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
 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:
 Staph Aureus (both MSSA and MRSA)
 Streptococcus
 Gram negative:
 Pseudomonas
 Acinetobacter
 Klebsiella
 Others:
 Candida/Aspergillus
 Viruses (rare)
 WHO GETS VAP?
Host Environment
 People being Age Intubation
mechanically Sex (M>F) Length of
ventilated (Both ETT Underlying ventilation

and tracheostomy) disease Tube cuff pressure

state Reintubation
 Risk factors: (chronic Sedation
disease,
Body postion*
conscious
level, sepsis Use of gastric
etc) protection*
NG feeding
Unit hygiene*
 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/1927
6975
 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