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Implementation of Ventilator Bundle Approach in Prevention of Ventilator Associated Pneumonia in Geriatric ICU patients

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Ahmad salama

on 27 September 2012

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Transcript of Implementation of Ventilator Bundle Approach in Prevention of Ventilator Associated Pneumonia in Geriatric ICU patients

Introduction Ventilator-associated pneumonia (VAP) is pneumonia in a patient on mechanical ventilatory support for more than 48 hours.

Different host related factors are reported for VAP according to Torpy et al. (2008) as follows:
1. Advanced age
2. Co-morbid disease: Also severity of illness, functional status, and prolonged mechanical ventilation, but not necessarily age alone, have all been implicated as factors contributing to the often-undesirable outcomes experienced by older adults
Studies directed at decreasing VAP rates have identified numerous risk factors. The predominant risk factors for acquiring VAP are inadequate hand washing, supine positioning of patients, and ventilator mismanagement practices The identification of these risk factors allows the development of strategies for the prevention of Health Associated Pneumonia (HAP) and VAP and the design of treatment protocols. An important precursor for the development of VAP is colonization of the oral cavity. The CDC 2003 guidelines reported that 63% of patients admitted to an ICU have oral colonization with a pathogen associated with VAP. The most prevalent bacteria are gram-negative Pseudomonas aeruginosa and enterobacteria and gram-positive Staphylococcus aureus . Pathogenesis of VAP Early onset VAP occurs 48 to 96 hours after intubation and is associated with antibiotic-susceptible organisms. Late-onset VAP occurs more than 96 hours after intubation and is associated with antibiotic-resistant organisms. Onset of VAP The evaluation of patients with suspected VAP should begin with a comprehensive medical history and clinical examination and a chest radiograph to determine the degree of lung parenchymal involvement and the presence of any complications such as a pleural effusion or cavitations . DIAGNOSIS OF VAP Implementation of Ventilator Bundle Approach in Prevention of Ventilator Associated Pneumonia in Geriatric ICU patients Empiric antimicrobial coverage should account for the resistance patterns of common pathogenic isolates in any particular unit. Once microbiologic results including sensitivities are known, “de-escalation” of antimicrobial coverage to fit the culture results is indicated, using the most narrowly focused antibiotics appropriate TREATMENT, PREVENTION & CONTROL OF VAP Because initially adequate antibiotic therapy is so important in reducing the mortality from VAP, when patients are at risk for MDR organisms, initial therapy should be broad and known to be effective against MDR pathogens, especially Pseudomonas aeruginosa and MRSA, and tailored to the local antibiogram Different societies had recommended different methods for VAP approach as following:
The American Association of Critical-Care Nurses AACN (2006) recommended steps for reducing the incidence of VAP; these steps are based on the best practice guidelines for patients receiving mechanical ventilation, these steps incorporate the following guidelines from the CDC,2003 for preventing nosocomial pneumonia:
-Elevation of the head of the bed to 30º to 45º unless medically contraindicated.
-Continuous removal of subglottic secretions.
-Change of ventilator circuit no more often than every 48 hours, and
-Washing of hands before and after contact with each patient. Prevention of VAP 1. Elevation of the head of the bed to 30–45
The semi-recumbent position, achieved by elevation of the head of the bed, is an integral portion of the VAP bundle. It has been speculated that the semi-recumbent position may decrease VAP by reduction in gastroesophageal reflux and subsequent aspiration of gastrointestinal, oropharyngeal, and nasopharyngeal secretions. 2.Daily ‘sedation vacation’ and daily assessment of readiness to extubate
Sedation vacations’ are an integral component of the VAP bundle and can have major implications in that patients who are extubated early are at decreased risk of VAP. 3.Peptic ulcer disease prophylaxis
Although included within the Ventilator Bundle, this is not a specific strategy for VAP prevention. It was included in the Ventilator Bundle as a strategy to prevent stress related mucosal disease, as mechanical ventilation is a significant risk factor position. 4.Deep Venous Thrombosis (DVT) prophylaxis
Sedated ventilated patients are at significantly increased risk for DVT. Hence, DVT prophylaxis is an important component of standard care of these patients Body Prevention Strategies to prevention of oral colonization Strategies to minimize contamination of equipment Strategies to reduce colonization of the aerodigestive tract Strategies to prevent aspiration General preventive measures 5. Chlorhexidine antiseptic
The use of the oral antiseptic chlorhexidine gluconate has been definitively demonstrated to be an effective VAP prevention strategy, and its use has been advocated in the most recent evidence-based VAP prevention clinical practice guidelines. Furthermore, safety, feasibility, and cost considerations for this intervention are all very favorable.
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