Rev: 17 January 2019

Ventilator Associated Pneumonia Diagnosis of VAP was covered in the previous discussion Rev: 17 January 2019

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 Rev: 17 January 2019

Handwashing Strict handwashing before and after handling patient or patient’s equipment or supplies Rev: 17 January 2019

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 Rev: 17 January 2019 Drakulovic MB. Lancet.1999;354:1851-1858.

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%: p=0.003) Confirmed VAP: 5% 23% (CI for difference 4-32%: p=0.018) Rev: 17 January 2019 Drakulovic MB. Lancet.1999;354:1851-1858.

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 Rev: 17 January 2019 Drakulovic MB. Lancet.1999;354:1851-1858.

Positioning DO’s and DON’Ts Maintain HOB > 30 degrees unless contraindicated. Leave patient in supine position for prolonged periods http://www.engin.umich.edu/alumni/engineer/03SS/protective/ Forget to turn tube feedings off prior to placing patient in supine position http://www.rtmagazine.com/Articles.ASP?articleid=r0202F03 Continue Q 2 hour turning schedule.  Rev: 17 January 2019 http://www.tccd.edu/neutral/DivisionDepartmentPage.asp?pagekey=191&menu=1

Rev: 17 January 2019 Picture from Sage

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. Rev: 17 January 2019

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 26:301-308. Rev: 17 January 2019

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 Rev: 17 January 2019

Management of Oral 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 Rev: 17 January 2019

Management of Oral and Tracheal Secretions (3a) Care of Equipment: Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O) Rev: 17 January 2019

Management of Oral 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 Rev: 17 January 2019

Management of Oral 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 patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper or towel. Rev: 17 January 2019

Management of Oral 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 patient’s 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. Rev: 17 January 2019

Management of Oral 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 patient’s 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. Rev: 17 January 2019

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 patient’s 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. Rev: 17 January 2019

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 (p=0.004) Rev: 17 January 2019 Kress JP. N Engl J Med. 2000; 342: 1471-1477.

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 Rev: 17 January 2019

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. Rev: 17 January 2019

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. Rev: 17 January 2019

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 Rev: 17 January 2019

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 Rev: 17 January 2019

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 Patient positioning Oral Care Daily “Sedation Vacation” General measures to improve Critical Care Peptic ulcer disease prophylaxis Deep vein thrombosis (DVT) prophylaxis Rev: 17 January 2019

Summary: Consider 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 Rev: 17 January 2019

Summary: Consider 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 Rev: 17 January 2019

Summary: Consider 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 Rev: 17 January 2019

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) Rev: 17 January 2019

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.1999;354:1851-1858 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. 1998;26:301-308. 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. 2004;53 (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. 2005;171:388-416. Garcia R. Addressing JCAHO’s Patient Safety Goal #7: Focus on Key HICPAC Strategies for the Prevention of VAP. Brookdale University Medical Center, Brooklyn, NY:APIC Seminar; 2004 Rev: 17 January 2019