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VAP, not on my WATCH !!!. France Ellyson ANM, MNH ICU Kuwait 2014. http://www.youtube.com/watch?v=RueE4or4rMU. Introduction. Mechanical ventilator is one of the most important life saving devices used in conditions like: Respiratory failure Protection of airway Head injury Postoperative - PowerPoint PPT Presentation
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VAP, not on my WATCH !!!
France EllysonANM, MNH ICU
Kuwait 2014
• http://www.youtube.com/watch?v=RueE4or4rMU
Introduction
Mechanical ventilator is one of the most important life saving devices used in conditions like:• Respiratory failure• Protection of airway• Head injury• Postoperative• Shock
What is Ventilator Associated Pneumonia?
• A nosocomial pneumonia associated with mechanical ventilation (either Endotracheal tube or Tracheostomy) that develops within 48 hours or more of hospital admission and which was not present at time of admission.
• Now considered a PREVENTABLE HEALTHCARE ERROR
National institute of health excellence (NICE) -2007center for disease control and prevention
What is VAP?
• Pneumonia that occurs at least 2 days after a patient is intubated (CDC GUIDELINES)
• The presence of the ET-tubes leads to VAP (not the ventilator)
• VAP rate increases with the # of days on mechanical ventilation
• Mortality varies according to the type of organisms
• Multi-resistant organisms have a higher mortality
Epidemiology
• Hospital acquired pneumonia (HAP) is the second most common hospital infection.
• VAP is the most common Intensive Care Unit (ICU) infection.
• 90% of all nosocomial infections occuring in ventilated patients are pneumonias.
• Causes more death than any of the other healthcare associated infection
Incidence
• VAP occurs in 10-20% of all ventilated patients Crit Care Clin (2002)
• Incidence increases with duration of MV: 3%/day for first 5 days, 2%/day for 6-10 days and 1%/day after 10 days.
• The incidence of VAP is highest in the following groups: Trauma, burns, neurosurgical post-op pts
• Mortality rate is 37% and 43% with antibiotic resistant organism
Critical Care Societies Collaborative (CCSCs)
Incidence Cont….
• Increases ventilatory support requirements and ICU stay by 4.3 days
• Increases hospital LOS (length of stay) by 4 to 9 days
• Increases medical cost ($5,000 to $40,000 per VAP) Critical Care Medicine
2005;33:2184-93
Causative Organisms:
Early onset Late onset
• Hemophilus influenza• Streptococcus
pneumoniae• Staphylococcus aureus
(methicillin sensitive)• Eschrichia coli• Klebsiella
• Pseudomonas aeruginosa
• Acinetobacter• Staphylococcus
aureus (methicillin resistant)
How is the pneumonia happening?
• Most plausible mechanism and source:– Leakage around the ETT cuff (primary route)…
aspiration of bacteria– High rate of the oropharyngeal or
tracheobronchial colonization (gram neg bacilli)– Bacteria from the tongue– Bacteria from environment: caregivers’ hand,
air, water, dust– Contaminated equipment (ventilator tubing,
aerosol, etc.)– Suctioning equipment
Risk Factors: Host Related• Medical / surgical disease• Immunosuppression • Malnutrition (Alb<2.2g/dl)• Advanced age• Pt’s position (supine)• LOC – impaired LOC,
delirium, coma• Medications – sedation,
steroids, previous antibiotic use, NM blockers
• Number of intubations- reintubations
Risk Factors: Device Related
• Mechanically ventilated with ETT or Tracheostomy tube
• Prolonged MV - MV > 48 hours
• Number of intubations, reintubations
• NGT or Orogastric tube• Use of humidifier
Risk Factors: Health Care Personnel Related
• Improper hand washing• Failure to change gloves
between contacts with pts
• Failure to wear personal protective equipment when required
Pathogenesis
Bacteria enter the lower respiratory tract via following pathways:• Aspiration of organisms from the
oropharynx and GI tract (most common cause)
• Direct inoculation• Inhalation of bacteria
Aspiration
ETT/T NGT/OGT
• Holds vocal cords open
• Predispose pt to micro and macro aspiration of colonized bacteria from oropharynx
• Leakage of secretions containing bacteria around ETT cuff
• Interrupts gastro-esophageal sphincter leading to GI reflux and aspiration
• Increase oropharyngeal colonization and stagnation of oropharyngeal and nasal secretions
A New Streamlined Surveillance Definition for Ventilator-Associated Pneumonia Critical Care Med 2012 vol.40, no.1
Any one of the following:
• NO CONSENSUS AMONG PHYSICIANS!!!
