1. VENTILATOR CARE BUNDLE
Wan Ahmad Asyraf bin Wan Md Adnan
Moderator: Dr Nik Azman bin Nik Adib

2. Introduction
Problems with Ventilation
Ventilator Care Bundle
Conclusion
References

3. Introduction
Intensive care patients are almost always synonymous with ventilation
It has been proven to help in managing patients in critical care settings
Unfortunately, ventilator patients are at high risk of developing several serious complications.

4. Problems with Ventilation
Multiple serious complications may arise in ventilated patients
These include:
Ventilator associated pneumonia
Venous thromboembolism (VTE)
Stress-induced gastrointestinal bleeding

5. Ventilator Associated Pneumonia
Complications
Ventilator Associated Pneumonia
Life threatening complications, associated in up to 50% of ventilated patients
Mortality rate 2-3 times more
Definition:
Pneumonia occurring more than 48 hours after patients have been intubated and received mechanical ventilation

6. Ventilator Associated Pneumonia
Complications
Ventilator Associated Pneumonia
Clinical criteria for suspicion
New or persistent infiltrate on CXR
Plus 2 of the following
Purulent endotracheal secretions
Increasing oxygen requirements
Core temperature > 38.0 C
TWC < 3.5 or > 11.0
Diagnosis
Endotracheal aspirate
Diagnostic bronchoscopy

7. Ventilator Associated Pneumonia
Complications
Ventilator Associated Pneumonia
Early vs late VAP
Bacteriology
Early: susceptible gram negative bacteria
Late: higher chances of multiresistant organisms
Prognosis:
Early: less severe
Late: higher mortality and morbidity
Risk factors
Pulmonary disease, sepsis, major surgery, multiorgan failure, enteral nutrition, GI prophylaxis, positioning, reintubation, paralytic agent

8. Ventilator associated pneumonia
Complications
Ventilator associated pneumonia
Common mechanisms by which VAP develops:
Aspiration of secretions
Colonisation of the aerodigestive tracts
Use of contaminated equipment

9. Venous thromboembolism
Complications
Venous thromboembolism
High prevalence of VTE
Most patients in hospital have risk factors for VTE (critical care patients have higher risks)
DVT and PE are usually clinically silent in hospital settings (even more silent in ventilated patients)
Difficult to predict
Screening at-risk patients is not effective and will involve high cost

10. Venous thromboembolism
Adverse consequences
Increase mortality
High cost of investigations
Cost of treatment for DVT and PE
Risk of recurrence
Significant mortality and morbidity due to VTE in critically ill patients
For example: pulmonary embolism
Between 7 to 27% of death in ICU may have been caused or contributed by PE (based on post mortem examinations)
Out of those number, only 30% has clinical suspicion of PE

11. Stress-induced gastrointestinal bleeding
Complications
Stress-induced gastrointestinal bleeding
Critically ill patients are at higher risk of developing stress ulcer
In addition to premorbid risk factors which they already have
Incidence of overt gastrointestinal bleeding in ICU patients is estimated to range from %
As high as 15% if no prophylaxis were given

12. Others Cumulative cost of all the complications
Increased length of stay in intensive care
Higher direct cost for treatment
Increased bed occupancy rate

13. Ventilator Care Bundle
a set of individual components, combined to make a set of quality indicators for a specific system, procedure or treatment
Examples:
Ventilator care bundle, sepsis bundle, central venous line bundle
Individual components improve care
Even greater improvement when applied together
‘standard of care’
Ventilator care bundle
Designed to minimise complications which may arise when patients are on ventilator
Guidelines tend to be long policy, whilst bundle meant to be short, simple and easier to implement

14. Ventilator Care Bundle
4 key components (according to MRIC)
Head of bed
% of patients nursed with the head of bed at least 30 degrees
Sedation vacation
% of patients who have had their sedation held within the last 24 hours
Peptic ulcer (PU) prophylaxis
% of patients receiving PU prophylaxis within 24 hours of admission
VTE prophylaxis
% of patients receiving prophylaxis within 24 hours of admission
Some studies added an extra component to this bundle later on
Daily oral care
Reference: MRIC (malaysian registry of intensive care)

