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Ventilator Associated Pneumonia

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Management of oropharyngeal and tracheal secretions ... B, Boutigny H, Roussel-Delvallez M, Chopin C. Colonization of dental plaque: A ... – PowerPoint PPT presentation

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Title: Ventilator Associated Pneumonia


1
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2
Ventilator Associated Pneumonia
  • Diagnosis of VAP was covered in the previous
    discussion

3
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

4
Handwashing
  • Strict handwashing before and after handling
    patient or patients equipment or supplies

5
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.
6
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.
7
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.
8
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
9
Picture from Sage
10
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.

11
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.

12
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

13
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

14
Management ofOral and Tracheal Secretions (3a)
  • Care of Equipment
  • Maintain endotracheal tube cuff pressure at
    desired level (usually 20 cmH2O)

15
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

16
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.

17
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.

18
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.

19
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.

20
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.
21
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

22
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.
23
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.
24
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

25
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

26
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

27
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

28
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

29
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

30
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)

31
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
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