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Ramírez-Estrada S, Peña-López Y, Serrano-Megías M, Rello J. Ventilator-associated events in adults: A secondary analysis assessing the impact of monitoring ventilator settings on outcomes. Anaesth Crit Care Pain Med 2024; 43:101363. [PMID: 38432476 DOI: 10.1016/j.accpm.2024.101363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Ventilator-associated events (VAE) is a tier implemented for surveillance by the CDC in the USA. Implementation usefulness for clinical decisions is unknown. METHODS We conducted a secondary analysis from a prospective, multicentre, international study, to assess the impact on outcomes of using tiers with shorter follow-up (VAE24), lower oxygenation requirements (light-VAE) or both (light VAE24). RESULTS A cohort of 261 adults with 2706 ventilator-days were included. The median (IQR) duration of mechanical ventilation (MV) was 9 days (5-21), and the median (IQR) length of stay in the intensive care unit (ICU) was 14 days (8-26). A VAE tier was associated with a trend to increase from 32% to 44% in the ICU mortality rates. VAE Incidence was 24 per 1,000 ventilator-days, being increased when reduced the oxygenation settings requirement (35 per 1,000 ventilator-days), follow-up (41 per 1,000 ventilator-days) or both (55 per 1,000 ventilator-days). A VAE tier was associated with 13 extra (21 vs. 8) days of ventilation, 11 (23 vs. 12) ICU days and 7 (31 vs. 14) hospitalization days, outperforming the modified tiers' performance. CONCLUSIONS The modification of ventilator settings (consistent with ventilator-associated events) was associated with worse outcomes among adults with prolonged mechanical ventilation. Monitoring ventilator-associated events at the bedside represents a new tool for quality improvement.
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Affiliation(s)
| | - Yolanda Peña-López
- Global Health eCore, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Hospital Campus, Barcelona 08035, Spain; University of Texas Southwestern Medical Center, Dallas, TX 75235, USA.
| | - Marta Serrano-Megías
- Greenlife Research Group, Health Science, University of San Jorge, Zaragoza 50830, Spain.
| | - Jordi Rello
- Formation, Recherche, Evaluation (FOREVA), Centre Hôpitalier Universitaire Nîmes, Nîmes 30900, France.
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Simmons JSC, Bourgault AM, Sole ML, Peach BC. A Review of Chlorhexidine Oral Care in Patients Receiving Mechanical Ventilation. Crit Care Nurse 2024; 44:45-53. [PMID: 38821530 DOI: 10.4037/ccn2024995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
BACKGROUND Chlorhexidine gluconate has been considered the criterion standard of oral care for patients receiving mechanical ventilation because of its ability to reduce the incidence of ventilator-associated events. Optimal concentrations and frequencies remain unclear, as do adverse events related to mortality in various intensive care unit populations. OBJECTIVE To examine the current evidence for the efficacy of chlorhexidine gluconate in reducing the incidence of ventilator-associated events, mortality, intensive care unit length of stay, and duration of mechanical ventilation in patients receiving ventilator support. METHODS In this integrative review, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, and Health Source: Nursing/Academic Edition were searched using terms related to mechanical ventilation and chlorhexidine gluconate oral care with dates ranging from 2012 to 2023. RESULTS Seventeen articles were included in this review: 8 systematic reviews, 8 randomized clinical trials (3 of which were not included in any systematic review), and 1 quasi-experimental study. Chlorhexidine gluconate oral care was associated with a reduced incidence of ventilator-associated events, but efficacy depended on concentration and frequency of administration. With stratification by intensive care unit population type, a nonsignificant trend toward increased mortality was found among non-cardiac surgical patients who received this care. CONCLUSION The evidence regarding the efficacy of chlorhexidine gluconate oral care in reducing ventilator-associated events in specific intensive care unit populations is contradictory. Recently published guidelines recommend de-implementation of chlorhexidine gluconate oral care in all patients receiving mechanical ventilation. Such care may be beneficial only in the cardiac surgical population.
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Affiliation(s)
| | - Annette M Bourgault
- Annette M. Bourgault is an associate professor, University of Central Florida College of Nursing. She is the Editor of Critical Care Nurse journal
| | - Mary Lou Sole
- Mary Lou Sole is the Dean and a professor, University of Central Florida College of Nursing
| | - Brian C Peach
- Brian C. Peach is an assistant professor, University of Central Florida College of Nursing
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Al-Dorzi HM, Arabi YM. Quality Indicators in Adult Critical Care Medicine. GLOBAL JOURNAL ON QUALITY AND SAFETY IN HEALTHCARE 2024; 7:75-84. [PMID: 38725886 PMCID: PMC11077517 DOI: 10.36401/jqsh-23-30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/29/2023] [Accepted: 10/31/2023] [Indexed: 05/12/2024]
Abstract
Quality indicators are increasingly used in the intensive care unit (ICU) to compare and improve the quality of delivered healthcare. Numerous indicators have been developed and are related to multiple domains, most importantly patient safety, care timeliness and effectiveness, staff well-being, and patient/family-centered outcomes and satisfaction. In this review, we describe pertinent ICU quality indicators that are related to organizational structure (such as the availability of an intensivist 24/7 and the nurse-to-patient ratio), processes of care (such as ventilator care bundle), and outcomes (such as ICU-acquired infections and standardized mortality rate). We also present an example of a quality improvement project in an ICU indicating the steps taken to attain the desired changes in quality measures.
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Affiliation(s)
- Hasan M. Al-Dorzi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Intensive Care, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Yaseen M. Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Intensive Care, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
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4
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Guillamet CV, Kollef MH. Is Zero Ventilator-Associated Pneumonia Achievable? Updated Practical Approaches to Ventilator-Associated Pneumonia Prevention. Infect Dis Clin North Am 2024; 38:65-86. [PMID: 38040518 DOI: 10.1016/j.idc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions took pride in implementing effective VAP prevention bundles that combined at least head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. Spontaneous breathing and awakening trials have also consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP.
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Affiliation(s)
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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de Araújo ECF, da Silva RO, Raymundo MLB, Vieira TI, de Sousa SA, Santiago BM, Cavalcanti YW. Does the presence of oral health teams influence the incidence of ventilator-associated pneumonia and mortality of patients in intensive care units? Systematic review. SPECIAL CARE IN DENTISTRY 2023; 43:452-463. [PMID: 36210508 DOI: 10.1111/scd.12785] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/05/2022] [Accepted: 09/10/2022] [Indexed: 07/21/2023]
Abstract
AIMS To verify whether oral health teams influence the oral health status, ventilator-associated pneumonia incidence and mortality rate of patients in Intensive Care Units (ICU). MATERIALS AND METHODS Bibliographic searches were performed in PubMed, Scopus, Web of Science, Lilacs, Embase, Livivo, Open Grey, Academic Google, and Cochrane databases. The assessment of the methodological quality and risk of bias of the included studies and a random-effects meta-analysis to summarize relative risk data for ventilator-associated pneumonia (VAP) and mortality were performed. An analysis of the certainty of the evidence was performed for the main outcomes analyzed. RESULTS Records of 518 studies were analyzed by reading titles and abstracts. Five studies were included according to eligibility criteria. The meta-analysis showed that ICU patients undergoing dental care by an oral health team had a lower incidence of VAP (OR = 0.33; 95% CI: 014-0.76) but did not lower mortality rates (OR = 0.46 95% CI: 0.16-1.32). The certainty of the evidence was considered very low. CONCLUSION Dental care provided by oral health teams in a hospital environment did not influence oral health status or mortality, although it contributed to a reduction in VAP of patients admitted to the ICU.
