VAP Prevention in Trauma: What Works?. Patient Presentation to ER 64yo male, passenger, MVC,...

VAP Prevention in Trauma: What Works?

Patient Presentation to ER• 64yo male, passenger, MVC, high-speed

rollover, SBP 60 on arrival

• Blood transfusion initiated for hypotension

• Emergent Endotracheal intubation in ED

• Severe Flail chest by physical exam– Bilateral hemo-pneumothorax– Bilateral closed tube thoracostomy

• FAST – Positive for hemoperitoneum

• Plan: To OR for emergent laparotomy

Initial CXR

In Operating Rooom• In OR

• Laparotomy, splenectomy, repair liver laceration, packs, abdominal VAC

• Blood pressure normalized after abdominal hemorrhage controlled

• To ICU postoperatively

• Severe hypoxemia

• Chest CT scan obtained postop to evaluate intra-thoracic injuries

Imaging – Chest CT

Hospital Course – PostInjury Day 5

• On Day 5 of mechanical ventilation

• Fever to 38.3°C

• Purulent sputum

• White blood cell (WBC) count of 15 x 109/L (15 000/µL) with 90% polymorphonuclear (PMN) leukocytes

• Chest radiograph shows new bilateral patchy lower lobe infiltrates

Further investigations

• Tracheal aspirate shows numerous PMN leukocytes, and Gram-positive cocci

• Laboratory results:– Respiratory: FiO2 0.6, tidal volume (VT) 500

mL, respiratory rate 16 breaths/min on SIMV, Pressure Support ventilation, PEEP 10

– Arterial blood gas: pH 7.42, PaCO2 44 mmHg,

PaO2 72 mmHg

• Presumptive diagnosis is VAP

Definitions: The ATS/IDSA Guidelines

Healthcare-associated pneumonia (HCAP)

– Includes HAP and VAP

– Pneumonia in patients

• Hospitalized for 2 days in an acute care facility within 90 days of infection

• Resided in a NH or LTC facility

• Attended a hospital or hemodialysis center

• Received IV antibiotic therapy, chemotherapy or wound care within 30 days of current infection

• Family member of patient with MDR pathogens

Hospital-acquired pneumonia (HAP)

– Pneumonia occurring 48 hours post-hospital admission

Ventilator-associated pneumonia (VAP)

– Pneumonia occurring 48-72 hours post-intubation

Am J Resp Crit Care Med 2005;171:388-416

Hospital Course

• Persistent need for mechanical ventilation

• Developed Ventilator-associated Pneumonia

• OR for removal abdominal packs, transgastric jejunostomy for enteral nutrition and abdominal wall closure

• Echo confirmed blunt myocardial injury

• Tracheostomy

• ICU LOS > 3 weeks

• Eventual full recovery

Decline in VAP cases/1000 ventilator days in ICUs in U.S. (Note higher VAP rates in Surgical and Neurosurgical ICUs & Highest rates in

Burn/Trauma ICUs.)

