Ventilator Associated Pneumonia

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(No Transcript)
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Ventilator Associated Pneumonia

• Diagnosis of VAP was covered in the previous
  discussion

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Adult Ventilator Bundle

• VAP prevention measures
• Handwashing
• Patient positioning
• Oral care
• Management of oropharyngeal and tracheal
  secretions
• Daily Sedation Vacation and daily assessment of
  readiness to extubate
• General measures to improve care
• Peptic ulcer disease prophylaxis
• Deep vein thrombosis (DVT) prophylaxis

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Handwashing

• Strict handwashing before and after handling
  patient or patients equipment or supplies

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Patient Positioning

• Elevate the Head of the Bed 30-45o by flexing bed
  or reverse Trendelenberg
• Reduces chance of gastric reflux and aspiration
  of gastric contents
• Proper position in bed
• keep joints in neutral, semi-flexed position
• minimize abdominal compression

Drakulovic MB. Lancet.19993541851-1858.
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Evidence for Elevating Head of Bed

• Elevate the Head of the Bed 30-45o by flexing bed
  or reverse Trendelenberg
• Randomized controlled trial 86 adult intubated
  patients on mechanical ventilation assigned to
  semi-recumbent (45o) or supine position
  
• Semi-recumbent Supine
• Suspected VAP 8 34
• (CI for difference 10-42 p0.003)
• Confirmed VAP 5 23
• (CI for difference 4-32 p0.018)

Drakulovic MB. Lancet.19993541851-1858.
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Patient Positioning

• Precautions
• Head elevation in patient with hypovolemia -
  possible significant hypotension
• Transporting patients on ventilatory support
• Spine precautions
• May need to use Reverse Trendelenberg
  

Drakulovic MB. Lancet.19993541851-1858.
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Do
Positioning DOs and DONTs
Dont

• Leave patient in supine position for prolonged
  periods

• Maintain HOB gt 30 degrees unless contraindicated.

http//www.engin.umich.edu/alumni/engineer/03SS/pr
otective/

• Forget to turn tube feedings off prior to placing
  patient in supine position

http//www.rtmagazine.com/Articles.ASP?articleidr
0202F03

• Continue Q 2 hour turning schedule. 

http//www.tccd.edu/neutral/DivisionDepartmentPage
.asp?pagekey191menu1
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Picture from Sage
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Oral care

• Colonization of oropharynx -
• Normal flora includes both Gram-positive and
  anaerobic bacteria.
• When normal flora compromised, more susceptible
  to colonization by microorganisms (e.g.,
  Gram-negative bacilli), not normally found in
  oropharyngeal secretions.
• Migration to lower airway can lead to VAP
• Pfeifer, LT Orser, L. Gefer, C. McGuinness,
  R. and Hannon, CV (2001). Preventing
  ventilator-associated pneumonia. American Journal
  of Nursing, 101(8), 24AA-24GG.

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Oral care

• Colonization of Oropharynx - Dental Plaque
• Colonization of dental plaque is either present
  on admission or acquired in 40 of ICU patients.
• Positive dental plaque culture significantly
  associated with subsequent nosocomial infections
  particularly aerobic pathogens.
• ICU patients at risk due to
• Difficulties performing adequate oral hygiene
• Changes in properties of saliva
• Reduction of anaerobic flora secondary to
  antibiotics
• Fourrier, F. Buvivier, B. Boutigny, H.
  Roussel-Delvallez, M, and Chopin, C. (1998)
  Colonization of dental plaque A source of
  nosocomial infections in intensive care unit
  patients. Critical Care Medicine 26301-308.

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Oral care Protocol

• Assess oral cavity at least every shift
• Brush teeth each shift with suction oral brush
  and 1.5 hydrogen peroxide solution
• Oral care every 2 hours with suction oral swabs
  and 1.5 hydrogen peroxide solution
• Hypopharyngeal/subglottic suctioning at least q6h
  and as necessary
• Apply mouth moisturizer as needed
• Sage oral care kit can make compliance easier

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Management ofOral and Tracheal Secretions

• Proper care of oral and tracheal secretions is
  essential to minimize risk of aspiration
• To prevent aspiration of pooled secretions
  hypopharyngeal suctioning should be performed
  before
• suctioning the ETT
• repositioning the ETT
• deflating the cuff
• repositioning your patient

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Management ofOral and Tracheal Secretions (3a)

