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NON-ANTIBIOTIC STRATIGIES IN ICU

NON-ANTIBIOTIC STRATIGIES IN ICU. Prof. M H Mumtaz. NON ANTIBIOTIC STRATEGIES IN ICU. “Preventing Ventilator Associated Pneumonia”. INFECTION CONTROL. Why at Risk? Underlying Disease. Drug Therapy. Multiple Lines. Organisms From Other Patients. VENTILATED ASSOCIATED PNEUMONIA (VAP).

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NON-ANTIBIOTIC STRATIGIES IN ICU

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  1. NON-ANTIBIOTIC STRATIGIES IN ICU Prof. M H Mumtaz

  2. NON ANTIBIOTIC STRATEGIES IN ICU “Preventing Ventilator Associated Pneumonia”

  3. INFECTION CONTROL • Why at Risk? • Underlying Disease. • Drug Therapy. • Multiple Lines. • Organisms From Other Patients.

  4. VENTILATED ASSOCIATED PNEUMONIA (VAP) Nosocomial pneumonia (NP) that occurs 48 hrs of initiating CMV. Early VAP Late VAP <5 days >5 days

  5. VAP EFFECT ON STAY IN ICU. Three fold Craig CP, Conelly S; AMJ Infec Control 1984.  10-32 fold. Jimenez P. et al; Critical Care Medicine 1989.

  6. PREVENTIVE MEASURES •  Cost. •  Stay. •  Morbidity. •  Mortality.

  7. PREVENTIVE MEASURES • Conventional infection control measures. • Strategies related to GIT. • Strategies related to patient placement. • Strategies related to artificial airway. • Strategies related to mechnical ventilator.

  8. CONVENTIONAL MEASURES1. STEPS BEFORE ENTERING ICU • Jackets. • White Coats. • Ties & Dopata. • Change Clothes.

  9. 2. STEPS BEFORE APPROACHING PATIENT • Put on apron. • Wash hands & gloves. • Donot share equipment. • Donot use own stethoscope. • Wash hands on leaving.

  10. PREVENTIVE MEASURES Conventional Measures 2. Approaching the patient, 4 things to do. • Hand wash. • Dochbeling GN, Stanley Gb. Comparative efficacy of alterantive hand washing agents in reducing nosocomial infections in ICU” • N Engl J Med. 1992;327.

  11. PREVENTIVE MEASURES • Protective gowns. • Klein BS, Perlof WH, MAKI DG, “Reduction of nosocomial infection during paediatric intensive care by protective isolation • N Engl Med 1989, 320” • Use of stethoscope. • Contamination – Resp Equipment. • Condensed water in circuit. • Manipulaiton – circuits. • Chlorhexidine oral rins.

  12. BARRIER NURSING (REVERSE) • Immunocompromised. • Radiotherapy. • Immune disease.

  13. BASIC PRINCIPALS • Don’t Enter Unnecessarily. • Wear Apron. • Wash Hands. • Wear Gloves. • Display on Door

  14. BARRIER NURSING(Patients with Serious Infection) • Wear Apron & Leave In. • Wash Hands. • Wear Gloves. • Don’t Enter Unnecessarily. • Wear Mask.

  15. 1. STRATEGIES RELATED TO GIT • Stress Ulcer Prophylaxis. • Gastric Overdistension. • Nutritional Support.

  16. STRESS ULCER PROPHYLAXIS • Why We Need? • Ulcer Formation And Perforation. • Haemorrhage. • Drugs Available. • Antacids. • H2 Receptor Blockers. • Proton Inhibitors. • Sucralfate. • Target PH<4.

  17. STRESS ULCER PROPHYLAXIS Drawback. Multiplication of bacteria & Colonisation in RT. “Gastro Pulmonary Route” Oesophageal wall Nasogastric tube.