Type of ICU2004 Pooled

mean 1

2006 Pooled mean 2

2007 Pooled mean 3

2008 Pooled mean 4

2009 Pooled mean 5

2010 Pooled mean/ 50% median 6

Burn 12.0 12.3 10.7 10.7 7.4 5.8 / 3.3

Medical-Major teaching 4.9 3.1 2.5 2.4 1.9 1.4 / 1.0

Medical-All other -- -- -- 2.2 1.4 1.0 / 0.0

Medical cardiac 4.4 2.8 2.5 2.1 1.5 1.3 / 0.0

Medical/Surgical-Major teaching 5.4 3.6 3.3 2.9 2.0 1.8 / 1.1

Medical/Surgical-All other, ≤ 15 beds

5.1 2.7 2.3 2.2 1.4 1.2 / 0.0

Medical/Surgical-All other, > 15 beds

-- -- -- 1.9 1.2 1.1 / 0.3

Neurologic -- -- 7.1 6.7 3.9 4.8 / 4.8

Neurosurgical 11.2 7.0 6.5 5.3 3.8 3.1 / 2.3

Pediatric cardiothoracic -- -- -- 0.6 0.7 0.7

Pediatric medical -- -- -- 2.3 0.9 1.1

Pediatric medical/surgical 2.9 2.5 2.1 1.8 1.1 1.2 / 0.0

Surgical-Major teaching 9.3 5.2 5.3 4.9 3.8 3.5 / 1.7

Surgical-All other -- -- -- -- -- 2.5 / 1.2

Surgical Cardiothoracic 7.2 5.7 4.7 3.9 2.1 1.6 / 0.4

Trauma 15.2 10.2 9.3 8.1 6.5 6.0 / 5.3

CONGRATULATIONS!!!

Commandments of VAP Prevention

1. Use the correct definitions

2. Understand VAP pathophysiology

3. Use a “bundled” approach

4. Monitor compliance/efficacy

5. Use new technologies when needed

(high-risk patients)

6. Zero VAP is not achievable

Serial X-rays (2 or more) with one of the following:

New or progressive & persistent Infiltrate / Consolidation / Cavitation

1 of the following Clinical Criteria:

• Fever (>38oC / 100.4oF) with no other cause

• Leukopenia (<4,000 /mm3) or Leukocytosis (>12,000 / mm3)

• Altered Mental Status with no other cause (in > 70 y.o.)

PNEU-1: CDC Clinical Definition of VAP

Initiated in January 2002

2 of the following Clinical Criteria:• New Purulent Sputum or change in character / resp. secretions / suction

requirement

• New onset or worsening Cough or Dyspnea / Tachypnea• Rales or bronchial Breath Sounds• Worsening Gas Exchange (Desaturations, PaO2/FiO2 < 240, FiO2 or PEEP

requirement)

• Hemoptysis or pleuritic Chest Pain (in immunocompromised patients)

I

II

CDC / NNIS Definition of VAP: 2002

Pneumonia I: Clinically definedPos. serial X-ray finding andOne category I and two category II clinical signs

Pneumonia II: Common bacterial / fungal pneumoniaPos. serial X-Ray finding andOne category I and one category II clinical signs andOne category I or II laboratory finding

Pneumonia II: Atypical pneumonia Pos. serial X-Ray finding andOne category I and one category II clinical signs andOne category III laboratory finding

Pneumonia III: Immunocompromised patientPos. serial X-Ray finding andOne category I or II clinical sign andOne category I, II or III laboratory finding

1 of the following Laboratory Criteria:

PNEU-2: CDC Laboratory Definition of VAP

+ Blood Culture not related to another infection

+ Pleural Fluid Culture

+ Quantitative Culture from BAL / PSB or >5% intracellular organisms in BAL cells

+ Histology- Abscess formation or consolidation w. intense PMN accumulation- Pos. quantitative culture

+ Culture of Resp. Secretions (Virus or Chlamydia)

+ Viral Ag / Ab in Secretions

+ 4-fold Rise of Viral IgG

+ PCR (Chlamydia or Mycoplasma)

+ Micro-IF test (Chlamydia)

• Legionella- Pos. culture or micro-IF test from

resp. secretions or tissue- Serogroup1 Ag in urine (RIA/EIA)- 4-fold rise to (> 1:128) of L. pneumophilia Ab (indirect IFA)

+ Matching CulturesBlood and sputum for Candida spp.

+ PSB / BAL for Pneumocystis or FungiDirect microscopic exam or culture

+ HistologyFungal invasion of parenchyma

I II III

SCCM 2006

VAP, HAP

• New VAP Definition– CDC NHSN and other organizations– Definition to be used for surveillance– Ventilator-associated Events:– Good news… patients on rescue mechanical

ventilation (HFOV, ECMO, Prone) excluded– Bad news…Ventilator-associated condition

and Infection-related Ventilator-associated condition will be used for public reporting.

