Prevención no farmacológica de la neumonía asociada a ventilación mecánica

[Prevention of ventilator-associated pneumonia: a comparison of level of knowledge in three critical care units]

OBJECTIVE

To determine the level of knowledge of the prevention of ventilator-associated pneumonia guidelines of nurses working in three intensive care units (ICU) in 3 university hospitals in a Spanish region, and evaluate the relationship between this level of knowledge and years worked in the ICU.

METHOD

A descriptive, prospective, cross-sectional, multicentre study was conducted using a validated and reliable questionnaire, made up by 9 questions with closed answers drawn from the EVIDENCE study. A total of 98 questionnaires were collected from ICU nurses of the three university hospitals (A, B, and C) from January to April 2014. The sample from hospital A responded the most, in contrast with the sample from hospital B, which was the one with the less participation. The Pearson correlation was calculated in order to determine the relationship between nurse years worked in ICU and level of knowledge.

RESULTS

Hospital A obtained in the best mean score in the questionnaire, 6.33 (SD 1.4) points, followed by hospital C with 6.21 (SD 1.4), and finally, the hospital B with 6.06 (SD 1.5) points. A p=.08 was obtained on relating years worked with the level of knowledge.

CONCLUSION

The results showed a high level of knowledge compared other studies. There was a tendency between the years worked in the unit and the level of knowledge in ventilator-associated pneumonia prevention.

Adherence to the items in a bundle for the prevention of ventilator-associated pneumonia

OBJECTIVE

To assess adherence to a ventilator care bundle in an intensive care unit and to determine the impact of adherence on the rates of ventilator-associated pneumonia.

METHODS

A total of 198 beds were assessed for 60 days using a checklist that consisted of the following items: bed head elevation to 30 to 45º; position of the humidifier filter; lack of fluid in the ventilator circuit; oral hygiene; cuff pressure; and physical therapy. Next, an educational lecture was delivered, and 235 beds were assessed for the following 60 days. Data were also collected on the incidence of ventilator-acquired pneumonia.

RESULTS

Adherence to the following ventilator care bundle items increased: bed head elevation from 18.7% to 34.5%; lack of fluid in the ventilator circuit from 55.6% to 72.8%; oral hygiene from 48.5% to 77.8%; and cuff pressure from 29.8% to 51.5%. The incidence of ventilator-associated pneumonia was statistically similar before and after intervention (p=0.389).

CONCLUSION

The educational intervention performed in this study increased the adherence to the ventilator care bundle, but the incidence of ventilator-associated pneumonia did not decrease in the small sample that was assessed.

[Cuff pressure control at the intersinve care unit: influence of nursing professionals' training]

OBJETIVE

To analyze proper control of endotracheal cuff pressure in an intensive care unit. The specific objective is to verify whether training of nursing professionals improves monitoring endotracheal cuff pressure.

BASIC PROCEDURES

the study type is descriptive, observational and retrospective. All patients were admitted to the Critical Unit II of the Clínico San Carlos Hospital between May 2010-November 2011, requiring either a tracheal tube or tracheal cannula. Studied variables were: number of in range measures, number of intubated patients, or with tracheal cannula and register. Four cuts were made on all admitted patients admitted during the study period in order to measure endotracheal cuff pressure. Two cuts were performed before the professional nurses training and the other two cuts after a specific training with respect to endotracheal cuff pressure and Zero pneumonia.

RESULTS

There were 74 measurements. The first cut obtained 40.74% of measures in range. In the second cut 61.90% of measures were identified in range. In the third cut, it was found that 85.7% of measures were in range and in the fourth court, it was noted the 89.47% of measures were in range.

CONCLUSIONS

Monitoring of the endotracheal cuff pressure was inadequate before specific training of professionals. Nursing professionals training facilitates the correct measurement of the endotracheal cuff pressure, which improves patient safety.

Prevention of ventilator-associated pneumonia

Invasive mechanical ventilation (IMV) represents a risk factor for the development of ventilator-associated pneumonia (VAP), which develops at least 48h after admission in patients ventilated through tracheostomy or endotracheal intubation. VAP is the most frequent intensive-care-unit (ICU)-acquired infection among patients receiving IMV. It contributes to an increase in hospital mortality, duration of MV and ICU and length of hospital stay. Therefore, it worsens the condition of the critical patient and increases the total cost of hospitalization. The introduction of preventive measures has become imperative, to ensure control and to reduce the incidence of VAP. Preventive measures focus on modifiable risk factors, mediated by non-pharmacological and pharmacological evidence based strategies recommended by guidelines. These measures are intended to reduce the risk associated with endotracheal intubation and to prevent microaspiration of pathogens to the lower airways.

Knowledge levels of intensive care nurses on prevention of ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia constitutes a significant concern for ventilated patients in the intensive care unit.

AIM

This study was planned to evaluate the knowledge of nurses working in general intensive care units concerning evidence-based measures for the prevention of ventilator-associated pneumonia.

