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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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slide2
VAP
  • Incidence

~ 10 - 30% ventilated patients

7-15 / 1000 ventilator days

  • Atributable mortality of 0-50%
  • Atributable increase LOS of ~ 3 weeks
prevent vap care bundle
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
slide4

128 ventilated patients

Randomised: daily sedation break and titration v. standard care

Outcomes: duration of ventilation, ICU & hospital stay

slide5

p=0.19

p=0.02

p=0.004

Ventilator

ICU

Hospital

slide6

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

slide7

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

slide8

300 ventilated patients

Randomised: daily weaning trial v. standard care

Outcomes: duration of ventilation, ICU & hospital stay

rct of protocol directed v physician directed weaning from mechanical ventilation
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

rct of protocol directed v physician directed weaning from mechanical ventilation11
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

avoiding ventilation
Avoiding Ventilation
  • Daily sedation titration and weaning protocols will reduce ventilator days and ICU stay
  • VAP may be less common
slide15

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)
semi recumbency
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
subglottic drainage
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
prevent vap care bundle25
Prevent VAP Care Bundle
  • Assess sedation requirements daily
  • Assess suitability for weaning and extubation daily
  • Semi-recumbent position
  • Oral chlorhexidine
  • ? Subglottic drainage
do vap prevention programmes work
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

conclusion
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