How do we Diagnose? 2-1-2
Radiologic evidence X 2 Consecutive days• New, progressive
or persistent infiltrate
• Consolidation, opacity or cavitation
How do we diagnose? 2-1-2Clinical Signs:At least 1of the following:• Fever > 38 °C with no
other recognized cause
• Leukopenia (<4,000 WBC/mm3) or leukocytosis (>12,000 WBC/mm3)
How do we Diagnose? 2-1-2At least 2 of the following:
• New onset of purulent sputum or change in character of secretions
• New onset or worsening cough, dyspnea or tachypnea
• Rales or bronchial sounds• Worsening gas exchange
(decreased sats, increased oxygen requirements)
Treatment Protocol
• Start when VAP is suspected• Do not delay• Individualized to institution – Hospital
epidemiologic data, drug cost and availability
• Individualized to pt - Early onset vs Late onset of VAP, prior antibiotic use, underlying disease, renal, liver, etc
• Surveillance cultures
Duration of Treatment
• Standard duration 7-14 days• Longer duration > 14-21 days risk of toxicity
and resistance• Shorter < 7 days risk of recurrence• Depends on severity• Isolation of microorganism
Prevention
• Specific practices have been shown to decrease VAP
• Strong evidence that a collaborative, multidisciplinary approach incorporating many interventions is paramount
• Intensive education directed at nurse and respiratory care practitioners resulted in a 57% decrease in VAO
Crit Care Med (2002)
The VAP Bundle
BUNDLE
• “Group of evidence based interventions that whenever implemented together result in better outcomes”
Introduction of VAP BUNDLE
1. Elevation of HOB to between 30-45°2. Daily sedative interruption and daily assessment
of readiness to extubate3. The utilization of endotracheal tubes with
subglottic secretion drainage (Not at MNH yet)4. Stress ulcer disease prophylaxis – including
initiation of safe enteral nutrition within 24-48 hours of ICU admission
5. IN 2010 5TH COMPONENT of Daily oral care and decontamination with Chlorhexidine
Crit.Care 2012 vol.40, no.1
Additional Evidence-Based Component of Care:
HANDWASHING• Single most important
and ( easiest!!) method for reducing the transmission of pathogens
• Use of waterless antiseptic preparations is acceptable and may increase compliance
HOB 30-45°
• HOB 30-45° unless contraindicated
• Especially recommended for Neuro population
• To prevent aspiration during enteral feeding
Daily sedative interruption and daily assessment of readiness to extubate
OVERSEDATION predisposes pts to:
• Thromboemboli• Pressure ulcers• Gastric regurgitation and aspiration• VAP• Sepsis
Daily sedative interruption and daily assessment of readiness to extubate
OVERSEDATION predisposes pts to:
• Difficulty in monitoring neuro status• Increased use of diagnostic procedures• Increased ventilator days• Prolonged ICU and Hospital stay
Daily Wake-up
• Every pt must be awakened daily unless contraindicated
• Daily weaning assessments reduce the duration of MV
• If pt becomes symptomatic – rebolus and restart infusion at lower dose than original dose
• Goal is to decrease sedation
Stress Ulcer Prophylaxis
• Sucralfate, H2 receptor blocker and proton pump inhibitor – increases gastric ph and minimize bacterial colonization and reduces risk of VAP
Enteral Feedings
• Initiation of safe enteral nutrition within 24-48 hours of ICU admission
• Early initiation decreases bacterial colonization
• HOB 30-45°• Routinely + PRN
verification tube placement
Additional Evidence-Based Component of Care:
• Deep venous thrombosis (DVT) prophylaxis (unless contraindicated) – TED stockings– SCD machine– Heparin S/C
Deep venous Thrombosis Prophylaxisand early mobility practices
• Pt turning Q 2hours increase pulmonary drainage and decreases risk VAP
• Early mobilization
Daily Oral care• Oral assessment Q shift
• Brushing teeth, tongue and gums with a soft toothbrush (minimally twice daily)
• Moisturizing agent for mouth
• Antiseptic rinse
• Swabs are not effective at removing plaques
• Chlorhexidine decontamination of mouth
• Routine suctioning of mouth to manage oral secretions and minimize risk of aspiration
Sage Oral Care Products
• http://www.youtube.com/watch?v=MYO_MddtYNs
Mouthcare
• Using chlorhexidine gluconate 0.12% (Peridex) solution every 6-12 hours to perform oral care, according to your protocol
• solution is used to rinse the patients’ mouth.
