Ventilator Care Bundle

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Ventilator Care Bundle
Assignment Critical care Nursing OUM

• Dr. S.N. Silva
• (MBBS)

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VENTILATOR ASSOCIATED PNEUMONIA
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AIMS AND OBJECTIVES

• To present a clinical case illustrating the
  problem of ventilator-associated pneumonia (VAP)
• To discuss the diagnosis and management of VAP,
  along with a review of the evidence
• To highlight controversies in dealing with VAP

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CASE PRESENTATION

• BB 73 M
• Presented to SMH with 10/7 history of
  laryngitis
• Cough/SOB/Fever

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CASE PRESENTATION

• PMHx
• Prostate Ca
• Bilateral TKRs for OA
• Hypertension
• DHx
• Antihypertensives
• Zoladex
• NKDA

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CASE PRESENTATION

• Initially managed on medical ward
• However, deteriorated 1/7 into admission
• Tachycardia/hypotension/tachypnoea
• Transferred to ICU, deteriorated further
• Intubated
• Ventilated. Needing high FiO2/PEEP
• Inotropic support
• Broad spectrum antibiotics
• Over 2/52, gradual improvement. Antibiotics
  stopped

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CASE PRESENTATION

• Improving- FiO2 now 40, PEEP 8
• Tracheostomy for weaning
• Then deterioration
• FiO2 60 to maintain PO2 8
• Tachypnoea
• Pyrexia

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???
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WHAT IS VAP?

• Er, noone really knows
• Suggested diagnostic criteria
• New CXR changes and one of
• Fever
• Leukocytosis
• Increasingly purulent secretions
• 48 hours or longer after institution of
  mechanical ventilation
• Confirmation by microbiological sampling
  (BAL/tracheal brushings)

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WHAT IS VAP?

• Wide range of organisms
• Gram positive
• Staph Aureus (both MSSA and MRSA)
• Streptococcus
• Gram negative
• Pseudomonas
• Acinetobacter
• Klebsiella
• Others
• Candida/Aspergillus
• Viruses (rare)

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WHO GETS VAP?
Host Environment
Age Sex (MgtF) Underlying disease state (chronic disease, conscious level, sepsis etc) Intubation Length of ventilation Tube cuff pressure Reintubation Sedation Body postion Use of gastric protection NG feeding Unit hygiene

• People being mechanically ventilated (Both ETT
  and tracheostomy)
• Risk factors

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WHY IS IT IMPORTANT?

• We see it all the time (27 of ICU patients)
• Mortality 27-76 (!)

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WHY IS IT IMPORTANT?
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WHAT SHOULD WE DO?

• Identify the at risk patient
• Reduce the risks
• Rapidly diagnose VAP when it occurs
• Treat appropriately

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REDUCING THE RISKS

• Care bundles
• Series of intervention grouped together as a
  single one
• Worked well with central venous catheters
  (Matching Michigan)

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REDUCING THE RISKS

• Elevation of bed 30-45 degrees
• DVT prophylaxis
• Humidification
• Oral hygiene/chlorhexidine mouthwash
• Gastric ulcer prophylaxis
• Appropriate ventilator tubing management
• Suctioning of oropharyngeal secretions
• Sedation holding/review

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REDUCING THE RISKS (Extra stuff from Europe)

• Microbiological surveillance
• Low nursepatient ratio
• Reduce antimicrobial prescriptions
• Orotracheal tubes/orogastric tubes
• Maintaining ETT cuff pressure gt20cmH20
• Subglottic aspiration
• Antiseptic coated ETTs

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ORAL DECONTAMINATION WITH CHLORHEXIDINE

• Simple
• Cheap
• Quite safe
• Makes sense

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SELECTIVE DIGESTIVE DECONTAMINATION

• Similar principle, but involves using oral
  decontamination NG tube antibiotics IV
  antibiotics in a variety of recipes
• Same principle as above

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GASTRIC ULCER PROPHYLAXIS

• Reduces risk of ventilator associated stress
  ulcers
• But INCREASES risk of VAP
• What to do?

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GASTRIC ULCER PROPHYLAXIS

• No single strategy of stress ulcer prophylaxis
  is preferred when mortality is used as the
  outcome. In the absence of a clinical trial
  demonstrating survival benefit the individual
  clinician's assumptions regarding the effect of
  prophylaxis on gastrointestinal bleeding and
  pneumonia and the attributable mortality of
  pneumonia vs. gastrointestinal bleeding will have
  a significant effect on the decision.

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RAPID DIAGNOSIS

• Sensitivity 77, specificity 42
• ?
• Other biomarkers being searched for- none yet
• (Procalcitonin/CRP useful treatment monitors, but
  not so useful for diagnosis)

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RAPID,SPECIFIC TREATMENT

• Start treatment early when suspected
• Broad-spectrum antibiotic (with antipseudomonal
  activity) /- aminoglycoside recommended

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Assignment

• Define terms
• VCB ?
• VAP OUM has done
• Critically ill patient - ?
• Critically ill patient with VAP

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Then..

• Discuss using VCB
• Significance of using VCB
• Critically Discuss VCB

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Ventilator Associated Pneumonia

• Multiple factors should be considered when
  addressing the issues of HAP and VAP. These
  factors include the following
• Whether or not to intubate the patient
• The route of intubation or placement of tubes
• Feeding the patient
• Body positioning
• Prevention of stress-related bleeding
• Prevention of deep venous thrombosis
• Use of antibiotics and control of colonization
• http//emedicine.medscape.com/article/304836-overv
  iew

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Ventilator Associated Pneumonia

• Who / When/ What?
• http//www.ncbi.nlm.nih.gov/pmc/articles/PMC159269
  4/
• While critically ill patients experience a
  life-threatening illness, they commonly contract
  ventilator-associated pneumonia. This nosocomial
  infection increases morbidity and likely
  mortality as well as the cost of health care.
  This article reviews the literature with regard
  to diagnosis, treatment, and prevention. It
  provides conclusions that can be implemented in
  practice as well as an algorithm for the bedside
  clinician and also focuses on the controversies
  with regard to diagnostic tools and approaches,
  treatment plans, and prevention strategies.

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Significance

• The application of the VAP bundle in chronic
  ventilated patients resulted in a significant
  reduction in the incidence of VAP.
• http//ccforum.com/content/12/S2/P433

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Significance

• Initiation of the VAP bundle is associated with
  a significantly reduced incidence of VAP in
  patients in the SICU and with cost savings.
• http//apicwv.org/docs/40.pdf

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Critically?

• The ventilator bundle should be modified and
  expanded to include specific processes of care
  that have been definitively demonstrated to be
  effective in VAP reduction or a specific VAP
  bundle created to focus on VAP prevention.
• http//www.ncbi.nlm.nih.gov/pubmed/19276975

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Critically ?

• Individual elements did not appear
• effective strict compliance with infection
  elements was needed. Efforts to prevent VAP may
  be successful in settings of high
• levels of compliance with all infection-speci?c
  elements and in settings with full-time HEs.
• http//www.cumc.columbia.edu/studies/pnice/pdf/Pog
  orzelska.pdf

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