Pathogenesis of HAP and VAP

• Usually requires that two important processes take place:

1. Bacterial colonization of the aerodigestive tract

2. Aspiration of contaminated secretions into the lower airway

Host Factors Prior Antibiotic Rx InvasiveDevices

Medication alteringGastric emptying + pH

Colonization of Aerodigestive tract

Contaminated water,Medication, solutions,Resp therapy equipment

AspirationInhalation

BronchiolitisTransthoracic InfectionPrimary BacteremiaPossible GI Translocation Focal or Multifocal

Bronchopneumonia

Confluent Bronchopneumonia

Lung Abscess

Host SystemicAnd LowerRespiratoryTract DefenseMechanisms

Secondary BacteremiaSIRSNonpulmonary organ dysfunction

Endotracheal Tube (ETT)

Subglottic Secretions

Endotracheal Tube Cuff

Pooled Secretions in Airway

Biofilm on ETT

Dispersal of Biofilm With Ventilation

Pathway of colonization: 1. Oral/nasal colonization 2. External migration 3. Microleakage past cuff 4. Colonization of bronchi and lungs 5. Tracheal suctioning care and colonizing internal surface 6. Inoculation of lungs with mucus-biofilm encased bacteria

ETT – Transoral – 3 days duration

Prevention of VAP

•The strategies aimed at preventing VAP:

– Decreasing aspiration incidence

• Positioning, HOB elevated

• CASS – aspiration of subglottic secretions

– Reducing bacterial colonization

• Ventilator weaning protocols (SAT/SBT)

• Chlorhexidine for posterior pharynx

• Silver-coated ETTs

Dodek P et al. J Crit Care. 2008;23:126-137.

Ventilator Bundle Elements

• HOB elevated > 30 degrees

• Scheduled readiness to wean assessment

• Sedation vacation/appropriate sedation

• DVT prophylaxis

• Stress ulcer prophylaxis

***If patient condition prohibits intervention it is NOT counted against the bundle compliance

• Four tertiary care hospitals

– St. Thomas, Nashville, TN

– University of Chicago, Chicago, IL

– Hospital of Univ Pennsylvania, Philadelphia, PA

– Penn Presbyterian Med Ctr, Philadelphia, PA

• 336 patients requiring mechanical ventilation

• Daily SAT/SBT (intervention group, n=168)

• Sedation, usual care, daily SBT (control, n=168)

SAT / SBT

•Spontaneous

Awakening

Trial

•Spontaneous

Breathing

Trial

Awakening and Breathing Controlled (ABC) trial

VAP: TIME COURSE

Cumulative Incidence ICU VAP

0%

10%

20%

30%

40%

50%

60%

5 10 15 20 25 30Days

Garrard et al Chest 1995; 108: 17SVAP increases 1-3% with each day of MVRisk of death increases 2 to 10-fold

PREVENT INFECTION1. Vaccinate2. Get the catheters out

PREVENT INFECTION1. Vaccinate2. Get the catheters out

DIAGNOSE AND TREAT INFECTION EFFECTIVELY 3. Target the pathogen4. Access the experts

DIAGNOSE AND TREAT INFECTION EFFECTIVELY 3. Target the pathogen4. Access the experts

USE ANTIMICROBIALS WISELY5. Practice antimicrobial control6. Use local data7. Treat infection, not contamination8. Treat infection, not colonization9. Know when to say “no” to vanco10. Stop treatment when infection is cured or unlikely

USE ANTIMICROBIALS WISELY5. Practice antimicrobial control6. Use local data7. Treat infection, not contamination8. Treat infection, not colonization9. Know when to say “no” to vanco10. Stop treatment when infection is cured or unlikely

PREVENT TRANSMISSION11. Isolate the pathogen12. Break the chain of contagion

PREVENT TRANSMISSION11. Isolate the pathogen12. Break the chain of contagion

12 Steps to Prevent Antimicrobial Resistance in Hospitalized Adults

CDC. Available at: www.cdc.gov/drugresistance /healthcare. December 2001.