ET Tube Care
• Cuff pressure (between 20-30cm H2O)
• Oral intubation preferred
• Continuous or intermittent sub-glottic aspiration
• Avoid unnecessary disconnection of MV circuit
• Open vs close suctioning… benefits is not demonstrated yet
Prevent micro-aspiration of secretions
• 100-150ml of oral secretion can accumulate in patient mouth in 24hrs
• Mouth can colonize as quickly as 24hr after admission
• Intermittent and continuous subglottic suctioning
• Suctioning of the mouth before position change
Suctionning of Oral Secretions
• Suction oropharyngeal secretions Q 2hours, before repositionning, before suctionning ETT, before mobilizing patient and PRN
• Gently follow tongue to suction back of throat
• Use yankauer suction
SuctioningOral suction devices (Yankauer)• Follow policy for use
and storage• ?Harbor potentially
pathogenic bacteria within 24 hours
• Date and change Q day
• Rinse with sterile water after each use
• Allow to air dry
Subglottal Suctioning
Should be done using a 14 French sterile suction catheter• Prior to ETT
suctionning• Prior to pt change of
position• Prior to extubation* Continuous subglottic ETT with dedicated lumen above cuff may reduce risk of VAP
Prevent contamination of equipment
• Ventilator tubing
• Heat and moisture exchangers (green filters) are preferred over humidifiers (CDC B-II)
• Sterile suctioning
• Be careful with the tubing of the ventilator when you suction patient…
• Remove contaminated condensate from ventilator circuit (CDC, A-II)
Summary• Nosocomial pneumonia and especially VAP are the
most frequent infectious complications in the ICU, and they significantly contribute to morbidity and mortality
• VAP is an important determinant of ICU and Hospital lengths of stay and healthcare costs
• No standard to diagnose• Several simple preventative measures (VAP
bundle) and timely initiation of appropriate antibiotics ensure better outcomes in pts with VAP
• http://www.youtube.com/watch?v=Ehi2Vt8UdRc
References
National Guideline Clearinghouse (current). Guideline Summary NGC-6634: Prevention of ventilator-associated pneumonia. Retrieved from: http://files.i-md.com/medinfo/material/f97/4eb0b88d44aece1112f7bf97/4eb0b8a944aece1112f7bf9a.pdf
Niel-Weise, B. & all. (2011). An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Critical Care 2011, 15:R111.
Postma, D.F., Sankatsing, S.U.C., Thijsen, S.F.T. & Enderman, H. (2012). Effetcs of chlorhexidine oral decomtamination on respiratory colonization during mechanical ventilation in intensive care unit patients. Infection Control and Hospital Epidemiology, vol 33 no.5, pp.527-530.
Safer Healthcare now (2012). Ventilator associated pneumonia. Retrived from: http://www.saferhealthcarenow.ca/en/interventions/vap/pages/default.aspx
Safer Healthcare now (2012). Getting Started Kit. Retrieved from http://www.saferhealthcarenow.ca/EN/Interventions/VAP/Documents/VAP%20Getting%20Started%20Kit.pdf
ReferencesAlhazzani, W. & all. (2013) Tooth brushing for critically ill mechanically ventilated patients: a
systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia. DOI: 10.1097/ccm.0b013e3182742d45
Center for Disease Control and prevention(2011). Improving Surveillance for Ventilator-Associated Events in Adults. Obtain from MUHC Infection Control Departement.
Chan, E.Y., Ruest, A., Omeade, M. & Cook, D.J (2007). Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ, doi: 10.1136/bmj.39136.528160.BE
Fagon, J-Y. (2011). Biological markers and diagnosis of ventilator-assocaited pneumonia. Critical Care 20111, 15:130.
Koenig, S.M. & Truwit, J.D. (2006) Ventilator-assocaited pneumonia: diagnosis, treatment, and prevention. Clinical Microbiology Reviews, doi: 10.1123/CMR.00051-05
Hillier B. Wilson C. Chamberlain D. King L. (2013). Preventing ventilator-associated pneumonia through oral care, product selection, and application method: a literature review. AACN Advanced Critical Care. 24(1):38-58.
Insitute for Healthcare Improvement (2011). IHI ventilator bundle: daily oral care with chlorhexidine. Retrieved from http://www.ihi.org/knowledge/pages/changes/dailyoralcarewithchlorhexidine.aspx