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Affiliation(s)
- Elza Cristina Farias de Araújo
- Department of Clinical and Social Dentistry, University of Paraíba (UFPB), Cidade Universitária, João Pessoa, Paraíba, Brazil
| | - Rênnis Oliveira da Silva
- Department of Clinical and Social Dentistry, University of Paraíba (UFPB), Cidade Universitária, João Pessoa, Paraíba, Brazil
| | - Maria Letícia Barbosa Raymundo
- Department of Clinical and Social Dentistry, University of Paraíba (UFPB), Cidade Universitária, João Pessoa, Paraíba, Brazil
| | - Thiago Isidro Vieira
- Department of Clinical and Social Dentistry, University of Paraíba (UFPB), Cidade Universitária, João Pessoa, Paraíba, Brazil
| | - Simone Alves de Sousa
- Department of Clinical and Social Dentistry, University of Paraíba (UFPB), Cidade Universitária, João Pessoa, Paraíba, Brazil
| | - Bianca Marques Santiago
- Department of Clinical and Social Dentistry, University of Paraíba (UFPB), Cidade Universitária, João Pessoa, Paraíba, Brazil
| | - Yuri Wanderley Cavalcanti
- Department of Clinical and Social Dentistry, University of Paraíba (UFPB), Cidade Universitária, João Pessoa, Paraíba, Brazil
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6
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Arabi YM, Al Aseri Z, Alsaawi A, Al Khathaami AM, Al Qasim E, Alzahrani AA, Al Qarni M, Abdukahil SAI, Al-Dorzi HM, Alattasi A, Mandourah Y, Alaama TY, Alabdulaali MK, Alqahtani A, Shuaibi A, Al Qarni A, Alkatheri M, Al Hazme RH, Vishwakarma RK, Aldibasi O, Alshahrani MS, Attia A, Alharthy A, Mady A, Abdelrahman BA, Mhawish HA, Abdallah HA, Al-Hameed F, Alghamdi K, Alghamdi A, Almekhlafi GA, Qasim SAH, Al Haji HA, Al Mutairi M, Tashkandi N, Alabbasi SO, Al Shehri T, Moftah E, Kalantan B, Matroud A, Naidu B, Al Zayer S, Burrows V, Said Z, Soomro NA, Yousef MH, Fattouh AA, Tahoon MA, Muhammad M, Alruwili AM, Al Hanafi HA, Dandekar PB, Ibrahim K, AlHomsi M, Al Harbi AR, Saleem A, Masih E, Al Rashidi NM, Amanatullah AK, Al Mubarak J, Al Radwan AAA, Al Hassan A, Al Muoalad S, Alzahrani AA, Chalabi J, Qureshi A, Al Ansari M, Sallam H, Elhazmi A, Alkhaldi F, Malibary A, Ababtain A, Latif A, Berenholtz SM. Impact of a national collaborative project to improve the care of mechanically ventilated patients. PLoS One 2023; 18:e0280744. [PMID: 36716310 PMCID: PMC9886257 DOI: 10.1371/journal.pone.0280744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/19/2022] [Indexed: 02/01/2023] Open
Abstract
This prospective quasi-experimental study from the NASAM (National Approach to Standardize and Improve Mechanical Ventilation) collaborative assessed the impact of evidence-based practices including subglottic suctioning, daily assessment for spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), head of bed elevation, and avoidance of neuromuscular blockers unless otherwise indicated. The study outcomes included VAE (primary) and intensive care unit (ICU) mortality. Changes in daily care process measures and outcomes were evaluated using repeated measures mixed modeling. The results were reported as incident rate ratio (IRR) for each additional month with 95% confidence interval (CI). A comprehensive program that included education on evidence-based practices for optimal care of mechanically ventilated patients with real-time benchmarking of daily care process measures to drive improvement in forty-two ICUs from 26 hospitals in Saudi Arabia (>27,000 days of observation). Compliance with subglottic suctioning, SAT and SBT increased monthly during the project by 3.5%, 2.1% and 1.9%, respectively (IRR 1.035, 95%CI 1.007-1.064, p = 0.0148; 1.021, 95% CI 1.010-1.032, p = 0.0003; and 1.019, 95%CI 1.009-1.029, p = 0.0001, respectively). The use of neuromuscular blockers decreased monthly by 2.5% (IRR 0.975, 95%CI 0.953-0.998, p = 0.0341). The compliance with head of bed elevation was high at baseline and did not change over time. Based on data for 83153 ventilator days, VAE rate was 15.2/1000 ventilator day (95%CI 12.6-18.1) at baseline and did not change during the project (IRR 1.019, 95%CI 0.985-1.053, p = 0.2812). Based on data for 8523 patients; the mortality was 30.4% (95%CI 27.4-33.6) at baseline, and decreased monthly during the project by 1.6% (IRR 0.984, 95%CI 0.973-0.996, p = 0.0067). A national quality improvement collaborative was associated with improvements in daily care processes. These changes were associated with a reduction in mortality but not VAEs. Registration The study is registered in clinicaltrials.gov (NCT03790150).
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Affiliation(s)
- Yaseen M. Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- * E-mail:
| | - Zohair Al Aseri
- Department of Emergency, Department of Intensive Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulmohsen Alsaawi
- Department of Medical Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ali M. Al Khathaami
- Quality and Patient Safety Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Eman Al Qasim
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Abdullah A. Alzahrani
- Quality and Patient Safety Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Al Qarni
- Quality and Patient Safety Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sheryl Ann I. Abdukahil
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Hasan M. Al-Dorzi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Abdulaleem Alattasi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Yasser Mandourah
- Department of Military Medical Services, Ministry of Defense, Riyadh, Saudi Arabia
| | - Tareef Y. Alaama
- Deputyship of Curative Services, Ministry of Health, Riyadh, Saudi Arabia
| | | | - Abdulrahman Alqahtani
- Executive Director of Medical Affairs Department, Ministry of Health, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ahmad Shuaibi
- Department of Medical Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Dammam, Saudi Arabia
| | - Ali Al Qarni
- Department of Medicine, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa, Saudi Arabia
| | - Mufareh Alkatheri
- Quality and Patient Safety Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Raed H. Al Hazme
- Department of Health Informatics, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Biomedical Informatics, College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Ramesh Kumar Vishwakarma
- Department of Bioinformatics and Biostatistics, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Statistics Department, European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Omar Aldibasi
- Department of Bioinformatics and Biostatistics, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Saeed Alshahrani
- Department of Critical Care, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Ashraf Attia
- Department of Critical Care, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | | | - Ahmed Mady
- Department of Intensive Care, King Saud Medical City, Riyadh, Saudi Arabia
- Department of Anesthesiology and Intensive Care, Tanta University Hospital, Tanta, Egypt
| | | | - Huda Ahmad Mhawish
- Department of Intensive Care, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Fahad Al-Hameed
- Department of Intensive Care, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Khalid Alghamdi
- Department of Intensive Care, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Adnan Alghamdi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ghaleb A. Almekhlafi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Saleh Abdorabo Haider Qasim
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Hussain Ali Al Haji
- Respiratory Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Al Mutairi
- Respiratory Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nabiha Tashkandi
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shatha Othman Alabbasi
- Respiratory Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Tariq Al Shehri
- Respiratory Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Emad Moftah
- Rehabilitation Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Basim Kalantan
- Rehabilitation Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Amal Matroud
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Brintha Naidu
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Salha Al Zayer
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Victoria Burrows
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Zayneb Said