• Care of Equipment
• Maintain endotracheal tube cuff pressure at
  desired level (usually 20 cmH2O)

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Management ofOral and Tracheal Secretions (3b)

• Care of Equipment
• Maintain endotracheal tube cuff pressure at
  desired level (usually 20 cmH2O)
• Use Ballard system or use 2 people to assist

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Management ofOral and Tracheal Secretions (3c)

• Care of Equipment
• Maintain endotracheal tube cuff pressure at
  desired level (usually 20 cmH2O)
• Use Ballard system or use 2 people to assist
• Keep end of vent circuit, suction catheter or
  Yankauer tip and patients manual ventilation bag
  off the bed. Hang them up or place them on a
  sterile paper or towel.

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Management ofOral and Tracheal Secretions (3d)

• Care of Equipment
• Maintain endotracheal tube cuff pressure at
  desired level (usually 20 cmH2O)
• Use Ballard system or use 2 people to assist
• Keep end of vent circuit, suction catheter or
  Yankauer tip and patients manual ventilation bag
  off the bed. Hang them up or place them on a
  sterile paper or towel.
• Help keep the vent circuit free from accumulated
  water. Drain water away from the patient.

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Management ofOral and Tracheal Secretions (3e)

• Care of Equipment
• Maintain endotracheal tube cuff pressure at
  desired level (usually 20 cmH2O)
• Use Ballard system or use 2 people to assist
• Keep end of vent circuit, suction catheter or
  Yankauer tip and patients manual ventilation bag
  off the bed. Hang them up or place them on a
  sterile paper (from gloves or gauze).
• Help keep the vent circuit free from accumulated
  water. Draining water away from the patient.
• Change the suction canister and mouth care kit
  every 24 hours.

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Management of Oral and Tracheal Secretions (3f)

• Care of Equipment
• Maintain endotracheal tube cuff pressure at
  desired level (usually 20 cmH2O)
• Use Ballard system or use 2 people to assist
• Keep end of vent circuit, suction catheter or
  Yankauer tip and patients manual ventilation bag
  off the bed. Hang them up or place them on a
  sterile paper (from gloves or gauze).
• Help keep the vent circuit free from accumulated
  water by draining water away from the patient.
• Change the suction canister and mouth care kit
  every 24 hours.

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Sedation Vacation

• Sedation vacation discontinuation of sedation
  until patient is responsive (awake)
• 128 adults on mechanical ventilation randomized
  to sedation vacation group or control sedation
  group.
• Duration of ventilation
• sedation vacation group 4.9 days
• control sedation group 7.3 days
• (p0.004)

Kress JP. N Engl J Med. 2000 342 1471-1477.
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PUD Prophylaxis

• Why?
• Reduces acid production in stomach and the
  consequent risk of bleeding from gastric erosions
  and peptic ulcers
• Identified Issues and Concerns
• Some studies have shown increased rates of
  ventilator associated pneumonia in patients on
  prophylactic treatments, e.g. sucralfate
• Anecdotal Experience
• None significant

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PUD Prophylaxis

• Surviving Sepsis Campaign Guidelines
• Stress ulcer prophylaxis should be given to all
  patients with severe sepsis. H2 receptor
  inhibitors are more efficacious than sucralfate
  and are the preferred agents. Proton pump
  inhibitors have not been assessed in a direct
  comparison with H2 receptor antagonists and,
  therefore, their relative efficacy is unknown.
  They do demonstrate equivalency in ability to
  increase gastric pH.

Dellinger RP. Crit Care Med. 2004 32 858-873.
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DVT Prophylaxis

• Systematic review of risks of venous
  thromboembolism and its prevention
• We recommend, on admission to the intensive care
  unit, all patients be assessed for their risk of
  VTE. Accordingly, most patients should receive
  thromboprophylaxis (Grade 1A).

