VAP, not on my WATCH !!!

1. VAP, not on my WATCH !!! France Ellyson ANM, MNH ICU Kuwait 2014

2. http://www.youtube.com/watch?v=RueE4or4rMU

3. Introduction Mechanical ventilator is one of the most important life saving devices used in conditions like: • Respiratory failure • Protection of airway • Head injury • Postoperative • Shock

4. What is Ventilator Associated Pneumonia? • A nosocomial pneumonia associated with mechanical ventilation (either Endotracheal tube or Tracheostomy) that develops within 48 hours or more of hospital admission and which was not present at time of admission. • Now considered a PREVENTABLE HEALTHCAREERROR National institute of health excellence (NICE) -2007 center for disease control and prevention

5. What is VAP? • Pneumonia that occurs at least 2 days after a patient is intubated (CDC GUIDELINES) • The presence of the ET-tubes leads to VAP (not the ventilator) • VAP rate increases with the # of days on mechanical ventilation • Mortality varies according to the type of organisms • Multi-resistant organisms have a higher mortality

6. Epidemiology • Hospital acquired pneumonia (HAP) is the second most common hospital infection. • VAP is the most common Intensive Care Unit (ICU) infection. • 90% of all nosocomial infections occuring in ventilated patients are pneumonias. • Causes more death than any of the other healthcare associated infection

7. Incidence • VAP occurs in 10-20% of all ventilated patients Crit Care Clin (2002) • Incidence increases with duration of MV: 3%/day for first 5 days, 2%/day for 6-10 days and 1%/day after 10 days. • The incidence of VAP is highest in the following groups: Trauma, burns, neurosurgical post-op pts • Mortality rate is 37% and 43% with antibiotic resistant organism Critical Care Societies Collaborative (CCSCs)

8. Incidence Cont…. • Increases ventilatory support requirements and ICU stay by 4.3 days • Increases hospital LOS (length of stay) by 4 to 9 days • Increases medical cost ($5,000 to $40,000 per VAP) Critical Care Medicine 2005;33:2184-93

9. Causative Organisms: Early onset Late onset • Hemophilus influenza • Streptococcus pneumoniae • Staphylococcus aureus (methicillin sensitive) • Eschrichia coli • Klebsiella • Pseudomonas aeruginosa • Acinetobacter • Staphylococcus aureus (methicillin resistant)

10. How is the pneumonia happening? • Most plausible mechanism and source: • Leakage around the ETT cuff (primary route)… aspiration of bacteria • High rate of the oropharyngeal or tracheobronchial colonization (gram neg bacilli) • Bacteria from the tongue • Bacteria from environment: caregivers’ hand, air, water, dust • Contaminated equipment (ventilator tubing, aerosol, etc.) • Suctioning equipment

11. Risk Factors: Host Related • Medical / surgical disease • Immunosuppression • Malnutrition (Alb<2.2g/dl) • Advanced age • Pt’s position (supine) • LOC – impaired LOC, delirium, coma • Medications – sedation, steroids, previous antibiotic use, NM blockers • Number of intubations- reintubations

12. Risk Factors: Device Related • Mechanically ventilated with ETT or Tracheostomy tube • Prolonged MV - MV > 48 hours • Number of intubations, reintubations • NGT or Orogastric tube • Use of humidifier

13. Risk Factors: Health Care Personnel Related • Improper hand washing • Failure to change gloves between contacts with pts • Failure to wear personal protective equipment when required

14. Pathogenesis Bacteria enter the lower respiratory tract via following pathways: • Aspiration of organisms from the oropharynx and GI tract (most common cause) • Direct inoculation • Inhalation of bacteria

15. Aspiration ETT/T NGT/OGT • Holds vocal cords open • Predispose pt to micro and macro aspiration of colonized bacteria from oropharynx • Leakage of secretions containing bacteria around ETT cuff • Interrupts gastro-esophageal sphincter leading to GI reflux and aspiration • Increase oropharyngeal colonization and stagnation of oropharyngeal and nasal secretions

16. A New Streamlined Surveillance Definition for Ventilator-Associated Pneumonia Critical Care Med 2012 vol.40, no.1

17. Any one of the following: • NO CONSENSUS AMONG PHYSICIANS!!!

18. How do we Diagnose? 2-1-2 Radiologic evidence X 2 Consecutive days • New, progressive or persistent infiltrate • Consolidation, opacity or cavitation