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | | | | | | | - Majdi Muhammad
- Department of Intensive Care, Gurayat General Hospital, AlGurayat, Saudi Arabia
| | | | | | | | - Kamel Ibrahim
- Department of Intensive Care, King Khalid General Hospital, Majmaah, Saudi Arabia
| | - Mwafaq AlHomsi
- Department of Intensive Care, Buraydah Central Hospital, AlQassim, Saudi Arabia
| | - Asma Rayan Al Harbi
- Department of Intensive Care, King Fahad Specialist Hospital, AlQassim, Saudi Arabia
| | - Adel Saleem
- Department of Intensive Care, King Faisal Hospital, Makkah, Saudi Arabia
| | - Ejaz Masih
- Department of Intensive Care, King Khaled Hospital, Tabuk, Saudi Arabia
| | | | | | - Jaffar Al Mubarak
- Respiratory Services, King Khalid General Hospital, Hafer Al Batin, Saudi Arabia
| | | | - Ali Al Hassan
- Department of Intensive Care, King Khalid Hospital, Najran, Saudi Arabia
| | - Sadiyah Al Muoalad
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ammar Abdullah Alzahrani
- Respiratory Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Jamal Chalabi
- Department of Intensive Care, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa, Saudi Arabia
| | - Ahmad Qureshi
- Department of Intensive Care, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Madinah, Saudi Arabia
| | - Maryam Al Ansari
- Department of Intensive Care, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Dammam, Saudi Arabia
| | - Hend Sallam
- Department of Intensive Care, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Alyaa Elhazmi
- Department of Intensive Care, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fawziah Alkhaldi
- Nursing Services, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulrauf Malibary
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah Ababtain
- Respiratory Services, Royal Commission Health Services Program, Jubayl, Saudi Arabia
| | - Asad Latif
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Sean M. Berenholtz
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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7
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Deng J, Li F, Zhang N, Zhong Y. Prevention and treatment of ventilator-associated pneumonia in COVID-19. Front Pharmacol 2022; 13:945892. [PMID: 36339583 PMCID: PMC9627032 DOI: 10.3389/fphar.2022.945892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/07/2022] [Indexed: 07/10/2024] Open
Abstract
Ventilator-associated pneumonia (VAP) is the most common acquired infection in the intensive care unit. Recent studies showed that the critical COVID-19 patients with invasive mechanical ventilation have a high risk of developing VAP, which result in a worse outcome and an increasing economic burden. With the development of critical care medicine, the morbidity and mortality of VAP remains high. Especially since the outbreak of COVID-19, the healthcare system is facing unprecedented challenges. Therefore, many efforts have been made in effective prevention, early diagnosis, and early treatment of VAP. This review focuses on the treatment and prevention drugs of VAP in COVID-19 patients. In general, prevention is more important than treatment for VAP. Prevention of VAP is based on minimizing exposure to mechanical ventilation and encouraging early release. There is little difference in drug prophylaxis from non-COVID-19. In term of treatment of VAP, empirical antibiotics is the main treatment, special attention should be paid to the antimicrobial spectrum and duration of antibiotics because of the existence of drug-resistant bacteria. Further studies with well-designed and large sample size were needed to demonstrate the prevention and treatment of ventilator-associated pneumonia in COVID-19 based on the specificity of COVID-19.
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Affiliation(s)
- Jiayi Deng
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Fanglin Li
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Ningjie Zhang
- Department of Blood Transfusion, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yanjun Zhong
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
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Hassan EA, Elsaman SEA. Relationship between ventilator bundle compliance and the occurrence of ventilator-associated events: a prospective cohort study. BMC Nurs 2022; 21:207. [PMID: 35915444 PMCID: PMC9341085 DOI: 10.1186/s12912-022-00997-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 07/26/2022] [Indexed: 11/12/2022] Open
Abstract
Background Instead of ventilator-associated pneumonia (VAP), the modern definition of ventilator-associated events (VAEs) has been introduced to identify infectious and noninfectious respiratory complications. Some studies revealed that compliance to the ventilator bundle is associated with decreased occurrence of VAP, but little is known about its association with the decrease of VAEs occurrence. Methods A prospective cohort research design was used. Data were collected over eight months from May 2019 to February 2020 in five general intensive care units. The researchers assessed the compliance to ventilator care bundle using the Institute for Healthcare Improvement ventilation bundle checklist. Mechanically ventilated patients were prospectively assessed for the occurrence of VAEs using a pre-validated calculator from the Centers for Disease Control and Prevention. All are non-invasive tools and no intervention was done by the authors. Results A total of 141 mechanically ventilated patients completed the study. The odds ratio of having VAEs in patients who received ventilator bundle was -1.19 (95% CI, -2.01 to -0.38), a statistically significant effect, Wald χ2(1) = 8.18, p = 0.004. Conclusion/ implications for practice Ventilator bundle compliance was associated with a reduced risk for VAEs occurrence. Nurses should comply with the ventilator bundle because it is associated with decreased VAEs occurrence.
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Affiliation(s)
- Eman Arafa Hassan
- Critical Care and Emergency Nursing Department, Faculty of Nursing, Alexandria University, Alexandria, Egypt.
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9
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Wang M, Wang W, Jia X, He Q, Zhu S, Kang Y, Zhang R, Ren Y, Li L, Zou K, Zong Z, Sun X. Associations Between Antithrombosis and Ventilator-Associated Events, ICU Stays, and Mortality Among Mechanically Ventilated Patients: A Registry-Based Cohort Study. Front Pharmacol 2022; 13:891178. [PMID: 35924051 PMCID: PMC9339989 DOI: 10.3389/fphar.2022.891178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background: The effect of thromboembolism prophylaxis on clinical outcomes, such as ventilator-associated events (VAEs), ICU stays, and mortality, remains controversial. This study was conducted to evaluate the effect of pharmacological thromboprophylaxis on VAEs, ICU stays, and ICU mortality among patients receiving mechanical ventilation (MV). Materials and Methods: A retrospective cohort study was conducted based on a well-established registry of healthcare-associated infections at ICUs in the West China Hospital system. Patients who consistently received MV for at least 4 days from 1 April 2015 to 31 December 2018 were included. Hazard ratios (HRs) were compared for three tiers of VAEs, ICU stays, and ICU mortality among patients receiving pharmacological thromboprophylaxis versus those without using the time-dependent Cox model. For the analyses of ICU stays and ICU mortality, we also used Fine-Gray models to disentangle the competing risks and outcomes of interest. Results: Overall, 6,140 patients were included. Of these, 3,805 received at least one prescription of antithrombosis agents. Treatments with antithrombosis agents were associated with lower risk of VAEs (HR: 0.87, 95% CI: 0.77, 0.98) and ICU mortality (HR: 0.72, 95% CI: 0.61, 0.86) than those without. Anticoagulants but not antiplatelet agents were associated with decreased risk of VAEs (HR: 0.86, 95% CI: 0.75, 0.98), ICU mortality (HR: 0.62, 95% CI: 0.51, 0.76), and less time to ICU discharge (HR: 1.15, 95% CI: 1.04, 1.28). Antithrombosis may be associated with decreased risk of VAEs in patients with D-dimer >5 mg/LFEU (HR: 0.84, 95%CI: 0.72, 0.98). Conclusions: Pharmacological thromboprophylaxis was associated with lower risk of VAEs and ICU mortality. Similar effects were observed between unfractionated heparins versus low-molecular-weight heparins.