16. Ventilator care bundle
Head of bed
Maintain patients in a semi recumbent position (minimum 30 degrees)
To minimise aspiration of gastric contents, oropharyngeal or nasopharyngeal secretions (associated with VAP)
67% reduction in VAP among patients maintained in semirecumbent positions during the first 24 hours of mechanical ventilation
RCT published in 1999 (Drakulovic et al): significantly lower incidence of VAP in patients in semi recumbent positions (c.f. supine position)
26% absolute risk reduction of clinically suspected nosocomial pneumonia
18% absolute risk reduction in aspiration penumonia
Improve ventilation
Spontaneous mode: diaphragm moves easier during inspiration as abdominal contents are lower in the cavity
Mandatory mode: minimise atelectasis
67% reduction: in multivariate study published in JAMA in 1993

17. Head of bed Exclusion criteria
Ventilator care bundle
Head of bed
Exclusion criteria
Patient on high dose of vasopressors/inotropes
Intraaortic balloon pump
Spine instability,
Pelvic instability
Compromised circulation (femoral lines)
Agitated (risk of falling out of bed)

20. Sedation vacation Sedation
Ventilator care bundle
Sedation vacation
Sedation
Fundamental part intensive care
Enables application of mechanical ventilation
Less distress
Different drugs used in ICU for that purpose
Benzodiazepines
Opioid
Propofol
Ketamine
Dexmedetomedine

21. Ventilator care bundle
Sedation vacation
Discontinuation of sedation after very prolonged infusion
frequently resulted in ‘hangover’ effect
Longer than expected time to wake up
Prospective observational study (1998)
Continuous IV sedation associated with prolongation of mechanical ventilation (compared to bolus IV sedation or no sedation)
Kollef et al (1998): single adult ICU, only benzodiazepines were primarily used

22. Ventilator care bundle
Sedation vacation
Aim: to minimise duration of mechanical ventilation (eventually reducing the risk of VAP)
Periodic sedative interruptions
Daily assessment of readiness to extubate
RCT published in 2000 (Kress et al):
Daily interruption resulted in significant reduction of mechanical ventilation time (7.3 days to 4.9 days)

23. Ventilator care bundle
Sedation vacation
“Withhold sedatives every morning at 8 am except in patients requiring continuous deep sedation. Analgesics should be continued for patients requiring pain relief.”
Exceptions:
Patients on cerebral protection, severe sepsis, ARDS, prone positions, on muscle relaxant infusions
Risk:
Increased potential for self extubation
Pain & anxiety

25. Peptic ulcer prophylaxis
Ventilator care bundle
Peptic ulcer prophylaxis
Critically ill patients on mechanical ventilation have an increased risk of ‘stress ulcers’ which may progress to gastrointestinal bleeding
Associated with five-fold increase in ICU mortality
Rationale for prophylaxis
Reduce volume of gastric juice
Increase pH of gastric contents
Acidic content aspiration has a greater pulmonary inflammatory response

26. Peptic ulcer prophylaxis
Ventilator care bundle
Peptic ulcer prophylaxis
When to start?
Mechanical ventilation
Coagulopathy
Hypoperfusion state, organ dysfunction
Severe head injury, spinal cord injury
Severe burns
High dose corticosteroids
Patients who are not fed with 2 risk factors of peptic ulcer (NSAIDs, steroids, previous history)

27. Peptic ulcer prophylaxis
Ventilator care bundle
Peptic ulcer prophylaxis
Which medications?
Sucralfate (vs H2 receptor antagonist) seems to have the upper hand initially
Lower risk of late-onset VAP
4% higher risk of clinically significant bleeding
Maintain normal gastric pH (lower GNB colonisation)
H2 receptor antagonist has gained more popularity later on
Based on double blind RCT published in 1998
Lower risk of bleeding as compared to sucralfate
With no significant difference in the rates of VAP, duration of stay in ICU and mortality
Proton pump inhibitor
Unknown relative efficacy as prophylaxis (equivalent ability to increase gastric pH as compared to H2 receptor antagonist)
Used in proven ulcers or already on PPI treatment
Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. A randomized controlled trial. (1994)
-sucralfate: lower risk of VAP, higher risk of bleeding)
Multicenter prospective study of ventilator-associated pneumonia during acute respiratory distress syndrome. Incidence, prognosis, and risk factors. ARDS Study Group.
-higher risk of VAP with sucralfate
Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers. The role of gastric colonization. (1987)
-GNB colonisation (associated with higher pH) more frequent in patients receiving H2 receptor antagonist and antacids (as compared to sucralfate)

