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Preventing VAP - evidence for a care bundle

Preventing VAP - evidence for a care bundle. VAP. Incidence ~ 1 0 - 30% ventilated patients 7-15 / 1000 ventilator days Atributable mortality of 0-50% Atributable increase LOS of ~ 3 weeks. Prevent VAP Care Bundle. Reduce time on ventilator: Assess sedation requirements daily

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Preventing VAP - evidence for a care bundle

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  1. Preventing VAP - evidence for a care bundle

  2. VAP • Incidence ~ 10 - 30% ventilated patients 7-15 / 1000 ventilator days • Atributable mortality of 0-50% • Atributable increase LOS of ~ 3 weeks

  3. Prevent VAP Care Bundle Reduce time on ventilator: • Assess sedation requirements daily • Assess suitability for weaning and extubation daily While on ventilator: • Semi-recumbent positioning • Oral chlorhexidine • ? Subglottic drainage

  4. 128 ventilated patients Randomised: daily sedation break and titration v. standard care Outcomes: duration of ventilation, ICU & hospital stay

  5. p=0.19 p=0.02 p=0.004 Ventilator ICU Hospital

  6. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Brook AD, Ahrens TS, Schaiff R et al Crit Care Med.1999;27:2609-15 321 ventilated patients Randomised: nurse-led sedation protocol v. standard care Outcomes: duration of ventilation, ICU & hospital stay

  7. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Brook AD, Ahrens TS, Schaiff R et al Crit Care Med.1999;27:2609-15 P<0.001 P=0.013 P=0.003

  8. 300 ventilated patients Randomised: daily weaning trial v. standard care Outcomes: duration of ventilation, ICU & hospital stay

  9. RCT of protocol-directed v. physician-directed weaning from mechanical ventilation. Kollef MH, Shapiro SD, Silver P et al.Crit Care Med. 1997; 25:567-74

  10. RCT of protocol-directed v. physician-directed weaning from mechanical ventilation. Kollef MH, Shapiro SD, Silver P et al.Crit Care Med. 1997; 25:567-74

  11. Avoiding Ventilation • Daily sedation titration and weaning protocols will reduce ventilator days and ICU stay • VAP may be less common

  12. 86 ventilated patients • VAP in • 23% supine patients • (28.4/1000 Vent d) • v. • 5% semi-recumbent • (7.3/1000 Vent d) • NNT (95%CI) = 6 (3-23)

  13. Semi-recumbency • 45o head-up tilt is very difficult to achieve • No benefit of semi-recumbency ~30o over standard care ~10o • Supine position is harmful

  14. Oro-pharyngeal Antiseptics

  15. Crit Care Med 2007; 35:595–602

  16. Subglottic drainage • In patients expected to be ventilated > 3 days • In patients to be intubated de novo • Halves the risk of VAP • NNT = 8 (95% CI 5-15) • Shortens ventilation 2 days & ICU stay 3 days

  17. Prevent VAP Care Bundle • Assess sedation requirements daily • Assess suitability for weaning and extubation daily • Semi-recumbent position • Oral chlorhexidine • ? Subglottic drainage

  18. Do VAP prevention programmes work? Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Zack JE et alCrit Care Med 2002; 30: 2407-12 An educational intervention to reduce VAP in an integrated health system: a comparison of effects. Babcock HM et alChest 2004; 125: 2224-31 Reducing VAP rates through a staff education programme. Salahuddin N et al J Hosp Infect. 2004; 57 :223-7 Adherence to simple and effective measures reduces the incidence of VAP. Baxter AD et al Can J Anaesth. 2005; 52: 535-41

  19. VAP in Critical Care, RIE

  20. Conclusion • There is reasonable evidence from RCTs and their metanalyses to support the elements of the proposed ‘ Prevent VAP Care Bundle’ • Other groups have halved VAP rates through education programmes, reinforcing adoption of protocols to prevent VAP

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