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Affiliation(s)
- Mingqi Wang
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Wen Wang
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Xue Jia
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- Department of Postgraduate, West China Hospital of Sichuan University, Chengdu, China
| | - Qiao He
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Shichao Zhu
- Department of Infection Control, West China Hospital of Sichuan University, Chengdu, China
| | - Yan Kang
- Intensive Care Unit, West China Hospital of Sichuan University, Chengdu, China
| | - Rui Zhang
- Information Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Ren
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Ling Li
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Kang Zou
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Zhiyong Zong
- Department of Infection Control, West China Hospital of Sichuan University, Chengdu, China
- Center of Infection Diseases, West China Hospital of Sichuan University, Chengdu, China
- *Correspondence: Xin Sun, ; Zhiyong Zong,
| | - Xin Sun
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
- *Correspondence: Xin Sun, ; Zhiyong Zong,
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10
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Hu L, Peng K, Huang X, Wang Z, Wu Q, Xiao Y, Hou Y, He Y, Zhou X, Chen C. Ventilator-associated pneumonia prevention in the Intensive care unit using Postpyloric tube feeding in China (VIP study): study protocol for a randomized controlled trial. Trials 2022; 23:478. [PMID: 35681155 PMCID: PMC9178536 DOI: 10.1186/s13063-022-06407-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 05/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia is a challenge in critical care and is associated with high mortality and morbidity. Although some consensuses on preventing ventilator-associated pneumonia are reached, it is still somewhat controversial. Meta-analysis has shown that postpyloric tube feeding may reduce the incidences of ventilator-associated pneumonia, which still desires high-quality evidence. This trial aims to evaluate the efficacy and safety profiles of postpyloric tube feeding versus gastric tube feeding. METHODS/DESIGN In this multicenter, open-label, randomized controlled trial, we will recruit 924 subjects expected to receive mechanical ventilation for no less than 48 h. Subjects on mechanical ventilation will be randomized (1:1) to receive postpyloric or gastric tube feeding and routine preventive measures simultaneously. The primary outcome is the proportion of patients with at least one ventilator-associated pneumonia episode. Adverse events and serious adverse events will be observed closely. DISCUSSION The VIP study is a large-sample-sized, multicenter, open-label, randomized, parallel-group, controlled trial of postpyloric tube feeding in China and is well-designed based on previous studies. The results of this trial may help to provide evidence-based recommendations for the prevention of ventilator-associated pneumonia. TRIAL REGISTRATION Chictr.org.cn ChiCTR2100051593 . Registered on 28 September 2021.
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Affiliation(s)
- Linhui Hu
- Department of Critical Care Medicine, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China.,Department of Clinical Research Center, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China
| | - Kaiyi Peng
- Department of Critical Care Medicine, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China
| | - Xiangwei Huang
- Department of Critical Care Medicine, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China
| | - Zheng Wang
- Department of Critical Care Medicine, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China
| | - Quanzhong Wu
- Department of Surgical Intensive Care Unit, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China
| | - Yumei Xiao
- Department of Neurocritical Care Unit, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China
| | - Yating Hou
- Department of Oncology, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China
| | - Yuemei He
- Department of Clinical Research Center, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China
| | - Xinjuan Zhou
- Department of Clinical Research Center, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China
| | - Chunbo Chen
- Department of Critical Care Medicine, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China. .,Department of Clinical Research Center, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, Guangdong, China. .,Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080, Guangdong, China. .,Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, China. .,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510080, Guangdong, China.
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11
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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12
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Li HY, Wang HS, Wang YL, Wang J, Huo XC, Zhao Q. Management of Ventilator-Associated Pneumonia: Quality Assessment of Clinical Practice Guidelines and Variations in Recommendations on Drug Therapy for Prevention and Treatment. Front Pharmacol 2022; 13:903378. [PMID: 35668946 PMCID: PMC9163435 DOI: 10.3389/fphar.2022.903378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/29/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose: To assess the quality of clinical practice guidelines (CPGs) related to drug therapy for prevention and control of ventilator-associated pneumonia (VAP) and compare the differences and similarities between recommendations. Methods: Electronic databases (including PubMed, Cochrane library, Embase, Web of Science), guideline development organizations, and professional societies were searched to identify CPGs for VAP from 20 January 2012 to 20 January 2022. The Appraisal of Guidelines Research & Evaluation (AGREE) II instrument was used to evaluate the quality of the guidelines. The recommendations on drug therapy for prevention and treatment for each guideline were extracted, and then a descriptive synthesis was performed to analyze the scope/topic, and consistency of the recommendations. Results: Thirteen CPGs were included. The median score and interquartile range (IQR) in each domain are shown below: scope and purpose 72.22% (63.89%,83.33%); stakeholder involvement 44.44% (38.89%,52.78%); rigor of development 43.75% (31.25%,57.29%); clarity and presentation 94.44% (77.78%,94.44%); applicability 20.83 (8.34%,33.34%) and editorial independence 50% (33.33%,66.67%). We extracted 21 recommendations on drug therapy for prevention of VAP and 51 recommendations on drugs used for treatment. Some controversies remained among the included guidelines. Conclusion: There is considerable variability in the development processes and reporting of VAP guidelines. Despite many similarities, the recommendations still had some inconsistencies in the details. For the prevention and treatment of VAP, local microbial epidemiology and antibiotic sensitivity must be considered, and recommendations should be regularly revised as new evidence emerges.
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Affiliation(s)
- Hong-Yan Li
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Hai-Shan Wang
- Department of Intensive Care Unit, Yantai YEDA Hospital, Yantai, China
| | - Ying-Lin Wang
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Jing Wang
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Xue-Chen Huo
- Department of Hepatobiliary Surgery, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
- *Correspondence: Xue-Chen Huo, ; Quan Zhao,
| | - Quan Zhao
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
- *Correspondence: Xue-Chen Huo, ; Quan Zhao,
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13
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Vieira PC, de Oliveira RB, da Silva Mendonça TM. Should oral chlorhexidine remain in ventilator-associated pneumonia prevention bundles? Med Intensiva 2022; 46:259-268. [PMID: 35598950 DOI: 10.1016/j.medine.2020.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/23/2020] [Indexed: 01/19/2023]
Abstract
Ventilator-associated pneumonia (VAP) is related with high mortality, duration of mechanical ventilation and costs. Recent studies have questioned the safety and effectiveness of oral chlorhexidine to prevent VAP. We sought to verify whether the adverse effects of this substance outweigh its benefits. We searched several databases and selected studies that investigated the use of oral chlorhexidine and its impact on mortality. No association between oral chlorhexidine and lower VAP rates was found on meta-analyses of double-blind randomized trials, however significant increase in mortality was reported. It is speculated that chlorhexidine can cause damage to several organic sectors and cytotoxicity. Although it still can be beneficial in specific settings, robust evidence to recommend its routine application for all mechanically ventilated patients is lacking; therefore, given the possibility of harm, it would be better to follow the principle of non-maleficence until more studies becomes available.
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Affiliation(s)
- P C Vieira
- Intensive Care Unit, Uberlândia Clinical Hospital, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil; Health Science PhD Program, Faculty of Medicine, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil; Neurointensivism Postgraduate Program, Teaching and Research Institute, Sírio-Libanês Hospital, Bela Vista, São Paulo, Brazil.