METHOD

This study design is cross-sectional. It was carried out on nurses working in the general intensive care units of anesthiology and re-animation clinics. Collection of research data was performed by means of a Nurse Identification Form and a Form of Evidence-Based Knowledge concerning the Prevention of Ventilator-Associated Pneumonia. Characterization statistics were shown by percentage, median and interquartile range. Chi-square and Wilcoxon tests and Kruskal-Wallis tests were used as appropriate.

RESULTS

The median value of total points scored by nurses on the questionnaire was 4.00 ± 2.00. The difference between the nurses' education levels, duration of work experience and participation in in-service training programmes on ventilator-associated pneumonia prevention and the median value of their total scores on the questionnaire was found to be statistically significant (p < 0.05).

CONCLUSION

The conclusion of the study was that critical care nurses' knowledge about ventilator-associated pneumonia prevention is poor.

Ventilator-associated pneumonia management in critical illness

PURPOSE OF REVIEW

Ventilator-associated pneumonia (VAP) is a frequent adverse event in the intensive care unit.We review recent publications about the management and prevention of VAP.

RECENT FINDINGS

The latest care bundles introduced standard interventions to facilitate implementation of evidence-based clinical guidelines and to improve the outcome of patients. Recent studies find that prevention management of ventilated patients decreases the risk of VAP. Enteral feeding, considered a risk factor for VAP, currently has been recommended, with appropriate administration, for all critical ill patients if no contraindications exist.

SUMMARY

In view of the recently available data, it can be concluded that the implementation of care bundles on the general management of ventilated patients in daily practice has reduced the VAP rates. The main pharmacological measures to prevent VAP are proper hands hygiene, high nurse-to-patient ratio, avoid unnecessary transfer of ventilated patients, use of noninvasive mechanical ventilation, shortening weaning period, avoid the use of nasal intubation, prevent bio-film deposition in endotracheal tube, aspiration of subglottic secretions, maintenance of adequate pressure of endotracheal cuffs, avoid manipulation of ventilator circuits, semi-recumbent position and adequate enteral feeding.In addition, updated guidelines incorporate more comprehensive diagnostic protocols to the evidence-based management of VAP.

[Hot topics in respiratory infections]

Se efectúa una revisión de los artículos más interesantes de infecciones respiratorias, publicados en el último trimestre del año 2009 y en 2010. En cuanto a las bronquiectasias, destacan las Guidelines de la British Thoracic Society, así como diversos artículos de la evolución natural del proceso y el impacto de las reagudizaciones de ésta, así como del tratamiento inhalatorio antibiótico de las bronquiectasias. Con respecto a la tuberculosis, es recomendable señalar el documento de consenso SEPAR-SEIMC para el manejo de la tuberculosis, así como las publicaciones sobre la utilización de interferón-gamma en el diagnóstico de infección tuberculosa. Las nuevas recomendaciones SEPAR de neumonía adquirida en la comunidad (NAC) se han publicado muy recientemente, y junto con ellas destacan estudios de etiología viral de las NAC, impacto del tratamiento corticoideo en las neumonías, duración del tratamiento antibiótico y medidas preventivas de neumonías, tanto comunitarias como nosocomiales.

[Evaluation of the compliance of semirecumbent position between 30-45° in intubated patients]

AIMS

To determine compliance of the standard "semirecumbent position between 30-45° in patients with artificial airway (AA)". To know the opinion of the professionals on this issue.

MATERIAL AND METHODS

An observational, prospective study was carried out in December 2009 in the ICU department of a tertiary hospital that excluded the limitation of therapeutic effort, prone position and antitrendelemburg.

DATA COLLECTED

headrest angle, professional experience of the nurse, shift, perception of the auditor, diagnostic, type of AA (tracheostomy or endotracheal tube), mechanical ventilation (MV) (yes/no) and enteral nutrition (EN). Nurses were surveyed to verify if they knew the standard, if they complied with it, the method used and their suggestions. We used the Student's t test and ANOVA for multivariable analysis, and Fisher's χ2; p<0.05=significant.

RESULTS

A total of 546 valid measurements were obtained from 53 patients, of which 40.9% had the correct semirecumbent position (30-45°). Professionals with <1 year of experience were those who raised the headrest the least, with only 26.4% of these measurements over 30°. The standard was met in only 34.8% of the neurocritical patients (NC) vs non NC (46.7%) (p<0.05). It was <30° in 29.2% of patients with tracheostomy vs 44% measurements performed on patients with TOT (p<0.05). There were no differences between shifts, the use of MV or EN. Diagnostic accuracy of the auditor: sensitivity: 91.6%; specificity: 72.5%; positive predictive value: 70.2%; negative predictive value (NPV): 92.4%. 97.9% of responders know the standard. Visual judgment was used in 97.2% of the cases.

CONCLUSIONS

Measured compliance was less than 50% although the standard is well known by the nursing team. Even though the subjective perception has a high NPV, it does not achieve the standard.