Resumen

Introduccin

Estada en la UCIN
Bajo peso al Nacer
Re intubaciones
Displasia Bronco
Pulmonar
Alimentacin Enteral
Intubacin
Traqueal
Ventilacin Mecnica
Transfusiones

Objetivos
The

objective of this study was to

examine the risk factors associated with
VAP, particularly 7-day versus 14-day
ventilator circuit changes, in the NICU.

Mtodos

Estudio Observacional Retrospectivo

All neonates with birth weight 2000 g admitted to the NICU

between January 2009 and June 2012 on a ventilator for 48 h
were included in the study.

The interval of ventilator circuit changes was changed from

every 7 days to every 14 days on July 1st, 2011 in the NICU at
Osaka Medical College Hospital.

Thus, period 1 with 7-day ventilator circuit changes was from

January 1st, 2009 to June 30th, 2011, and period 2 with 14-day
ventilator circuit changes was from July 1st, 2011 to June 30th,
2012

Mtodos

To establish the oral resident flora in neonates, the infants' mouths

were smeared with breast milk early after birth, and the neonates
were nursed with mother's milk as much as possible in our NICU.

Oral care was performed, and a closed system suction catheter for
multiple-time use was used in all cases [4,12]. Post-pyloric tube
feeding was used for enteral nutrition. if possible, because it has
been suggested that placement of a postpyloric tube can reduce
the risk of aspiration and VAP.

VAP was diagnosed by two pediatricians using criteria for 1- yearolds established by Foglia et al.

Mtodos: Criterios de VAP

Neonatal patients who are mechanically ventilated for more than or equal to
48 h must have new onset abnormal chest radiographs and worsening gas
exchange (oxygen desaturations, increased oxygen requirements, or
increased ventilator demand) and at least three of the following:

temperature instability with no other recognized cause;

new onset of purulent sputum, change in character of sputum, increased

respiratory secretions, or increased suctioning requirements;

apnea, tachypnea, nasal flaring with retraction of the chest wall, or grunting;
wheezing, rales, or rhonchi; cough; and bradycardia <100 b/min or
tachycardia (>170 beats/min).

Mtodos

First, to examine the incidence and risk factors associated with VAP, the
neonates were divided into groups with and without VAP, and univariate
logistic regression analysis and adjustments for other variables were performed.

Sex, Apgar score at 1 min, Apgar score at 5 min, body weight,

gestational age (GA), period 1 or 2, caesarean birth, days in incubator,
days with ventilator, and tube changes (times) were analyzed. Patients
with circuit changes because the circuit was visibly soiled or mechanically
malfunctioning were excluded.

Second, to examine the effect of the frequency of changing ventilator circuits

on the incidence of VAP, circuit changes every 7 days in period 1 and every 14
days in period 2 were compared. Patients on a ventilator for 14 days or more
were enrolled during the whole period.

Resultados

A total of 71 (31 in
period 1 and 40 in
period 2) neonates
hospitalized in the
NICU at Osaka Medical
College Hospital
between January 2009
and June 2012 was
enrolled.

Resultados

Most patients were premature, and all were in incubators and

treated with a ventilator. Body weight in 80% (57/71) of infants
was < 1500 g and GA in 62% was < 30 weeks

In the comparison between the with and without VAP groups,

body weight was significantly smaller in the with VAP group,
and days on ventilator and times of ventilator tube changes
were significantly greater in the with VAP group than in the
without VAP group.