| | - R B de Oliveira
- Intensive Care Unit, Uberlândia Clinical Hospital, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil
| | - T M da Silva Mendonça
- Health Science PhD Program, Faculty of Medicine, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil
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14
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Song H, Hu W, Zhou X, Tao J, Zhang S, Su X, Wu W. Clinical Benefits From Administering Probiotics to Mechanical Ventilated Patients in Intensive Care Unit: A PRISMA-Guided Meta-Analysis. Front Nutr 2022; 8:798827. [PMID: 35155520 PMCID: PMC8829544 DOI: 10.3389/fnut.2021.798827] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/14/2021] [Indexed: 12/14/2022] Open
Abstract
Background The use of probiotics has been considered as a new intervention for ventilator-associated pneumonia (VAP) prevention in the intensive care unit (ICU). The aim of this meta-analysis was to evaluate the effect of probiotics on mechanical-ventilated patients in ICU. Methods PubMed, Embase, Scopus, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) from their respective inception through October 10, 2021. All studies meeting the inclusion criteria were selected to evaluate the effect of probiotics on patients receiving mechanical ventilation in ICU. Results A total of 15 studies involving 4,693 participants met our inclusion criterion and were included in this meta-analysis. The incidence of VAP in the probiotic group was significantly lower (odds ratio [OR] 0.58, 95% CI 0.41 to 0.81; p = 0.002; I2 = 71%). However, a publication bias may be present as the test of asymmetry was significant (p = 0.007). The probiotic administration was associated with a significant reduction in the duration of mechanical ventilation (mean difference [MD] −1.57, 95% CI −3.12 to −0.03; p = 0.05; inconsistency [I]2 = 80%), length of ICU stay (MD −1.87, 95% CI −3.45 to −0.28; p = 0.02; I2 = 76%), and incidence of bacterial colonization (OR 0.59, 95% CI 0.45 to 0.78; p = 0.0001; I2 = 34%). Moreover, no statistically significant differences were observed regarding the incidence of diarrhea (OR 0.90, 95% CI 0.65 to 1.25; p = 0.54; I2 = 12%) and mortality (OR 0.91, 95% CI 0.80 to 1.05; p = 0.19; I2 = 0%) between probiotics group and control group. Conclusion Our meta-analysis shows that probiotics are associated with a reduction in VAP, as well as the duration of mechanical ventilation, ICU length of stay, and bacterial colonization, but no significant effects on ICU mortality and occurrence of diarrhea. However, in consideration of the significant heterogeneity and publication bias, our findings need to be further validated. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42020150770.
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Affiliation(s)
- Hongzhuan Song
- Department of Hematology, Haining People's Hospital, Haining, China
| | - Wenqing Hu
- Department of Emergency, Haining People's Hospital, Haining, China
| | - Xiujie Zhou
- Department of Hematology, Haining People's Hospital, Haining, China
| | - Jiaping Tao
- Department of Hematology, Haining People's Hospital, Haining, China
| | - Siyi Zhang
- Department of Hematology, Haining People's Hospital, Haining, China
| | - Xuhong Su
- Department of Hematology, Haining People's Hospital, Haining, China
| | - Wenjun Wu
- Department of Hematology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Wenjun Wu
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15
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Weinberger J, Cocoros N, Klompas M. Ventilator-Associated Events: Epidemiology, Risk Factors, and Prevention. Infect Dis Clin North Am 2021; 35:871-899. [PMID: 34752224 DOI: 10.1016/j.idc.2021.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events in 2013 to increase the objectivity and reproducibility of surveillance and to encourage quality improvement programs to focus on preventing a broader array of complications. Ventilator-associated events are associated with a doubling of the risk of dying. Prospective studies have found that minimizing sedation, increasing spontaneous awakening and breathing trials, and conservative fluid management can decrease event rates and the duration of ventilation. Multifaceted interventions to enhance these practices can decrease ventilator-associated event rates.
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Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 200 Washington Street, Boston, MA 02111, USA
| | - Noelle Cocoros
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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16
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The Impact of a Multidisciplinary Education Program for Intensive Care Unit Staff Regarding Ventilator Care Bundle on the Frequency of Ventilator-Associated Events. Dimens Crit Care Nurs 2021; 40:210-216. [PMID: 34033440 DOI: 10.1097/dcc.0000000000000484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Ventilator bundles have been reported to reduce the risk of ventilator-associated pneumonia. However, data concerning the role of the education of the intensive care unit (ICU) staff regarding the items in the bundle and the importance to adhere to its items on the development of ventilator-associated events (VAEs) are limited. This study aimed to compare the frequency of VAEs in subjects admitted to the ICU before and after the education of the ICU staff. METHODS A total of 105 subjects were enrolled in this retrospective study. The ICU staff, including the physicians, respiratory therapists, and nurses, received a 2-day educational lecture regarding items in the bundle as well as the need to adhere to its items. The study population was divided into two according to the admission date: subjects who were admitted before the education of the ICU staff regarding the ventilator bundle (preeducation) and subjects who were admitted after the education of the ICU staff regarding the ventilator bundle (posteducation). The difference in VAE rate in subjects admitted before and after bundle training was the primary outcome measure of this study. RESULTS The bundle compliance rates presented by days were significantly higher in the posteducation group compared with the preeducation group. Moreover, the frequency of VAEs was significantly lower in posteducation subjects compared with preeducation subjects (4.7% vs 19.0%, P = .042). Ventilator-associated event rate was also lower in posteducation subjects compared with preeducation subjects (2.5/1000 vs 9.8/1000 ventilator days). There were no significant differences among the groups with respect to ICU mortality. CONCLUSION The educational intervention performed in this study not only increased the adherence to the ventilator care bundle but also led to a significant reduction in the rate of the VAEs in patients receiving mechanical ventilator support in the ICU.
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Caution, not causality: The limitations of risk factor and outcome research on ventilator-associated events. Infect Control Hosp Epidemiol 2021; 42:989-990. [PMID: 33934733 PMCID: PMC8280391 DOI: 10.1017/ice.2021.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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18
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Kanchanasuwan S, Kositpantawong N, Singkhamanan K, Hortiwakul T, Charoenmak B, Ozioma F N, Doi Y, Chusri S. Outcomes of Adjunctive Therapy with Intravenous Cefoperazone-Sulbactam for Ventilator-Associated Pneumonia Due to Carbapenem-Resistant Acinetobacter baumannii. Infect Drug Resist 2021; 14:1255-1264. [PMID: 33824595 PMCID: PMC8018428 DOI: 10.2147/idr.s305819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/18/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction The efficacy of adjunctive therapy with cefoperazone-sulbactam (CEP-SUL) for ventilator-associated pneumonia (VAP) due to carbapenem-resistant A. baumannii (CRAB) is unclear. Methods We retrospectively analyzed the therapeutic effect of adding CEP-SUL to standard regimens for VAP due to CRAB. Patients with VAP due to CRAB strains that were susceptible to CEP-SUL were enrolled into the study. The patients were divided into two groups: those who receive cefoperazone-sulbactam (CEP-SUL+), and those who did not receive cefoperazone-sulbactam (CEP-SUL). Mortality rates and resource utilization of these two groups were compared. Factors associated with mortality were explored. Results Eighty patients were enrolled into the study, 52 CEP-SUL+ and 28 CEP-SUL-. The baseline characteristics of the two groups were comparable, except for median Acute Physiology and Chronic Health Evaluation (APACHE) II score which was significantly higher for CEP-SUL+. Thirty-day, and in-hospital mortality rates for CEP-SUL+ were significantly lower than CEP-SUL- with values of 35%, 39% and 61%, 68%, for CEP-SUL+ and CEP-SUL-, respectively. The survival rate for CEP-SUL+ was significantly higher compared with CEP-SUL- (P < 0.001). The number of hospital days, ventilator days since diagnosis of VAP and hospital costs were lower for CEP-SUL+. Conclusion Overall results suggested that patients with VAP due to CRAB strains who received adjunctive therapy with CEP-SUL had lower mortality rates and resource utilization compared with CEP-SUL-.