  18. H2 RECEPTOR BLOCKERSCONFLICTING VIEWS There is definite increased incidence of NP “Apte NM & others” Gastric colonization & pneumonia in intubated critially ill patients receiving stress ulcer prophylaxis, a randomised controlled trial. Crit. Care Med 192.80:59-593.

  19. STRESS ULCER PROPHYLAXIS No increased risk of NP Martin LF, booth FV Karlstadt RG. Continuous intravenous cimetidine decreases stress related GI hemorrhage without promoting pneumonia. Crit. Care Med 1993 21;19-30

  20. Stress ulcer prophylaxis Cook DJ, Guyatt GH & others.A comparision of sucral fate and ranitidine for prevention of upper GIT bleeding in patients requiring mechanical ventilation. N Engl J Med 1998, 338;791-97. “Failed ot identify increased risk of NP in either group”

  21. STRATEGIES RELATED TO GIT • Gastric overdistention. • Adequate nutrition • Prevent NP. • Nasogastric tube. • Pathway for bacteria. • reflow of bacteria. • Overdistention. • Fascilitate reflux.

  22. GASTRIC OVERDISTENTION • Fascilitate reflux. • Food. • Bacteria. • Can be reduced. •  of narcotics. •  of anticholinergics. • Use prokinetic agents. • Monitor residual volume. • Nasojejunal feeding.

  23. STRATEGIES RELATED TO GIT • Nutritional support. • Malnutrition  • host defence.  •  Nosocomial P • Entral feeding.  • Colonisation.  • NP if PH>4. • Supine posutre • NP.

  24. NUTRITIONAL SUPPORT “Orojejunal feeding bypassing the stomach, better method in ICU” Montecalvo MA, Stegr KA. Nutritional outcome and pneumonia in critical care patients randomised trial gastric versus jejunal tube feeding. Lancet 1999, 35;1851-8,

  25. NUTRITIONAL SUPPORT Should immunonutrition become routine in critically ill patients? A systematic review of the evidence. Heyland DK, Novak F, & others. TAMA 2001. 286;944-53.

  26. STRATEGIES RELATED TO PATIENT PLACEMENT • Semirecumbent Body Position. • Postural Changes by Rotating Beds.

  27. SEMIRECUMBENT BODY POSITION Torres A, Serra-Batlles J, & others. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation. The effect of body position. Ann Intern Med 1992, 116;540-3.

  28. SEMIRECUMBENT BODY POSITION Orozco Levi M, Torres A, & others. Semirecumbent position protects from pulmonary aspiration but not completely from gastro-oesophageal reflux on mechanically ventilated patients. AMJ Respir Crit Care Med 1995, 152;1387-90.

  29. SEMIRECUMBENT BODY POSITION Drakulovic M, Torres A, & others. Supine body position is a risk factor of NP in mechanically ventilated patients, A randomised clinical trial. Lancet 1999, 354;1851-8.

  30. RECOMMENDATIONS “If no contraindication, head of the bed should be elevated 30-45o for those receiving mechanically ventilation and having enteral tube in place”

  31. POSTURAL CHANGES BY ROTATING BEDS de Boisllane BP. Castron & others. “Effect of air supported, continous, postural oscillations on the risk of early ICU pneumonia in non-traumatic critical illness” Chest 1993, 103:1543-7.

  32. POSTURAL CHANGES BY ROTATING BEDS Nelson LD, Chol SC: Kinetic therapy in Critically Ill Trauma Patients. Clin. Intensive Care 1992, 37:248-52.

  33. POSTURAL CHANGES BY ROTATING BEDS • Hospital Stay – No Reduction. • Expensive. • Mortality – No Reduction.

  34. 4. STRATEGIES RELATED TO ARTIFICIAL AIRWAY A. Respiratory Airway Care. • Avoid Micro-aspiration. • Adequate Tube Cuff Pressure. • Suction Catheter System. • Single Use System. • Multiple Use System. • Avoid Nasal Intubation. • Oro-tracheal Intubation. • Tracheostomy.