19. How do we diagnose? 2-1-2 Clinical Signs: At least 1of the following: • Fever > 38 °C with no other recognized cause • Leukopenia (<4,000 WBC/mm3) or leukocytosis (>12,000 WBC/mm3)

20. How do we Diagnose? 2-1-2 At least 2 of the following: • New onset of purulent sputum or change in character of secretions • New onset or worsening cough, dyspnea or tachypnea • Rales or bronchial sounds • Worsening gas exchange (decreased sats, increased oxygen requirements)

21. Treatment Protocol • Start when VAP is suspected • Do not delay • Individualized to institution – Hospital epidemiologic data, drug cost and availability • Individualized to pt - Early onset vs Late onset of VAP, prior antibiotic use, underlying disease, renal, liver, etc • Surveillance cultures

22. Duration of Treatment • Standard duration 7-14 days • Longer duration > 14-21 days risk of toxicity and resistance • Shorter < 7 days risk of recurrence • Depends on severity • Isolation of microorganism

23. Prevention • Specific practices have been shown to decrease VAP • Strong evidence that a collaborative, multidisciplinary approach incorporating many interventions is paramount • Intensive education directed at nurse and respiratory care practitioners resulted in a 57% decrease in VAO Crit Care Med (2002)

24. The VAP Bundle BUNDLE • “Group of evidence based interventions that whenever implemented together result in better outcomes”

25. Introduction of VAP BUNDLE • Elevation of HOB to between 30-45° • Daily sedative interruption and daily assessment of readiness to extubate • The utilization of endotracheal tubes with subglottic secretion drainage (Not at MNH yet) • Stress ulcer disease prophylaxis – including initiation of safe enteral nutrition within 24-48 hours of ICU admission • IN 2010 5TH COMPONENT of Daily oral care and decontamination with Chlorhexidine Crit.Care 2012 vol.40, no.1

26. Additional Evidence-Based Component of Care: HANDWASHING • Single most important and ( easiest!!) method for reducing the transmission of pathogens • Use of waterless antiseptic preparations is acceptable and may increase compliance

27. HOB 30-45° • HOB 30-45° unless contraindicated • Especially recommended for Neuro population • To prevent aspiration during enteral feeding 

28. Daily sedative interruption and daily assessment of readiness to extubate OVERSEDATION predisposes pts to: • Thromboemboli • Pressure ulcers • Gastric regurgitation and aspiration • VAP • Sepsis

29. Daily sedative interruption and daily assessment of readiness to extubate OVERSEDATION predisposes pts to: • Difficulty in monitoring neuro status • Increased use of diagnostic procedures • Increased ventilator days • Prolonged ICU and Hospital stay

30. Daily Wake-up • Every pt must be awakened daily unless contraindicated • Daily weaning assessments reduce the duration of MV • If pt becomes symptomatic – rebolus and restart infusion at lower dose than original dose • Goal is to decrease sedation

31. Stress Ulcer Prophylaxis • Sucralfate, H2 receptor blocker and proton pump inhibitor – increases gastric ph and minimize bacterial colonization and reduces risk of VAP

32. Enteral Feedings • Initiation of safe enteral nutrition within 24-48 hours of ICU admission • Early initiation decreases bacterial colonization • HOB 30-45° • Routinely + PRN verification tube placement

33. Additional Evidence-Based Component of Care: • Deep venous thrombosis (DVT) prophylaxis (unless contraindicated) • TED stockings • SCD machine • Heparin S/C

34. Deep venous Thrombosis Prophylaxisand early mobility practices • Pt turning Q 2hours increase pulmonary drainage and decreases risk VAP • Early mobilization

35. Daily Oral care • Oral assessment Q shift • Brushing teeth, tongue and gums with a soft toothbrush (minimally twice daily) • Moisturizing agent for mouth • Antiseptic rinse • Swabs are not effective at removing plaques • Chlorhexidine decontamination of mouth • Routine suctioning of mouth to manage oral secretions and minimize risk of aspiration

36. Sage Oral Care Products

37. http://www.youtube.com/watch?v=MYO_MddtYNs

38. Mouthcare • Using chlorhexidinegluconate 0.12% (Peridex) solution every 6-12 hours to perform oral care, according to your protocol • solution is used to rinse the patients’ mouth.