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Affiliation(s)
- Siripen Kanchanasuwan
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Narongdet Kositpantawong
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Kamonnut Singkhamanan
- Department of Biomedical Sciences, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Thanaporn Hortiwakul
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Boonsri Charoenmak
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Nwabor Ozioma F
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand.,Excellence Research Laboratory on Natural Products, Division of Biological Science, Faculty of Science and Natural Product Research Center of Excellence, Prince of Songkla University, Hat Yai, Songkhla, 90112, Thailand
| | - Yohei Doi
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Microbiology, Fujita Health University, Aichi, Japan
| | - Sarunyou Chusri
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand.,Department of Biomedical Sciences, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
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He Q, Wang W, Zhu S, Wang M, Kang Y, Zhang R, Zou K, Zong Z, Sun X. The epidemiology and clinical outcomes of ventilator-associated events among 20,769 mechanically ventilated patients at intensive care units: an observational study. Crit Care 2021; 25:44. [PMID: 33531078 PMCID: PMC7851639 DOI: 10.1186/s13054-021-03484-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 01/27/2021] [Indexed: 02/06/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection (HAI) in intensive care units (ICUs). Ventilator-associated event (VAE), a more objective definition, has replaced traditional VAP surveillance and is now widely used in the USA. However, the adoption outside the USA is limited. This study aims to describe the epidemiology and clinical outcomes of VAEs in China, based on a prospectively maintained registry. Methods An observational study was conducted using an ICU-HAI registry in west China. Patients that were admitted to ICUs and underwent mechanical ventilation (MV) between April 1, 2015, and December 31, 2018, were included. The characteristics and outcomes were compared between patients with and without VAEs. The rates of all VAEs dependent on different ICUs were calculated, and the pathogen distribution of patients with possible VAP (PVAP) was described. Results A total of 20,769 ICU patients received MV, accounting for 21,723 episodes of mechanical ventilators and 112,697 ventilator-days. In all, we identified 1882 episodes of ventilator-associated condition (VAC) events (16.7 per 1000 ventilator-days), 721 episodes of infection-related ventilator-associated complications (IVAC) events (6.4 per 1000 ventilator-days), and 185 episodes of PVAP events (1.64 per 1000 ventilator-days). The rates of VAC varied across ICUs with the highest incidence in surgical ICUs (23.72 per 1000 ventilator-days). The median time from the start of ventilation to the onset of the first VAC, IVAC, and PVAP was 5 (3–8), 5 (3–9), and 6 (4–13) days, respectively. The median length of hospital stays was 28.00 (17.00–43.00), 30.00 (19.00–44.00), and 30.00 (21.00–46.00) days for the three VAE tiers, which were all longer than that of patients without VAEs (16.00 [12.00–23.00]). The hospital mortality among patients with VAEs was more than three times of those with non-VAEs. Conclusions VAE was common in ICU patients with ≥ 4 ventilator days. All tiers of VAEs were highly correlated with poor clinical outcomes, including longer ICU and hospital stays and increased risk of mortality. These findings highlight the importance of VAE surveillance and the development of new strategies to prevent VAEs.
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Affiliation(s)
- Qiao He
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Wen Wang
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Shichao Zhu
- Department of Infection Control, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Mingqi Wang
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yan Kang
- Intensive Care Unit, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Rui Zhang
- Information Center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Kang Zou
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Zhiyong Zong
- Department of Infection Control, West China Hospital of Sichuan University, Chengdu, 610041, China. .,Center of Infection Diseases, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Xin Sun
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China.
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Vieira PC, de Oliveira RB, da Silva Mendonça TM. Should oral chlorhexidine remain in ventilator-associated pneumonia prevention bundles? Med Intensiva 2020; 46:S0210-5691(20)30325-9. [PMID: 33160703 DOI: 10.1016/j.medin.2020.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/15/2020] [Accepted: 09/23/2020] [Indexed: 12/12/2022]
Abstract
Ventilator-associated pneumonia (VAP) is related with high mortality, duration of mechanical ventilation and costs. Recent studies have questioned the safety and effectiveness of oral chlorhexidine to prevent VAP. We sought to verify whether the adverse effects of this substance outweigh its benefits. We searched several databases and selected studies that investigated the use of oral chlorhexidine and its impact on mortality. No association between oral chlorhexidine and lower VAP rates was found on meta-analyses of double-blind randomized trials, however significant increase in mortality was reported. It is speculated that chlorhexidine can cause damage to several organic sectors and cytotoxicity. Although it still can be beneficial in specific settings, robust evidence to recommend its routine application for all mechanically ventilated patients is lacking; therefore, given the possibility of harm, it would be better to follow the principle of non-maleficence until more studies becomes available.
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Affiliation(s)
- P C Vieira
- Intensive Care Unit, Uberlândia Clinical Hospital, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil; Health Science PhD Program, Faculty of Medicine, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil; Neurointensivism Postgraduate Program, Teaching and Research Institute, Sírio-Libanês Hospital, Bela Vista, São Paulo, Brazil.
| | - R B de Oliveira
- Intensive Care Unit, Uberlândia Clinical Hospital, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil
| | - T M da Silva Mendonça
- Health Science PhD Program, Faculty of Medicine, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil
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Nam K, Park JB, Park WB, Kim NJ, Cho Y, Jang HS, Hwang HY, Kim SH, Lee Y, Lee S, Bae J, Cho YJ, Kim EJ, Kim M, Jeon Y. Effect of Perioperative Subglottic Secretion Drainage on Ventilator-Associated Pneumonia After Cardiac Surgery: A Retrospective, Before-and-After Study. J Cardiothorac Vasc Anesth 2020; 35:2377-2384. [PMID: 33127285 DOI: 10.1053/j.jvca.2020.09.126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Although postoperative subglottic secretion drainage prevents ventilator-associated pneumonia (VAP) after cardiac surgery, its role during the perioperative period is unclear. For the present study, the effect of subglottic secretion drainage during and after cardiac surgery on postoperative VAP was investigated. DESIGN Retrospective, single-center, before-and-after study. SETTING Perioperative care of cardiac surgical patients in a tertiary university hospital. PARTICIPANTS Adult patients who underwent cardiac surgery from January 2013-December 2018. INTERVENTIONS Conventional and subglottic suctioning endotracheal tubes were used in the control and intervention groups before and after a change in institutional policy, respectively. In the intervention group, subglottic secretion drainage was performed continuously during surgery and intermittently after surgery. MEASUREMENTS AND MAIN RESULTS The risk of postoperative VAP, identified by the National Healthcare Safety Network surveillance definition algorithm, was compared by weighted logistic regression. Logistic regression analyses, with propensity score matching and inverse probability weighting, also were performed. A total of 2,576 patients were analyzed (control [n = 2108]; intervention [n = 468]). Postoperative VAP occurred less frequently in the intervention group (1/468 [0.2%]) compared with the control group (30/2,108 [1.4%]). In the multivariate weighted logistic regression analysis, the risk of VAP after cardiac surgery was significantly lower in the intervention group than in the control group (odds ratio 0.29; 95% confidence interval 0.14-0.58). Similar results were obtained in multivariate analyses after propensity score matching (odds ratio 0.04; 95% confidence interval 0.01-0.14) and inverse probability weighting (odds ratio 0.16; 95% confidence interval 0.05-0.42). CONCLUSIONS Routine perioperative subglottic secretion drainage using subglottic suctioning endotracheal tubes in patients undergoing cardiac surgery was associated with a reduction in the risk of VAP after surgery.
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Affiliation(s)
- Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Bin Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Younghae Cho
- Department of Statistics, Sungkyunkwan University, Seoul, Korea
| | - Hwan Suk Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sue Hyun Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yeiwon Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jinyoung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Jin Kim
- Department of Infection Prevention and Control, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Minjeong Kim
- Infection Control Centre, Seoul National University Hospital, Seoul, Korea
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Risk factors and associated outcomes of ventilator-associated events developed in 28 days among sepsis patients admitted to intensive care unit. Sci Rep 2020; 10:12702. [PMID: 32728165 PMCID: PMC7391677 DOI: 10.1038/s41598-020-69731-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/20/2020] [Indexed: 12/16/2022] Open
Abstract
We hypothesized that Ventilator-Associated Event (VAE) within 28 days upon admission to medical intensive care units (ICUs) can be a predictor for poor outcomes in sepsis patients. We aimed to determine the risk factors and associated outcomes of VAE. A total of 453 consecutive mechanically ventilated (MV) sepsis patients were enrolled. Of them, 136 patients had immune profile study. Early VAE (< 7-day MV, n = 33) was associated with a higher mortality (90 days: 81.8% vs. 23.0% [non-VAE], P < 0.01), while late VAE (developed between 7 and 28 days, n = 85) was associated with longer MV day (43.8 days vs. 23.3 days [non-VAE], P < 0.05). The 90-day Kaplan–Meier survival curves showed three lines that separate the groups (non-VAE, early VAE, and late VAE). Cox regression models with time-varying coefficient covariates (adjusted for the number of days from intubation to VAE development) confirmed that VAE which occurred within 28 days upon admission to the medical ICUs can be associated with higher 90-day mortality. The risk factors for VAE development include impaired immune response (lower human leukocyte antigen D-related expression, higher interleukin-10 expression) and sepsis progression with elevated SOFA score (especially in coagulation sub-score).