  35. STRATEGIES RELATED TO ARTIFICIAL AIRWAY A. Respiratory Airway Care. • Avoid re-intubation. • VAP risk factor. • Cost effective.

  36. STRATEGIES RELATED TO ARTIFICIAL AIRWAY RE-INTUBATION Torres A, Gatell Jon, & others. Re-intubation increases the risk of nosocomial pneumonia in patients needing ventilation. AMJ Respi Crit Care Med 1995, 152:137-41.

  37. 4. STRATEGIES RELATED TO ARTIFICIAL AIRWAY • Design of ETT. • Why? • Stagnant oropharyngeal secretion aspiration. • ETT with extra suction lumen. • incidence of NP. • Cost effectiveness. • Sliver coated endotracheal tubes.

  38. DESIGN OF ETT • Shorr A, Omalley P: Continuous subglottic suctioning for prevention of VAP, potential economic implications.Chest 2001, 119:228-35. • Valles J, Artigas & others: Continuous aspiration of subglottic secretions in preventing VAP. Ann Intern Med 1995, 122:179-86.

  39. SILVER COATED ENDOTRACHEAL TUBES Prevention of biofilm. Tansen B, Kohnen W: Prevention of biofilm formation by polymer modification. J Ind Microbiol 1995, 15:391-6.

  40. 5. STRATEGIES RELATED TO MECHANICAL VENTILATION • Maintenance of ventilator equipment. • Heat & moisture exchange. • VAP. • No condensation. • Better than water heated homidifiers. • Use of sterile water. • Rinsing nebulizer.

  41. 5. STRATEGIES RELATED TO MECHANICAL VENTILATION • Adjustment of Sedation. • Excessive Sedation. • Sedation Interruption.

  42. 5. STRATEGIES RELATED TO MECHANICAL VENTILATION NIMV & Other Ventilation Strategies. Nourdine K, Compes, Carten MJ & others. Does non-invasive ventilation reduce ICU nosocomial infection risk? A prospective clinical survery. Intensive care Medicine 1994, 25:567-73.

  43. 5. STRATEGIES RELATED TO MECHANICAL VENTILATION Girou E, Schortgen F & others. Association of non-invasive ventilation with nosocomial infections and survival in critically ill patients. JAMA 2000, 284:2361-7.

  44. ANTIBIOTIC POLICY IN ICU

  45. ABDOMINAL SEPSIS Generalized Peritonitis. Localized Abdominal Abscess. • Cefuroxime 1.5g TDS + Metronidazole IV. • Ciprofloxacin 400 mg BD + Metronidazole IV. Duration of treatment five to seven days

  46. ABDOMINAL SEPSIS Severely ill with Prior Laparotomy • Tazocin 4.5g TDS + Gentamicin 7mg/kg as a single daily dose IV. • Seek Microbiology advice Duration of treatment five to seven days.

  47. ABDOMINAL SEPSIS Severe Pancreatitis: Prophylactic Regime • Cefuroxime 1.5g TDS + Metronidazole IV. • Seek Microbiology advice Duration of prophylaxis 14 days. Severe Pancreatitis suggested by APACHE II score > 8 at 24 hrs.

  48. WOUND INFECTION • Co-amoxiclav 1.2g TDS IV. • Clindamycin 600mg QDS + Ciprofloxacin 200mg BD IV. Do not treat if wound is only colonized

  49. RESPIRATORY TRACT INFECTION • Community Acquired. • Clarithromycin 500mg BD + Cefotaxime 2gm TDS IV. • Clithromycin 500mg BD + Ciprofloxacin 400mg BD IV.

  50. RESPIRATORY TRACT INFECTION Hospital (Ward) Acquired Pneumonia. • Ceftazidime 2g TDS IV + Gentamicin 7mg kg-1 day-1 as a single daily dose. • Ciprofloxacin 400mg BD IV + Teicoplanin 400mg + Gentamicin 7mg kg-1 day-1 as a single daily dose IV.

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