In this episode, I’ll discuss the effects of oral chlorhexidine vs an oral care bundle on mortality for mechanically ventilated patients in the ICU.
In recent years, the journal Intensive Care Medicine has published a cohort study and editorial that call into question the safety and efficacy of oral mouth care with chlorhexidine in ventilated ICU patients. Concerns include the risk of bias in the studies that have been used to justify oral care with chlorhexidine and the possibility that chlorhexidine may have direct negative effects on oral mucosa.
Since the beginning of 2018, a large randomized controlled trial has been underway looking at the De-adoption of Oral Chlorhexidine Prophylaxis and Implementation of an Oral Care Bundle for Ventilated Critically Ill Patients and it has recently been published in Intensive Care Medicine.
The study was a cluster-randomized controlled multicenter trial where patients were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle vs standard care of continuing chlorhexidine. There were 1560 patients who were in the control group and 1700 who received the oral care bundle.
The oral care bundle comprised twice daily (morning and evening) oral assessment and tooth brushing; mouth moisturization, lip moisturization with additional secretion removal every 4 hours.
The authors found that mortality, time to ventilator complication, and time to extubation were similar between groups. However, there was a statistically significant improvement in oral health dysfunction scores with the oral care bundle intervention (− 0.96; 95% CI − 1.75 to − 0.17; P = 0.02).
Unfortunately, the improvement in oral health scores was at a level below the pre-determined minimally clinically important difference.
The authors suggest that it is reasonable for ICUs to focus on improvements in oral care delivery until further evidence becomes available. Until then, it seems that oral chlorhexidine has neither the good nor bad effects previously attributed to it when compared to good oral care routines.
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