Geerts WH. Chest. 2004 126 338S-400S.
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Deep vein thrombosis (DVT) prophylaxis

• Atlas Toolkit keyword search DVT
• Educational Materials
• Risk Assessment and Order sets
• Utilization Monitoring/Evaluation Strategies
• HCA Facility Examples
• Healthstream Education Module
• 1. Log into Healthstream
• 2. Select the Find tab at the top of the screen
• 3. Select the category Patient Safety
• 4. Select the sub-category Medication Safety
• 5. Click the course name Venous Thromboembolism
  Risk Screening and Prophylaxis

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Pediatric Ventilator Bundle Applies to patients
of ages 1month- 13 years

• Same as Adult
• VAP prevention measures
• Handwashing
• Patient positioning
• Oral Care
• Management of oral and tracheal secretions
• Daily assessment of readiness to extubate
• General measures to improve Critical Care
• Peptic ulcer disease prophylaxis
• Different from Adult
• VAP prevention measures Sedation Vacation
• Deep vein thrombosis prophylaxis

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Neonatal Ventilator Bundle(0-28 days of age)

• No clear data on proven measures to reduce VAP in
  neonates. Recommendations based on common
  sense best practice.
• Same as Adult
• VAP prevention measures
• Handwashing
• Management of oral and tracheal secretions
• Daily assessment of readiness to extubate
• Different from Adult
• VAP prevention measures
• Patient positioning
• Oral Care
• Daily Sedation Vacation
• General measures to improve Critical Care
• Peptic ulcer disease prophylaxis
• Deep vein thrombosis (DVT) prophylaxis

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SummaryConsider these Components for your
Interventions and Checklists

• Handwashing
• Before entering patient room
• On exiting patient room
• Patient Position
• Bed elevated 30-45 degrees
• Patient properly positioned in bed
• Proper Oral Care every 2 hours

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SummaryConsider these Components for your
Interventions and Checklists

• Secretion Management
• Check and maintain proper ETT cuff pressure
• Use inline (Ballard) ETT suction
• Suction hypopharyngeal secretions as needed
• Keep end-of-circuit suction catheter clean and
  off patient bed

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SummaryConsider these Components for your
Interventions and Checklists

• Care of Ventilator Equipment
• Circuit drained of accumulated condensed water
• Change suction canister and oral care kit daily
• Sedation Vacation
• Discontinue sedation daily

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For a Successful Strategy to Reduce VAP

• Set an Aim Improve the health and well-being of
  ventilated patients by reducing the VAP rate.
• Set goals for example Reduce VAP rate by 50
  by April 2006. Implement use of ventilator
  bundle with greater than 95 reliability.
• Plan Well Adopt a change methodology that
• accelerates improvement such as The Model for
  Improvement.
• Benchmark use national benchmark (e.g.,
  National Healthcare Safety Network - NHSN)

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Selected references

• Drakulovic MB, Torres A, et al. Supine body
  position as a risk factor for noscomila pneumonia
  in mechanically ventilated patients a randomized
  trial. Lancet.19993541851-1858
• Pfeifer LT, Orser L, Gefer C, McGuinness R,
  Hannon CV. Preventing ventilator-associated
  pneumonia. American Journal of Nursing. 2001
  101(8), 24AA-24GG
• Fourrier F, Buvivier B, Boutigny H,
  Roussel-Delvallez M, Chopin C. Colonization of
  dental plaque A source of nosocomial infections
  in intensive care unit patients. Critical Care
  Medicine. 199826301-308.
• Kress JP, Pohlman AS, et al. Daily interruption
  of sedative infusions in critically ill patients
  undergoing mechanical ventilation. N Engl J Med.
  2000 342 1471-1477
• Schweickert WD, Gehlbach BK, et al. Daily
  interruption of sedative infusions and
  complications of critical illness in mechanically
  ventilated patients. Crit Care Med. 2004,
  32(6)1272-1276.
• Tablan OC, Anderson LJ, Besser R, Bridges C,
  Hajjeh R. Guidelines for preventing
  health-care-associated pneumonia, 2003
  recommendations of CDC and the Healthcare
  Infection Control Practices Advisory Committee.
  MMWR Recomm Rep. 200453 (RR-3)1-36.
• IHI.org A resource from the Institute for
  Healthcare Improvement. Getting Started Kit
  Prevent Ventilator-Associated Pneumonia,
  Bibliography. Accessed April 2006.
  http//www.ihi.org/NR/rdonlyres/FD28C31B-5E93-448D
  -B5DC-9941ACB6C150/0/VAPBibliographyFINAL.pdf
• American Thoracic Society Documents. Guidelines
  for the management of adults with
  hospital-acquired, ventilator-associated, and
  healthcare-associated pneumonia. Am J Respir Crit
  Care Med. 2005171388-416.
• Garcia R. Addressing JCAHOs Patient Safety Goal
  7 Focus on Key HICPAC Strategies for the
  Prevention of VAP. Brookdale University Medical
  Center, Brooklyn, NYAPIC Seminar 2004