Fanny Abdullah

Stase Intensive Care Unit (ICU) RSHS

Bagian Kardiologi dan Kedokteran Vaskular
UNPAD
 Ventilator-associated pneumonia
(VAP) is a sub-type of hospital aquired
pneumonia (HAP) which occurs in
people who are on mechanical
ventilation through an endotracheal or
tracheostomy tube for at least 48 hours
 Ventilator-associated pneumonia (VAP) is
common in the intensive care unit (ICU),
affecting 8 to 20% of ICU patients and up
to 27% of mechanically ventilated
patients
 Mortality rates in
patients with VAP
range from 20 to 50%
and may reach more
than 70% when the
infection is caused by
multi-resistant and
invasive pathogens
 VAP is thought to increase the mortality
of the underlying disease by about 30%

 VAP is also associated with considerable

morbidity, including prolonged ICU
length of stay, prolonged mechanical
ventilation, and increased costs of
hospitalization
Delayed diagnosis and
subsequent delay in
initiating appropriate
therapy may be
associated with worse
outcomes in patients
with VAP ,

on the other hand, an

incorrect diagnosis may
lead to unnecessary
treatment and
subsequent
complications related to
therapy
The American
Association of Critical-
Care Nurses (AACN)
VENTILATOR BUNDLE
recommended steps
for reducing the
incidence of VAP
 these
steps incorporate the following
guidelines from the Centers for Disease
Control and Prevention (CDC) for
preventing nosocomial pneumonia
elevation of the head of the
bed (HOB) 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.
 HOB elevation
 Appropriate DVT prophylaxis
 Appropriate PUD prophylaxis
 Appropriate sedation
 Assessment of readiness to extubate

 Institute for Healthcare ImprovementBoston, Massachusetts USA

 HOB elevated greater
than 30 degrees
 Reduces frequency
and risk of
nosocomial
pneumonia
 Simple, no-cost
intervention
 Incidence of
aspirations reduced
30%
 Thromboprophylaxis
effective in preventing
DVT
 Multiple methods of
thromboprophylaxis
• Unfractionated heparin
• Heparin
• Mechanical prophylaxis
 Baseline incidence of DVT
at 30%
 In critically ill patients
thromboprophylaxis is effective for
preventing deep venousthrombosis
(DVT).
 there is agreement that patients who are
critically ill or mechanically ventilated
are at high risk for DVT and should
receive thromboprophylaxis
 Reduces risk of upper GI bleeding
 Risk increased in:
• Mechanical ventilation greater than 48
hours
• Coagulopathy
 No specific therapy
Daily interruption
decreases vent LOS Hold sedation daily
until patient can
• Vent LOS reduced by 33% follow commands
• ICU LOS reduced by 35 %
 Reduce vent LOS, complications, and ICU costs
• Daily screening of respiratory function
• Spontaneous breathing trials
 Vent LOS reduced by 1.5 days
 Reduced self extubation, reintubation, trach,
prolonged mechanical ventilation
 No baseline data
 The CDC has not offered any
recommendations about oral care or
about how often to check the residual
volume in nasogastric tubes
 MORE RESEACH IS STILL NEEDED
Current Evidence About
the Ventilator Bundle and VAP
 Most published studies have focused on the
relationship between HOB elevation and the
incidence of VAP.
 regular hand washing with an alcohol-based
solution and limited wearing ofrings are
directly related to a decreased rate of VAP.
 Although the CDC has not recommended
strategies for oral care, a literature search
revealed that the use of chlorhexidine
oral rinse is directly associated with
reduced rates of respiratory infection
(3% with chlorhexidine vs 10% with
placebo; P<.05)
 Studieshave addressed
the use of chlorhexidine
before intubation, in
patients scheduled for
elective cardiac surgery
and in patients with
respiratory infections
such as tracheobronchitis
and pneumonia
 Tracheobronchial colonization causing
VAP occurred less often in patients
whose mouths had been decontaminated
with topical antibiotics than in those who
were given a placebo (P < .001 to .04).

 Oralaspiration could be a factor that

contributesto VAP.
 Current recommendations for general practice
in tube-fed patients include routine checking of
gastric residual volume every 4 to 6 hours and
withholding of feeding for 1 hour if gastric
residual volume is more than 1 to 1.5 times the
amount provided in an hour, or more than 150
mL before bolus feeding
 These practices, however, have not been
specifically studied in relation to VAP.

 Elevated gastric residual volume and

vomiting were associated with an increased
incidence of VAP.

 The supine position and the length of time

the patient stayed in that position were risk
factors for gastric aspiration.
 What we can accomplish?
• To achieve greater than 95% on the ventilator
bundle.

 How will we know that a change is an

improvement?
• Monitor percent of ventilator patients receiving
all five bundle elements
 What changes can we make that will result in
improvement?
• Improve education by distributing a FACT
SHEET
• Hold in-services for bedside providers
• Improve communication among providers by
using the DAILY GOALS SHEET during rounds in
the ICU.
QUALITY MEASURE ADVERSE COSTS
EVENTS
Elevate HOB xx deaths $xx
xx hospital days
DVT prophylaxis xx deaths $xx
xx hospital days
PUD prophylaxis xx deaths $xx
xx ICU
Appropriate sedation Xx ICU days $xx
 Appropriate Glucose Control
• Intensive insulin therapy
• Maintain blood glucose less than 110
mg/deciliter
• Decrease morbidity and morality
 Gastric Decontamination
• Reduce colonization with resistant gram negative
aerobic bacteria
• Reduce ICU and hospital mortality
 Ventilator bundles and performance
improvement
 Elements of a ventilator bundle
 Systems of independent redundancy
 Fact Sheet
 Additional elements for future
implementation