Touquet R. Perils of the recovery position: neurapraxia of radial and common peroneal nerve. J Accid Emerg Med. 1996 Jan;13(1):69-70. — View Citation

Leopold SJ, personal communication, November 2013.

Lim WS, Baudouin SV, George RC, Hill AT, Jamieson C, Le Jeune I, Macfarlane JT, Read RC, Roberts HJ, Levy ML, Wani M, Woodhead MA; Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009 Oct;64 Suppl 3:iii1-55. doi: 10.1136/thx.2009.121434. — View Citation

Markenson D, Ferguson JD, Chameides L, Cassan P, Chung KL, Epstein JL, Gonzales L, Hazinski MF, Herrington RA, Pellegrino JL, Ratcliff N, Singer AJ; First Aid Chapter Collaborators. Part 13: First aid: 2010 American Heart Association and American Red Cross International Consensus on First Aid Science With Treatment Recommendations. Circulation. 2010 Oct 19;122(16 Suppl 2):S582-605. doi: 10.1161/CIRCULATIONAHA.110.971168. Erratum in: Circulation. 2010 Nov 23;122(21):2227. Circulation. 2012 Apr 17;125(15):585. — View Citation

Maude RJ, Hoque G, Hasan MU, Sayeed A, Akter S, Samad R, Alam B, Yunus EB, Rahman R, Rahman W, Chowdhury R, Seal T, Charunwatthana P, Chang CC, White NJ, Faiz MA, Day NP, Dondorp AM, Hossain A. Timing of enteral feeding in cerebral malaria in resource-poor settings: a randomized trial. PLoS One. 2011;6(11):e27273. doi: 10.1371/journal.pone.0027273. Epub 2011 Nov 16. — View Citation

Rathgeber J, Panzer W, Günther U, Scholz M, Hoeft A, Bahr J, Kettler D. Influence of different types of recovery positions on perfusion indices of the forearm. Resuscitation. 1996 Jul;32(1):13-7. — View Citation

Resuscitation Council (UK) Resuscitation 2010 Guidelines Edited by Jerry P. Nolan ISBN 978-1-903812-21-1

Sakai T, Planinsic RM, Quinlan JJ, Handley LJ, Kim TY, Hilmi IA. The incidence and outcome of perioperative pulmonary aspiration in a university hospital: a 4-year retrospective analysis. Anesth Analg. 2006 Oct;103(4):941-7. — View Citation

Stroud M, Duncan H, Nightingale J; British Society of Gastroenterology. Guidelines for enteral feeding in adult hospital patients. Gut. 2003 Dec;52 Suppl 7:vii1-vii12. — View Citation

The 1997 Resuscitation Guidelines for use in the United Kingdom April 1997. Resuscitation Council (UK) Publication.

Turner S, Turner I, Chapman D, Howard P, Champion P, Hatfield J, James A, Marshall S, Barber S. A comparative study of the 1992 and 1997 recovery positions for use in the UK. Resuscitation. 1998 Dec;39(3):153-60. — View Citation

Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology. 1993 Jan;78(1):56-62. — View Citation

* Note: There are 25 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Composite of aspiration pneumonitis or pneumonia		48 hours after GCS13
Secondary	Proportion of patients developing hypoxia		48 hours after GCS13,
Secondary	Development of pneumonia or pneumonitis, assessed individually		48 hours after GCS13
Secondary	Mortality		7 days post discharge/last follow-up
Secondary	Time to mortality		7 days post discharge/last follow-up
Secondary	Coma recovery time, defined as time to GCS 15		during hospitalization (defined as time to GCS 15), expected less than 4 weeks
Secondary	The number of documented episodes of hypoxia		48 hours after GCS 13
Secondary	Percentage of observations in the recovery position		whilst GCS<12, expected less than 2 months
Secondary	Modified Rankin scale		on discharge, expected less than 2 months
Secondary	Composite of pressure sore, venous thrombosis, arm or leg peripheral nerve or joint injury		whilst GCS<12, expected less than 2 months
Secondary	Proportion of patients developing a pressure sore		whilst GCS<12, expected less than 2 months
Secondary	Proportion of patients developing a venous thrombosis,		whilst GCS<12, expected less than 2 months
Secondary	Proportion of patients developing a new arm or leg peripheral nerve injury		during hospitalization, expected less than 2 months
Secondary	Proportion of patients developing a new arm or leg joint injury		during hospitalization, expected less than 2 months
Secondary	Trends in Blood presure	measure Systolic and diastolic blood pressure levels	during hospitalization, expected less than 2 months
Secondary	Trends in heart rate		during hospitalization, expected less than 2 months
Secondary	Proportion of patients developing peripheral venous cannula function		whilst GCS<12, expected less than 2 months
Secondary	time to hypoxia		48 hours after GCS13, expected less than 2 months