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Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med 2020; 46:888-906. [PMID: 32157357 PMCID: PMC7095206 DOI: 10.1007/s00134-020-05980-0] [Citation(s) in RCA: 316] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 02/19/2020] [Indexed: 12/15/2022]
Abstract
Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections. Reported incidences vary widely from 5 to 40% depending on the setting and diagnostic criteria. VAP is associated with prolonged duration of mechanical ventilation and ICU stay. The estimated attributable mortality of VAP is around 10%, with higher mortality rates in surgical ICU patients and in patients with mid-range severity scores at admission. Microbiological confirmation of infection is strongly encouraged. Which sampling method to use is still a matter of controversy. Emerging microbiological tools will likely modify our routine approach to diagnosing and treating VAP in the next future. Prevention of VAP is based on minimizing the exposure to mechanical ventilation and encouraging early liberation. Bundles that combine multiple prevention strategies may improve outcomes, but large randomized trials are needed to confirm this. Treatment should be limited to 7 days in the vast majority of the cases. Patients should be reassessed daily to confirm ongoing suspicion of disease, antibiotics should be narrowed as soon as antibiotic susceptibility results are available, and clinicians should consider stopping antibiotics if cultures are negative.
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Affiliation(s)
- Laurent Papazian
- Médecine Intensive Réanimation, Hôpital Nord, Hôpitaux de Marseille, Chemin des Bourrely, 13015, Marseille, France. .,Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Groupe de recherche en Réanimation et Anesthésie de Marseille pluridisciplinaire (GRAM +), Faculté de médecine, Aix-Marseille Université, 13005, Marseille, France.
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, USA
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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24
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Wu VKS, Fong C, Walters AM, Lele AV. Prevalence, Clinical Characteristics, and Outcomes Related to Ventilator-Associated Events in Neurocritically Ill Patients. Neurocrit Care 2020; 33:499-507. [PMID: 31974871 PMCID: PMC7223985 DOI: 10.1007/s12028-019-00910-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background The prevalence, characteristics, and outcomes related to the ventilator-associated event(s) (VAE) in neurocritically ill patients are unknown and examined in this study. Methods A retrospective study was performed on neurocritically ill patients at a 413-bed level 1 trauma and stroke center who received three or more days of mechanical ventilation to describe rates of VAE, describe characteristics of patients with VAE, and examine the association of VAE on ventilator days, mortality, length of stay, and discharge to home. Results Over a 5-year period from 2014 through 2018, 855 neurocritically ill patients requiring mechanical ventilation were identified. A total of 147 VAEs occurred in 130 (15.2%) patients with an overall VAE rate of 13 per 1000 ventilator days and occurred across age, sex, BMI, and admission Glasgow Coma Scores. The average time from the start of ventilation to a VAE was 5 (range 3–48) days after initiation of mechanical ventilation. Using Centers for Disease Control and Prevention definitions, VAEs met criteria for a ventilator-associated condition in 58% of events (n = 85), infection-related VAE in 22% of events (n = 33), and possible ventilator-associated pneumonia in 20% of events (n = 29). A most common trigger for VAE was an increase in positive end-expiratory pressure (84%). Presence of a VAE was associated with an increase in duration of mechanical ventilation (17.4[IQR 20.5] vs. 7.9[8.9] days, p < 0.001, 95% CI 7.86–13.92), intensive care unit (ICU) length of stay (20.2[1.1] vs. 12.5[0.4] days, p < 0.001 95% CI 5.3–10.02), but not associated with in-patient mortality (34.1 vs. 31.3%. 95% CI 0.76–1.69) or discharge to home (12.7% vs. 16.3%, 95% 0.47–1.29). Conclusions VAE are prevalent in the neurocritically ill. They result in an increased duration of mechanical ventilation and ICU length of stay, but may not be associated with in-hospital mortality or discharge to home. Electronic supplementary material The online version of this article (10.1007/s12028-019-00910-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Christine Fong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Andrew M Walters
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA. .,Neurocritical Care Service, Neuroscience ICU, Seattle, USA. .,Department of Neurological Surgery, University of Washington, Seattle, WA, USA. .,Associate Faculty, Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, WA, 98104, USA.
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25
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Vincelette C, Thivierge-Southidara M, Rochefort CM. Conceptual and methodological challenges of studies examining the determinants and outcomes of omitted nursing care: A narrative review of the literature. Int J Nurs Stud 2019; 100:103403. [DOI: 10.1016/j.ijnurstu.2019.103403] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/30/2019] [Accepted: 08/19/2019] [Indexed: 10/26/2022]
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Barriers to the adoption of ventilator-associated events surveillance and prevention. Clin Microbiol Infect 2019; 25:1180-1185. [DOI: 10.1016/j.cmi.2019.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/28/2019] [Accepted: 03/28/2019] [Indexed: 12/12/2022]
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Liu J, Zhang S, Chen J, Mao Y, Shao X, Li Y, Cao J, Zheng W, Zhang B, Zong Z. Risk factors for ventilator-associated events: A prospective cohort study. Am J Infect Control 2019; 47:744-749. [PMID: 30584021 DOI: 10.1016/j.ajic.2018.09.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 09/28/2018] [Accepted: 09/28/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND In January 2013, the Centers for Disease Control and Prevention released new surveillance definitions for ventilator-associated event (VAE) to replace ventilator-associated pneumonia (VAP) in adult patients. VAEs are associated with prolonged mechanical ventilation and hospital death, but little is known about their risk factors and how best to prevent them. METHODS We compared VAE cases with non-VAE cases with regard to demographics, comorbidities, sedative exposures, opioids exposures, paralytic exposures, routes of nutrition, blood products, gastric retention, and fluid balance. Patients mechanically ventilated for ≥4 days between January 1, 2017, and December 31, 2017, in 2 adult intensive care units of a tertiary care teaching hospital in China were included. RESULTS On multivariable logistic regression, significant risk factors for VAEs were positive daily fluid balances of ≥ 50 mL between day of intubation and the fourth day of mechanical ventilation (relative risk [RR], 8.39; 95% confidence interval [CI], 2.99-23.50), sedative administered between the first day and the fourth day of invasive mechanical ventilation (RR, 15.69; 95% CI, 1.62-152.06), and daily gastric retention of ≥200 mL between day of intubation and the fourth day of mechanical ventilation (RR, 9.27; 95% CI, 1.89-45.47). CONCLUSIONS Positive daily fluid balances of ≥50 mL, sedatives administered, and gastric retention of ≥200 mL are risk factors for VAEs. Intervention studies are needed to determine if targeting these risk factors can lower VAE rates.