28. Peptic ulcer prophylaxis
Ventilator care bundle
Peptic ulcer prophylaxis
Dosage
Ranitidine
IV 50mg tds (bd dose in renal failure)
Oral 150mg bd (od dose in renal failure) once enteral feeding established
Pantoprazole
Active UGIB: Loading IV 80mg, then infusion 8mg/hr (over 48-72H)
Unclear associations between peptic ulcer prophylaxis and decreasing rates of VAP
Based on experience, VAP rates decrease precipitously when PUD prophylaxis is applied as part of interventions for ventilator care

29. VTE prophylaxis Rationale for prophylaxis: Risk factors
Ventilator care bundle
VTE prophylaxis
Rationale for prophylaxis:
High prevalence
Preventable adverse consequences
Efficient and effective
Risk factors
Before admission
Surgery, trauma, burns, malignancy, sepsis, immobilisation (stroke, cord injury), pregnancy, previous VTE
Acquired in ICU
CVL, sepsis, sedation and paralysis, mechanical ventilation

30. VTE prophylaxis Systematic review in 2001:
Ventilator care bundle
VTE prophylaxis
Systematic review in 2001:
Within 1st week of ICU admission, about 10-30% develop DVT
Unfractionated heparin (UFH) reduces incidence of DVT by 20%
Low molecular weight heparin (LMWH) decrease the incidence by a further 30%
Attia et al (2001): DVT and its prevention in critically ill adults

31. VTE prophylaxis

32. VTE prophylaxis Pharmacological modalities Withhold... Low dose UFH
Ventilator care bundle
VTE prophylaxis
Pharmacological modalities
Low dose UFH
LMWH
Fondaparinux sodium (pentasaccharide Factor Xa inhibitor)
Withhold...
Significant decrease in platelet count (30 – 50%)
Thrombocytopenia (< 50,000/mm3)
INR / aPTT ratio > 1.5

33. VTE prophylaxis Mechanical prophylaxis
Ventilator care bundle
VTE prophylaxis
Mechanical prophylaxis
Enhance effectiveness of pharmacological use
Conside when pharmacological use is contraindicated
Unclear associations between VTE prophylaxis and decreasing rates of VAP
VAP rates decrease precipitously when VTE prophylaxis is applied as part of interventions for ventilator care

35. Ventilator care bundle
Daily oral care
Chlorhexidine has long been proven as an inhibitor of dental plaque formation and gingivitis
Important adjunct to oral hygiene
Meta-analysis published in 2007
Oral decontamination using chlorhexidine in ventilated adults is associated with lower risk of VAP
Rationale:
Reduces bacteria in oral mucosa, thus decreasing the potential of bacterial colonisation in the upper respiratory tract

36. Ventilator care bundle
Compilations of measures
When applied together, can potentially minimise rates of VAP and other complications associated with ventilation
Considered as standard of care for every patients on mechanical ventilator
Failure of which will be considered as being negligent towards patient’s care

37. Summary What do I want if that ICU patient is me?
If you decide to intubate and ventilate me, please keep head of bed elevated (at least 30 degrees)
No unnecessary sedation for me
Kindly prescribe IV ranitidine
Do not make me starve, start early feeding
Please give me some kind of DVT prophylaxis
Gently wash my mouth with chlorhexidine rinse
Extubate me as soon as possible, when I’m ready
And do not forget to wash your hand before/after touching me

39. References
Malaysian Registry of Intensive Care,
Management Protocols in ICU 2012, Malaysian Society of Intensive Care, August 2012.
Institute for Healthcare Improvement,
Reducing Harm in Critical Care,
Zap the VAP Initiative.
Susan et al, Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals, Infection Control and Hospital Epidemiology. October 2008
Steven et al, Ventilator-Associated Pneumonia: Diagnosis, Treatment and Prevention, Clinical Mirobiology Reviews. October 2006
The Canadian Critical Care Trials Group, A Randomized Trial of Diagnostic Techniques for Ventilator-Associated Pneumonia, The New England Journal of Medicine. December 2006.
Mitra et al, Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial, Lancet. 2009
John et al, Daily Interruptions of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation, The New England Journal of Medicine. December 2000.
Deborah et al, A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation, The New England Journal of Medicine. December 1998.
Paul et al, Stress ulcer prophylaxis in the new millenium: A systematic review and meta-analysis, Critical Care Medicine. 2010