Ventilator Care Bundle Assignment – Critical care Nursing OUM Dr. S.N. Silva (MBBS)

VENTILATOR ASSOCIATED PNEUMONIA

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

CASE PRESENTATION BB 73 M Presented to SMH with 10/7 history of “laryngitis” Cough/SOB/Fever

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

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

CASE PRESENTATION Improving- FiO2 now 40%, PEEP 8 Tracheostomy for weaning Then deterioration: FiO2 60% to maintain PO2 8 Tachypnoea Pyrexia

???

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)

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

WHO GETS VAP? Host Environment Age Sex (M>F) 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:

WHY IS IT IMPORTANT? We see it all the time (27% of ICU patients) Mortality 27-76% (!)*

WHY IS IT IMPORTANT?

WHAT SHOULD WE DO? Identify the at risk patient Reduce the risks Rapidly diagnose VAP when it occurs Treat appropriately

REDUCING THE RISKS “Care bundles” Series of intervention grouped together as a single one Worked well with central venous catheters (“Matching Michigan”)*

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

REDUCING THE RISKS (Extra stuff from Europe) Microbiological surveillance Low nurse:patient ratio Reduce antimicrobial prescriptions Orotracheal tubes/orogastric tubes Maintaining ETT cuff pressure >20cmH20 Subglottic aspiration* Antiseptic coated ETTs*

ORAL DECONTAMINATION WITH CHLORHEXIDINE Simple Cheap Quite safe Makes sense

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

GASTRIC ULCER PROPHYLAXIS Reduces risk of ventilator associated stress ulcers… But INCREASES risk of VAP What to do?

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”.

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

RAPID,SPECIFIC TREATMENT Start treatment early when suspected Broad-spectrum antibiotic (with antipseudomonal activity) +/- aminoglycoside recommended

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

Then….. Discuss using VCB Significance of using VCB Critically Discuss VCB

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-overview

Ventilator Associated Pneumonia Who / When/ What? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592694/ 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.

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

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

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

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-specific elements and in settings with full-time HEs.” http://www.cumc.columbia.edu/studies/pnice/pdf/Pogorzelska.pdf