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Affiliation(s)
- Ji Liu
- School of Nursing, Xuzhou Medical University, Xuzhou, China; Emergency Intensive Care Unit, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Shenglei Zhang
- Intensive Care Unit, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jiaxuan Chen
- School of Clinical Medicine, Xuzhou Medical University, Xuzhou, China
| | - Yiping Mao
- Department of Nosocomial Infection Management, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.
| | - Xiaoqing Shao
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Yang Li
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Jianmei Cao
- Department of Nosocomial Infection Management, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Wei Zheng
- Department of Nosocomial Infection Management, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Bing Zhang
- Department of Nosocomial Infection Management, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhiyong Zong
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, China; Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China
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Rello J, Ramírez-Estrada S, Romero A, Arvaniti K, Koulenti D, Nseir S, Oztoprak N, Bouadma L, Vidaur L, Lagunes L, Peña-López Y. Factors associated with ventilator-associated events: an international multicenter prospective cohort study. Eur J Clin Microbiol Infect Dis 2019; 38:1693-1699. [PMID: 31236736 DOI: 10.1007/s10096-019-03596-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/17/2019] [Indexed: 01/02/2023]
Abstract
A secondary analysis of a prospective multicenter cohort was performed in six intensive care units (ICU) in four European countries (France, Greece, Spain and Turkey). The main objective was to identify factors associated with ventilator-associated events (VAEs) in adults who underwent mechanical ventilation (MV) ≥ 48 h. Secondary objectives were to identify: variables influencing VAE in the subpopulation with endotracheal intubation and in those subjects who were ventilated > 7 days. Subjects who had undergone MV ≥ 48 h were included. In subjects with multiple episodes of MV, only the first one was eligible. The adult definitions for VAEs were adjusted to the 2015 update of the CDC's 2013 National Healthcare Safety Network Association. Factors associated with VAE were estimated through multivariate Cox proportional hazards analysis. Among 163 adults (42 tracheostomies), 76 VAEs (34.9 VAEs/1,000 ventilator-days) were documented: 9 were Ventilator-Associated Conditions (VAC) and 67 Infection-related Ventilator-Associated Complications (IVAC)-plus (9 only IVAC and 58 Possible Ventilator-Associated Pneumonia). VAEs developed after a median of 6 days (interquartile range: 4-9). VAEs were independently associated with long-acting sedative/analgesic drugs (Hazard Ratio [HR]: 4.30), selective digestive decontamination (SDD) (HR: 0.38), and surgical/trauma admission (HR: 2.30). Among 116 subjects with endotracheal tube, SDD (HR: 0.21) and surgical/trauma admission (HR: 3.11) remained associated with VAE. Among 102 subjects ventilated >7 days, only long-acting sedative/analgesic agents (HR: 8.69) remained independently associated with VAE. In summary, SDD implementation and long-acting analgesic/sedative agents restriction prescription may prevent early and late VAEs, respectively. Bundles developed to prevent VAEs should include these two interventions.
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Affiliation(s)
- Jordi Rello
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBERES), Vall d'Hebron Research Institute, Ps Vall d'Hebron 119-AMI 14th floor, 08035, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.,European Society of Clinical Microbiology and Infectious Diseases-Study Group for Infections in Critically Ill Patients (ESGCIP-ESCMID), Basel, Switzerland
| | - Sergio Ramírez-Estrada
- Intensive Care Department, Clinica Corachan, Barcelona, Spain.,Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anabel Romero
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBERES), Vall d'Hebron Research Institute, Ps Vall d'Hebron 119-AMI 14th floor, 08035, Barcelona, Spain. .,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.
| | - Kostoula Arvaniti
- European Society of Clinical Microbiology and Infectious Diseases-Study Group for Infections in Critically Ill Patients (ESGCIP-ESCMID), Basel, Switzerland.,Intensive Care Unit, Papageorgiou Hospital, Thessaloniki, Greece
| | - Despoina Koulenti
- European Society of Clinical Microbiology and Infectious Diseases-Study Group for Infections in Critically Ill Patients (ESGCIP-ESCMID), Basel, Switzerland.,Critical Care Department, Attikon University Hospital, Athens, Greece.,UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Royal Brisbane Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Saad Nseir
- Critical Care Center, Hospital Universitaire Lille, Lille, France
| | - Nefise Oztoprak
- Department of Infectious Diseases and Clinical Microbiology Clinic, Antalya Education and Research Hospital, Antalya, Turkey
| | - Lila Bouadma
- Medical and Infectious Diseases ICU, Bichat-Claude-Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Loreto Vidaur
- Intensive Care Department, Donostia Univertsitate Ospitalea/CIBERES, Donostia, Spain
| | - Leonel Lagunes
- European Society of Clinical Microbiology and Infectious Diseases-Study Group for Infections in Critically Ill Patients (ESGCIP-ESCMID), Basel, Switzerland.,Intensive Care Department Hospital Especialidades Médicas, San Luís Potosí, Mexico
| | - Yolanda Peña-López
- Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.,Paediatric Critical Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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30
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Peña-López Y, Ramirez-Estrada S, Eshwara VK, Rello J. Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes. Expert Rev Respir Med 2018; 12:1037-1050. [PMID: 30460868 DOI: 10.1080/17476348.2018.1549492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.
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Affiliation(s)
- Yolanda Peña-López
- a Pediatric Critical Care Department , Vall d'Hebron Barcelona Hospital Campus , Barcelona , Spain
| | | | - Vandana Kalwaje Eshwara
- c Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education , Manipal University , Manipal , India
| | - Jordi Rello
- d Clinical Research/epidemiology In Pneumonia & Sepsis , Vall d'Hebron Institut of Research & Centro de Investigacion Biomedica en Red (CIBERES) , Barcelona , Spain
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Ramirez-Estrada S, Peña-Lopez Y, Kalwaje Eshwara V, Rello J. Ventilator-associated events versus ventilator-associated respiratory infections-moving into a new paradigm or merging both concepts, instead? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:425. [PMID: 30581833 PMCID: PMC6275412 DOI: 10.21037/atm.2018.10.54] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 10/21/2018] [Indexed: 01/06/2023]
Abstract
Despite ventilator-associated respiratory infections (VARI) are reported as the most common and fatal complications related to mechanical ventilation (MV), they are not the unique occurrences. The new classification of ventilator-associated events (VAE) proposed by the centers for disease control and prevention (CDC) enhance the spectra of complications due to MV including both infection-related and non-infectious events. Both VAEs and VARIs are associated with prolonged duration of MV, longer stay in hospital and in the intensive care unit (ICU) and more antibiotic consumption, nonetheless patients with VAEs have worst outcomes. The VARI and VAE algorithms are focused on different targets and the correlation between both classifications is shown to be poor. The diagnostic criteria of the traditional classification have limited accuracy and the non-infectious complications may be misinterpreted as VARI. While the VAE surveillance enhances the spectra of MV complications but excludes less severe VARIs. Noninfective events explain up to 30% of VAEs, the main causes being atelectasis, acute respiratory distress syndrome, pulmonary edema and pulmonary embolism. The bundles assessing VAE are associated with less incidence of VAP and improved outcomes but they fail to reduce the rates of VAE. Automated VAE surveillance is efficient and useful as a quality indicator in the ICU while the differences in the interpretation of VARI criteria limit its role in the design of global protocols and preventive strategies. We suggest that a more comprehensive strategy should combine both algorithms with emphasis on clinical outcomes.
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Affiliation(s)
- Sergio Ramirez-Estrada
- Critical Care Department, Clínica Corachan, Barcelona, Spain
- Medicine Department, Universitat Autónoma de Barcelona, (UAB), Barcelona, Spain
| | | | - Vandana Kalwaje Eshwara
- Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Jordi Rello
- Vall d'Hebron Institut of Research, Barcelona, Spain
- Centro de Investigación Biomédica en Red (CIBERES), Instituto Salud Carlos III, Madrid, Spain
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Chlorhexidine-related ventilator-associated events: Toward recognition? Infect Control Hosp Epidemiol 2018; 39:1144-1145. [PMID: 30064537 DOI: 10.1017/ice.2018.173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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