3. Get the ETT out

Patient awake / able to follow one step commands No shock / vasopressors (except Dopamine 3/kg/min)

“Respiratory load” not excessive / adequate cough / CXR PaO2 > 60 mm HG on FiO2 0.5 and PEEP 5

Wean to CPAP 5, PS 10 Reevaluate in one hour

RVR (f/Vt) 100 ? Cont. full vent support

Cont. CPAP 5, PS 10 for 30 min

RVR 100HR increment < 20/min

BP increment < 20 mm HgEntry Criteria fulfilled

Consider Extubation

Identify and treat potential causes of failure

Problems resolved

No

No

Wean to CPAP 5, PSV 10

No

No





• DVT prophylaxis



Semirecumbent position

•86 intubated, mechanically ventilated pts

•Randomized to semirecumbent (45º) or supine (0º) body position, study stopped early at interim analysis – VAP dx: clinical criteria, nonquant cx

•VAP rates lower in semirecumbent position

– Semirecumbent 3/39 (8%)

– Supine 16 of 47 (34%), p = 0.003

• Independent risk factors for VAP:

– Supine position, OR 6.8, p = 0.006

– Mechanical ventilation ≥ 7 days, OR 10.9, p = 0.001

Drakulovic MB et al. Lancet 1999 Nov 27;354:1851-8

Semirecumbent position

•221 intubated, mechanically ventilated pts

•Randomized to semirecumbent (45º) or supine (10º) body position

•Target position not achieved in 85% of study time in the intervention group

•VAP diagnosis by quantitative BAL cultures

•No difference in VAP rates

– Semirecumbent 10.7%

– Supine 6.5%

Van Nieuwenhoven et al. Crit Care Med 2006 Feb;34(2):396-402

• Odds ratio incidence of clinically diagnosed VAP (45º less than supine)

• Odds ratio of death incidence – no significant difference

Zlexiou V et al. J Crit Care 2009;24:515.

• The ventilator care bundle has been an effective strategy to reduce VAP and consists of 5 evidence-based therapies:

• Semirecumbent positioning • Stress ulcer prophylaxis • DVT prophylaxis • Adjustment of sedation until patient follows commands• Daily assessment of readiness to extubate

Berenholtz SM et al.

112 ICUs; 3228 ICU-months; 550,800 ventilator days

Quarterly VAP Rates - Keystone

P < 0.001 for pre-implementation vs. 16-18 and 28-30 month data

Quarterly VAP Rates - Keystone

Compliance increased from 32% at baseline to 75% and 84%.P < 0.001 for baseline compliance value vs. 16-18 and 28-30 month data

VAP – Keystone ICU Project

• CONCLUSIONS:

• A multifaceted intervention was associated with an increased use of evidence-based therapies

• and a substantial (up to 71%)

• and sustained (up to 2.5 years)

• decrease in VAP rates.

Berenholtz SM et al.





• DVT prophylaxis


• Chlorhexidine 2% q6h (UMich standard)• ? Add Colistin for GNR


Chlorhexidine and VAP Prevention

DeRiso et al., Chest 1996;109(6):1556-61

• Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery.

• N=353, PRCT

• CHX 0.12% oral rinse vs. Placebo

• 65% reduction in NI rate, (24/180 vs. 8/173; p<0.01)

• 69% reduction in Resp Inf (17/180 vs. 5/173; p<0.05)

• Mortality reduction in the CHX-treated group was also noted (1.16% vs 5.56%).

Chlorhexidine Decreases the Incidence of Ventilator-associated Pneumonia (VAP)

in Surgical ICU Patients

Genuit T, Bochicchio G, Napolitano L, Roghman MC

Surgical Infections, Volume 2(1):5-18, Spring 2001

OutcomesPneumonia (Incidence / 1000 Ventilator days)

2629

21

0

10

20

30

40

Control WP WP + CH

= NNIS 10 – 90 %ile for nosocomial pneumonia

Patients requiring MV for > 48 hours, n = 134

*

Ris

k o

f P

neu

mo

nia

Follow- up (Days)

0 10 20 30 40

0.00

0.25

0.50

0.75

1.00

Control

Weaning Protocol

Weaning Protocol + CHX

Outcomes: VAP Risk over Time

*

* p < 0.05

12

2119

0

10

20

30

Control WP WP + CH

*

Mortality(% mortality rate)

Chlorhexidine gluconate 0.12% was applied twice daily to the posterior pharynx after routine mouthcare and thorough suctioning.

