Table of Contents

Introduction ............................................................................................................................. 2 Indication ................................................................................................................................. 3 Four element of Ventilator care bundle (VCB) .................................................................. 4 Conclusion .............................................................................................................................. 5 References ............................................................................................................................. 6

VENTILATOR CARE BUNDLE

Introduction

Management of ventilator care bundle is to reduce the risk of Ventilatorassociated pneumonia (VAP) which is can can prevent from distress to patient, prolonged of stay, cost and increase higher rates of morbidity and mortality. Daily care bundle showed a positive results on compliance VAP. VAP is a nococomial infections that develops more than 48 hours after the patient intubated. Intubations can cause pneumonia after 48-72 hour and patient may get antibiotic resistant organisms. Ventilator associated pneumonia (VAP) is refers to nosocomial developing in a patient receiving mechanical ventilation 48 hours. VAP is diagnosed based on suspicion of VAP, chest X-rays shows new and or progressive pulmonary infiltrates, presence of either 2 of the following 4 criteria: Fever 38.5C or 36C within 24 hours Total white cell count >12 000/mm within 24 hours Purulent tracheobronchial secretions within 24 hours Reductions of PaO/fiO15% in the last 48 hours

Diagnosis is refers to the first episode of VAP. The definition of VAP does not require positive bacteriological culture. Tick the relevant organisms only if a diagnosis of VAP is confirmed. Positive culture is collection from tracheal aspirate, bronchoalveolar lavage or blood. Comman organism was found in positive culture is Methicillin resistant staphylococcus aureus (MRSA).

Prevention of VAP is a main concern within critical care patient because it is can reduce morbidity and mortality. High impact interventions (HIIs) were identified as the clinical procedures, mechanical ventilations is highest risk of causing a health care-associated infection. The original HII ventilation care bundle (2004) consisted of four elements: elevation of the head of the bed to 3045 degrees daily sedation hold; deep vein thrombosis (DVT) prophylaxis; gastric ulcer prophylaxis.

The first formal audit of the ventilator care bundle was completed in November 2004. It was performed within the Greater Manchester Critical Care Network and allowed comparison with the 11 other hospitals in the network. Our overall compliance with the bundle was 95.5%. This regional audit was performed again in April 2006 and our compliance was 95%. Both these studies showed DVT prophylaxis was the least adhered to (Westwell, S. (2008).

Indication

VCB is apply to patient with an integrated care pathway was first 24 hour of mechanical ventilation. Its aim was to standardize the treatment and care given to patients requiring mechanical ventilation regardless of where they were in the hospital. All elements of the VCB were incorporated within this document. This is for ensuring all elements of the bundle are performed; however, once the pathway ends there are no reminders to ensure good practice continues. This guideline important to the health care provider as knowledge base and the competency of the nurse in charge to ensure quality in the delivery of care. 3

Four element of Ventilator care bundle (VCB)

Elevation of the head of the bed to 30-45 degrees Patient with mecahanical ventilator is need to elevate of the head at least 3045 degrees to reduce the risk of VAP. Patients are at highly risk of aspiration of gastric contents when laid supine. Lay flat if attend procedure to patient such as position changes, venous access device insertion or removal or if sitting head up is contraindicated. Sedation holding Sedation holding also known as sedation vacations, sedation holidays or sedation interruption. Definition sedation vacation is discontinuation of sedative infusions until patients are awake on a daily basis. Sedation has been stopped for >4 hours. Discontinuation of sedative is to assess the readiness for weaning from mechanical ventilation. If patient over sedation or prolonged use of continuous infusion of a sedative agent may increased duration of ventilation, an increase in morbidity and mortality, prolonged ICU stay and possible increase in psychological distress. Reduction in the period of sedation was further facilitated by the introduction of spontaneous breathing trail guideline, which allows nursing and medical staff to assess a patients readiness for weaning and potential extubation. The guidelines implemented within the ICU allow an aggressive team approach to rapid weaning from mechanical ventilation. DVT prophylaxis 80% patients with Ventilator care bundle in an adult ICU may develop a DVT, leading to increased morbidity and mortality. Heparin has been used for many 4

years. This decreases the incidence of DVT by 50% in comparison with unfractionated heparin. DVT prophylaxis commonly use know is sc clexane, fundaparinux, heparin and........investigation of blood test especially platelet, PT APTT/INR to look for bleeding time before anticougulant drug prescribed. INR>1.5 or an APTT ratio>1.5. TED stoking and cuff pressure is use at the patient leg to prevent from DVT, also another altenative way to reduce a complication and return flow back of blood supplier from peripheral towards body. Peptic ulcer disease prophylaxis or treatment The risk of death secondary to significant gastrointestinal bleeding in critically ill patients who require mechanical ventilation and have a coagulopathy is increasingly. Early enteral feeding such as continous feeding, ryles tube feeding or TPN can significantly reduce the risk of gastric ulceration. Prevention of gastric ulceration in mechanical ventilated patients is necessary because of the increasing risk of mortality if complications. There is evidence which shows enteral feeding and lowering gastric pH by the use of gastric ulcer prophylaxis actually increases the risk oo VAP.Prescribing of prophylaxis such as ranitidine, omeperazole or pantoprazole

CONCLUSION

Daily continuous assessment from nurses and doctor may influnce early weaning of mechanical ventilation, prolonged stay, cost and morbidity and mortality. This practice can unneccasary if the results demonstrate poor hand hygiene compliance but the results can be taken as a feedback to the staff if raising awareness and directly improving practice. This checklist also refer from Serdang Hospital.

References

Westwell, S. (2008). Implementing a ventilator care bundle in an adult intensive care unit. Nursing In Critical Care, 13(4), 203-207. Retrieved from EBSCOhost.