Apgar scores at one minute tended to be lower in the with VAP

group than in the without VAP group

Resultados

Discusin

VAP is considered to be an important cause of infection-related

deaths in the ICU and is thought to have a negative effect on
patients' outcomes

Cernada reported that the incidence of VAP in neonates is

between 2.7 and 10.9 per 1000 ventilator days in developed
countries and may reach 37.2 per 1000 ventilator days in
developing countries

The rate of VAP per 1000 ventilator days was 8.44 in period 1,
and the rate of VAP per 1000 days was 9.88 in period 2 in the
present study; since both values were similar to those of
previous studies

Discusin

Yuan et al. reported that the risk factors for neonatal VAP
were re-intubation, duration of mechanical ventilation,
treatment with opiates, and endotracheal suctioning in their
retrospective cohort study

BW <626 g, ventilator use 26 days, and ventilator tube

change 1 time were significant predictors for VAP on
univariate analysis, and after adjustments for other
variables, only BW < 626 g was a significant independent
predictor for VAP in NICU patients in the present study

Discusin

Kollef et al. reported that eliminating routine ventilator circuit changes is

safe and cost-effective in adult patients on prolonged mechanical
ventilation [10]. In a meta-analysis, Han et al. reported that frequent
ventilator circuit changes are associated with a high risk of ventilatorassociated pneumonia in adults [13]. No routine circuit change is safe and
justified in adults

and, there is a small number of studies about VAP in neonates. It has been
reported that the 7-day ventilator circuit change did not contribute to
increased rates of VAP in the pediatric ICU in a prospective study [11].
Decreasing the frequency of ventilator circuit changes from every 7 days to
14 days had no adverse effect on the rate of VAP in the NICU in the present
study

Discusin

Strains cultured from VAP patients were S. aureus,

Staphylococci, P. aeruginosa, and others, which resembled
previous studies [15,19].

There are some limitations to this study.

First, this study was a retrospective, observational study,

Second, the sample size was small. Additional studies,

including multicenter, prospective studies, are necessary to
develop approaches for the prevention of neonatal VAP.

Conclusin

In conclusion,

body weight <626 g was a significant independent

predictor of VAP in NICU patients, and decreasing the
frequency of ventilator circuit changes from every 7 days
to every 14 days had no adverse effect on the rate of VAP
in the NICU.

Disclosures

The authors have no conflicts of interest to declare.

Acknowledgment

The authors would like to thank Shinya Ohue MD (Department of

Neonatal Pediatrics, Tokai University) for collection of useful clinical
data. The authors greatly appreciate the excellent assistance of Ms. T.
Takabayashi.

Criterios de VAP

Patients who are mechanically ventilated for more than or equal to 48 h must have two
or more abnormal chest radiographs with at least one of the following symptoms: new
or progressive and persistent infiltrate, consolidation, cavitation, and/or pneumatoceles
(in infants 1 year of age). However, in patients without underlying pulmonary or cardiac
disease (respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary
edema, or chronic obstructive pulmonary disease), one definitive chest radiograph is
acceptable. In addition to abnormal chest radiographs, a patient must have at least one
of the following symptoms: fever (38C) with no other recognized cause, leukopenia
(4,000 white blood cells [WBC]/mm3 ) or leukocytosis (12,000 WBC/mm3 ), and at least
two of the following criteria: new onset of purulent sputum, change in character of
sputum, increased respiratory secretions, or increased suctioning requirements; new
onset of or worsening cough, dyspnea, or tachypnea; rales or bronchial breath sounds;
and worsening gas exchange (e.g., O2 desaturations [e.g., PaO2/ FiO2 levels of 240],
increased oxygen requirements, or increased ventilation demand). T

The criteria described above may be used to diagnose VAP in children;

however, specific diagnostic criteria for VAP have been developed for
infants 1 year of age and children 1 and 12 years of age. Infants that
are 1 year old must have worsening gas exchange (oxygen
desaturations, increased oxygen requirements, or increased ventilator
demand) and at least three of the following criteria: temperature
instability with no other recognized cause; new onset of purulent
sputum, change in character of sputum, increased respiratory
secretions, or increased suctioning requirements; apnea, tachypnea,
nasal flaring with retraction of chest wall, or grunting; wheezing, rales,
or rhonchi; cough; and bradycardia (100 beats/min) or tachycardia
(170 beats/min). C