Conclusions

Protocol driven weaning from mechanical ventilation

in combination with

Chlorhexidine gluconate oral rinse

is effective in reducing the incidence of VAP and resource utilization in surgical ICU patients.

Chlebicki M et al. Crit Care Med 2007;35:596-602.

Chlorhexidine for VAP Prevention

Tantipong H et al. ICHE 2008;29:131-136.

•Randomized controlled trial, n=207

•2% Chlorhexidine vs. NS 4 times per day

•Outcome measure: VAP, CDC criteria

Chlorhexidine

gluconate

0.12% solution


The use of the oral antiseptic chlorhexidine should be considered.

•Prospective, randomized, double-blind, placebo-controlled multi-center trial

•N = 385

•Patients requiring MV for 48 hrs or more

•3 groups:

– Placebo

– CHX 2% - q6h

– CHX 2% - Colistin 2% - q6h

•Clinical criteria for diagnosis of VAP with CPIS

Koeman M et al. Am J Respir Crit Care Med 2006;173:1348–1355.


Hazard ratio (HR) for oral colonization

•Four studies, n=828 (Further large RCTs are needed)

•Toothbrushing does not decrease VAP [RR 0.77 (0.5-1.21)] or ICU mortality [RR 0.88 (0.70-1.10)

Gu WJ et al. Crit Care 2012;16:R190

Does Toothbrushing decrease VAP?

CASS Endotracheal tube

•Helps decrease the rate of ventilator-associated pneumonia (VAP) Shown to delay the early onset of VAP. Potential to reduce hospital-related costs associated with development of VAP

•Convenient and safe method for suctioning accumulated secretions in the subglottic space

•Large elliptical evacuation port located on dorsal side proximal to cuff provides effective evacuation

•Integral suction lumen allows continuous suctioning without risking trauma to the vocal cords as with manual catheter suctioning

•The CASS tube, with its integral suction lumen and evacuation port, provides a safe, convenient way to continuously suction the subglottic area.

•A large, elliptical evacuation port is located proximal to the cuff to allow effective suctioning of pooled secretions.

Continuous Aspiration of Subglottic Secretions (CASS) for Prevention of VAP: Meta-analysis

Dezfulian C et al. Am J Med 2005 Jan;118(1):11-18

• 5 studies

• N = 896

• Reduced VAP by nearly half (RR = 0.51)

• Delayed onset of VAP by 6.8 days

• In patients expected to require > 72 hrs MV

• No impact on mortality

CASS Tubes – New Modifications

• Endotracheal tubes with dorsal lumen for subglottic secretion drainage.

• The dorsal lumen opens above the endotracheal cuff.• In the current version this hole is closer to the cuff and the lumen

is larger.

Management of CASS Tubes

•Continuous soft aspiration with suction of 20-30cm H20

•Monitor intracuff pressure every 4 hours and maintain at 25-30cm H2O

•Check system every 4 hours with 2mL of air to assure that the suction lumen is patent

•Check the system if no secretions are recovered from the suction lumen

Rello J et al. Respir Care 2005;50(7):900–906.

• Randomized trial – 2 year period, n=714 (359 CASS)

• Patient requiring tracheostomy were distributed according to initial randomization (Shiley cuffed vs. Tracheosost Evac)

• Cuff pressure maintained between 20-30mm Hg

• CASS, continuous negative pressure 100-150mm Hg

• All patients received SUP with pantoprazoleBouza E et al. Chest 2008;134:938-946.

Continuous Aspiration of Subglottic Secretions (CASS)

Outcomes Control n= 331

CASS

n=359p

Incidence of VAP 5.3% 3.6% .2

Hospital antibiotic use, DDD 1,932 1,213 <.001

MV > 48 hours

VAP 19 (47.5%) 12 (26.7%) .04

VAP per 1,000 vent days 51.6 31.5 .03

ICU LOS, days 16.5 7.0 .01

Hospital Antibiotic use, DDD 1,877 1,206 <.001

Mortality 52.5 44.4 .3

Bouza E, et al. Chest. 2008;134:938-946.

