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Decreasing VAP Risk in the ED

Decreasing VAP Risk in the ED

Ventilator-associated pneumonia (VAP) results in increased morbidity, mortality, and healthcare costs. Unfortunately, clinical evidence of VAP occurs 48 hours or more after intubation, meaning it manifests days after the disease process has begun in the ED. Efforts are needed to implement interventions to reduce VAP risk in the ED setting and to make prevention a higher priority. Prevention Strategies For Decreasing VAP There is compelling evidence that pre-hospital and ED intubation, as well as ED length of stay, are risk factors for the development of VAP, particularly in the trauma population. In the March 2012 Journal of Emergency Medicine, my colleagues and I had an article published that identified several strategies to help EDs reduce the risk of VAP: Backrest Elevation: Continuous backrest elevation of 30° to 45° is recommended for all intubated ED patients without contraindications. A collaborative effort is required to ensure compliance. Oral Care: Oral care strategies should be implemented in the ED as early as possible. These include a chlorhexidine application to the oral cavity immediately after intubation and every 12 hours thereafter. Endotracheal Tubes (ETTs): Reducing the use of ETTs with non-invasive ventilation strategies may reduce VAP incidence. Guidelines suggest that intubation should be avoided, if possible. Cuff Pressure Management: The movement of secretions from the oral cavity into the subglottic space and eventually into the lungs increases the risk of VAP. An effective ETT cuff seal may reduce secretion movement. ETT cuff pressure monitoring should be performed as soon as possible after intubation, and pressures should be maintained between 20 cm H2O and 30 cm H2O in the ED and continued at regular...

Society of Critical Care Medicine’s 2012 Annual Congress

New research was presented at the 2012 Society of Critical Care Medicine’s Critical Care Congress from February 4-8 in Houston. The features below highlight just some of the studies that emerged from the conference. >> Analyzing Short-Course Antibiotic Use for VAP >> Caloric Restrictions & Acute Lung Injury >> Assessing VTE Prophylaxis After Intracranial Hemorrhage Analyzing Short-Course Antibiotic Use for VAP The Particulars: Antibiotic treatment for ventilator-associated pneumonia (VAP) caused by organisms other than non–lactose-fermenting Gram-negative bacilli (NLFGNB) is typically stopped after 8 days. Data suggest that infections persist at Day 8 when VAP is caused by NLF-GNB. It is unknown if an 8-day course of antibiotics for NLF-GNB infection would be adequate or result in persistent primary infection. Data Breakdown: A retrospective review of 77 patients with VAP showed that persistent primary infection was present in 60% of patients with NLF-GNB infection after 8 days of antimicrobial therapy. Among those with NLF-GNB, only 56% of pathogens obtained on repeat bronchoalveolar lavage remained sensitive to the antimicrobial therapy. Take Home Pearls: An 8-day course of antimicrobial therapy for VAP caused by NLF-GNB infection appears to be insufficient. Study results suggest this course of treatment may result in persistent primary infection.  Caloric Restrictions & Acute Lung Injury The Particulars: Mechanically ventilated patients are generally provided some form of artificial nutrition, but the optimal nutritional strategy in critically ill patients is undetermined. Some studies suggest better outcomes with initial full enteral feeding, while others indicate that hypocaloric feeding improves short-term outcomes. Data Breakdown: A study of mechanically ventilated patients randomized participants to receive trophic feeding (400 kcal/ day) or full enteral...

Society of Critical Care Medicine’s 2012 Annual Congress

New research was presented at the 2012 Society of Critical Care Medicine’s Critical Care Congress from February 4-8 in Houston. The features below highlight just some of the studies that emerged from the conference.   » Analyzing Short-Course Antibiotic Use for VAP » Caloric Restrictions & Acute Lung Injury » Assessing VTE Prophylaxis After Intracranial Hemorrhage Analyzing Short-Course Antibiotic Use for VAP The Particulars: Antibiotic treatment for ventilator-associated pneumonia (VAP) caused by organisms other than non–lactose-fermenting Gram-negative bacilli (NLFGNB) is typically stopped after 8 days. Data suggest that infections persist at Day 8 when VAP is caused by NLF-GNB. It is unknown if an 8-day course of antibiotics for NLF-GNB infection would be adequate or result in persistent primary infection. Data Breakdown: A retrospective review of 77 patients with VAP showed that persistent primary infection was present in 60% of patients with NLF-GNB infection after 8 days of antimicrobial therapy. Among those with NLF-GNB, only 56% of pathogens obtained on repeat bronchoalveolar lavage remained sensitive to the antimicrobial therapy. Take Home Pearls:An 8-day course of antimicrobial therapy for VAP caused by NLF-GNB infection appears to be insufficient. Study results suggest this course of treatment may result in persistent primary infection. Caloric Restrictions & Acute Lung Injury [back to top] The Particulars: Mechanically ventilated patients are generally provided some form of artificial nutrition, but the optimal nutritional strategy in critically ill patients is undetermined. Some studies suggest better outcomes with initial full enteral feeding, while others indicate that hypocaloric feeding improves short-term outcomes. Data Breakdown: A study of mechanically ventilated patients randomized participants to receive trophic feeding (400 kcal/day) or...

A New Approach to Reducing the HAI Burden

The prevention of hospital-acquired infections (HAIs)—particularly bloodstream infections (BSIs) and ventilator-associated pneumonia (VAP)—has become a focus of critical care and a marker for quality among ICUs due to their significant burden. Under rules created by the CMS, a catheter-related BSI (CR-BSI) is now considered one of the preventable complications that will not be incrementally reimbursed. As a result, hospitals are more closely scrutinizing rates of HAIs and increasingly making efforts to reduce their impact. Assessing Potential Strategies In the March 2010 Archives of Surgery, my colleagues and I published a retrospective analysis of data collected 6 months before and after institution of a chlorhexidine gluconate bathing protocol in a trauma ICU. Chlorhexidine is an antiseptic preparation that has demonstrated broad activity against yeasts, viruses, and bacteria (including multi-drug resistant organisms, such as MRSA and Acinetobacter baumannii). The study compared the efficacy of daily bathing with washcloths impregnated with 2% chlorhexidine with that of disposable washcloths without this substance to determine the effect on HAI rates as well as its effect on the rate of isolation of multidrug-resistant organisms. “Using routine decontamination bathing regimens may help decrease the potential for organism transmission.” We observed that introduction of 2% chlorhexidine gluconate to routine, daily whole-body bathing of trauma ICU patients was associated with a significant reduction in the incidence of CR-BSIs. While the incidence of VAP was not significantly affected by chlorhexidine baths, patients who received these baths were less likely to develop MRSA VAP. The rate of colonization with MRSA and Acinetobacter was significantly lower in the chlorhexidine group than in the comparison group. The intervention also appeared to change...
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