39. ET Tube Care • Cuff pressure (between 20-30cm H2O) • Oral intubation preferred • Continuous or intermittent sub-glottic aspiration • Avoid unnecessary disconnection of MV circuit • Open vs close suctioning… benefits is not demonstrated yet

40. Prevent micro-aspiration of secretions • 100-150ml of oral secretion can accumulate in patient mouth in 24hrs • Mouth can colonize as quickly as 24hr after admission • Intermittent and continuous subglottic suctioning • Suctioning of the mouth before position change

41. Suctionning of Oral Secretions • Suction oropharyngeal secretions Q 2hours, before repositionning, before suctionning ETT, before mobilizing patient and PRN • Gently follow tongue to suction back of throat • Use yankauer suction

42. Suctioning Oral suction devices (Yankauer) • Follow policy for use and storage • ?Harbor potentially pathogenic bacteria within 24 hours • Date and change Q day • Rinse with sterile water after each use • Allow to air dry

43. Subglottal Suctioning Should be done using a 14 French sterile suction catheter • Prior to ETT suctionning • Prior to pt change of position • Prior to extubation * Continuous subglottic ETT with dedicated lumen above cuff may reduce risk of VAP

45. Prevent contamination of equipment • Ventilator tubing • Heat and moisture exchangers (green filters) are preferred over humidifiers (CDC B-II) • Sterile suctioning • Be careful with the tubing of the ventilator when you suction patient… • Remove contaminated condensate from ventilator circuit (CDC, A-II)

46. Summary • Nosocomial pneumonia and especially VAP are the most frequent infectious complications in the ICU, and they significantly contribute to morbidity and mortality • VAP is an important determinant of ICU and Hospital lengths of stay and healthcare costs • No standard to diagnose • Several simple preventative measures (VAP bundle) and timely initiation of appropriate antibiotics ensure better outcomes in pts with VAP

47. http://www.youtube.com/watch?v=Ehi2Vt8UdRc

48. References National Guideline Clearinghouse (current). Guideline Summary NGC-6634: Prevention of ventilator-associated pneumonia. Retrieved from: http://files.i-md.com/medinfo/material/f97/4eb0b88d44aece1112f7bf97/4eb0b8a944aece1112f7bf9a.pdf Niel-Weise, B. & all. (2011). An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Critical Care 2011, 15:R111. Postma, D.F., Sankatsing, S.U.C., Thijsen, S.F.T. & Enderman, H. (2012). Effetcs of chlorhexidine oral decomtamination on respiratory colonization during mechanical ventilation in intensive care unit patients. Infection Control and Hospital Epidemiology, vol 33 no.5, pp.527-530. Safer Healthcare now (2012). Ventilator associated pneumonia. Retrived from: http://www.saferhealthcarenow.ca/en/interventions/vap/pages/default.aspx Safer Healthcare now (2012). Getting Started Kit. Retrieved from http://www.saferhealthcarenow.ca/EN/Interventions/VAP/Documents/VAP%20Getting%20Started%20Kit.pdf

49. References Alhazzani, W. & all. (2013) Tooth brushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia. DOI: 10.1097/ccm.0b013e3182742d45 Center for Disease Control and prevention(2011). Improving Surveillance for Ventilator-Associated Events in Adults. Obtain from MUHC Infection Control Departement. Chan, E.Y., Ruest, A., Omeade, M. & Cook, D.J (2007). Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ, doi: 10.1136/bmj.39136.528160.BE Fagon, J-Y. (2011). Biological markers and diagnosis of ventilator-assocaited pneumonia. Critical Care 20111, 15:130. Koenig, S.M. & Truwit, J.D. (2006) Ventilator-assocaited pneumonia: diagnosis, treatment, and prevention. Clinical Microbiology Reviews, doi: 10.1123/CMR.00051-05 Hillier B. Wilson C. Chamberlain D. King L. (2013). Preventing ventilator-associated pneumonia through oral care, product selection, and application method: a literature review. AACN Advanced Critical Care. 24(1):38-58. Insitute for Healthcare Improvement (2011). IHI ventilator bundle: daily oral care with chlorhexidine. Retrieved from http://www.ihi.org/knowledge/pages/changes/dailyoralcarewithchlorhexidine.aspx