RCT -n=714 – CASS (n=359) vs. Control (n=331) (cardiac surg, Madrid)– Antibiotic use in Daily Defined Doses - DDD

Silver-coated Endotracheal Tube

• Silver has interesting medical properties:

• Prevents biofilm formation

• Delays airway colonization

• Has bactericidal activity

• Reduces bacterial burden

• Reduces inflammation•Bardex I.C. and LubriSil I.C. catheters are made with Bacti-Guard® silver technology and Bacti-Guard® silver technology is licensed from Adhesive Technology (International) Licensing, B.V.•Bacti-Guard® * silver and hydrogel

Pathogenesis of VAPCommon Sources of VAP Pathogens: Aspiration Intubation Procedure Biofilm Formation Contaminated Secretions Contaminated respiratory equipment

Mechanism of Action: Silver-Coated ETT

• PR Single-blind, Multicenter Phase III study

• 54 centers in North America

• 2003 pts expected to require MV > 24 hours

• Primary outcome VAP, BAL > 104 CFU/ml

• VAP 4.8% vs. 7.5% (Relative Risk reduction 36%)

• Silver-coated ETT associated with delay in VAP

• Conclusion: Patients receiving a silver-coated ETT had a statistically significant reduction in VAP and delayed time to VAP occurrence compared with those receiving a similar uncoated ETT.

Kollef M et al. JAMA. 2008;300(7):805-813.


Silver ETT

The NASCENT Study ResultsMicrobiologically-confirmed VAP

7.50%

4.80%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

For all patients

Control Silver-Coated ETT

36%(p=0.03)

Mi c

r ob

iol o

gic

al l

y co

nfi

rmed

V

AP

Rat

e

Kollef, M. H. et al. JAMA 2008;300:805-813.

Covidien SealGuard ETT

ETT Ultrathin Polyurethane + SSDRCT, n=280, 1 Medical ICU, Spain

%

Control

Seal-GuardEvac

P=.02P=.001 P=.01

Lorente L, et al. AJRCCM. 2007:176:1079-1083.

HR 3.395%CI 1.7-6.7

HR 3.395%CI 1.2-9.1

HR 3.395%CI 1.3-9.0

62% Risk Reduction

n=140

n=140

Tracheostomy vs. Prolonged Intubation

Crit Care Med 2004 Vol. 32, No. 8:1689

•Adult pts projected to need MV for 14 days

•N = 120

•Early tracheostomy – within 48 hrs

•Late tracheostomy – within 14-16 days

Survival post-intubation

Kaplan-Meier curve. The time to death is displayed. There is a significantly better mortality rate in the early tracheotomy group than the prolonged translaryngeal group

at 30 days (p .005).

Mortality 31.7% vs. 61.7%

Tracheotomy vs. Prolonged IntubationOutcome Measures

Tracheotomy vs. Prolonged Intubation

• RCT, n = 209

– Early trach, 145 (6-8 days)

– Late trach, 119 (13-15 days)

• 12 Italian ICUs, 6/2004-2008

• Primary endpoint was VAP

– 30 (14%) Early trach

– 44 (21%) Late trach

– P = 0.07 (VAP defined by CPIS)

• Largest study to date

• Completed TracMan trial, n=900, 4 vs. 10 days

30 day Survival

Early Trach (ICU day 1-4) vs. Late Trach (on or after ICU day 10)





• DVT prophylaxis


• Chlorhexidine 2% q6h (UMich standard)• ? Add Colistin for GNR


VAP – Final Thoughts• Most common nosocomial infection in ICU patients

• Associated mortality rates and increased ICU resource utilization

• PREVENTION IS THE KEY!• Ventilator weaning protocols• Wake up and breathe (SAT/SBT)• Mouth / pharyngeal care• Chlorhexidine• Hand hygiene

VAP Prevention in Trauma: What Works?. Patient Presentation to ER 64yo male, passenger, MVC,...

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