Environmental contamination during tracheal suction. A comparison of disposable conventional catheters with a multiple-use closed system device

Comparative analysis of open and closed tracheal suction systems on mechanical ventilation efficiency in adults: A systematic review and meta-analysis

BACKGROUND

There are two types of suction methods used clinically: closed tracheal suction system (CTSS) and open tracheal suction system (OTSS). However, the safety and efficacy of these two suction systems for patients remain to be analysed.

OBJECTIVE

The objective of this study was to assess the safety and efficacy of OTSSs and CTSSs in adult mechanical ventilation.

METHODS

Computer searches were conducted on PubMed, Web of science, MEDLINE, CINAHL, and Cochrane Library databases. The search spanned from the inception of each database to December 2023. Two researchers independently reviewed and extracted data from the literature. Quality assessment was performed using the Cochrane Manual of Systematic Reviews, and meta-analysis was conducted using RevMan 5.3 software.

RESULTS

A total of 13 articles, involving 2822 patients, were included in the analysis. The meta-analysis showed that the CTSS could reduce the incidence of ventilator-associated pneumonia (odds ratio [OR] = 0.77, 95% confidence interval [CI]: [0.61, 0.98], P = 0.03). However, no significant difference existed in the microbial colonisation rate in the respiratory tract (OR = 1.40, 95% CI: [0.91, 2.15], P = 0.13), mechanical ventilation time (mean difference = -0.33, 95% CI: [-1.43, 0.78], P = 0.56), length of intensive care unit stay (mean difference = 0.23, 95% CI: [-0.90, 1.35], P = 0.69), and mortality (OR = 1.01, 95% CI: [0.84, 1.22], P = 0.89).

CONCLUSION

In comparison to the OTSS, the CTSS proves effective in reducing the incidence of ventilator-associated pneumonia. However, additional high-quality evidence is needed to evaluate respiratory microbial colonisation rates, the duration of mechanical ventilation, length of intensive care unit stay, and mortality.

[Suctioning in intubated and tracheotomized patients : A narrative review]

BACKGROUND

Endotracheal suctioning in intubated or tracheotomized critically ill patients is a daily task of various professional groups in intensive and emergency medicine; however, a German language summary of current evidence is lacking.

OBJECTIVE

The aim is to develop a narrative overview of current evidence on endotracheal suctioning of intubated or tracheotomized patients in the clinical setting.

MATERIAL AND METHODS

A literature search was conducted in the databases Cinahl, Cochrane Library, Livivo, and Medline via PubMed by nurses with an academic degree. In addition, a hand search and applying the snowball principle were performed. Following a successful critical appraisal, all English and German language publications addressing endotracheal suctioning in the context of hospital care were included.

RESULTS

A total of 23 full texts were included. After developing 6 main topics on endotracheal suction 19 articles were considered in the reporting. The results showed, among others, that routine deep suctioning once per shift is contraindicated and that the catheter should be advanced no more than 0.5-1 cm beyond the distal end of the tube or tracheal cannula. Closed suction catheters offer advantages, especially for staff protection, although studies are heterogeneous. Further training of staff is obligatory.

CONCLUSION

Few conclusive studies on endotracheal suction could be found; however, with the available evidence initial conclusions can be drawn which should be considered in, for example, internal standard operating procedures. Further research is needed.

Ventilator-associated Pneumonia: Is the Dilemma Still "Open" or "Closed"?

How to cite this article: Sinha S, Ahuja B. Ventilator-associated Pneumonia: Is the Dilemma Still "Open" or "Closed"? Indian J Crit Care Med 2022;26(7):778-779.

Surfaces and Air contamination by SARS-CoV-2 using High-flow Nasal Oxygenation or Assisted Mechanical Ventilation System in ICU rooms of COVID-19 Patients

BACKGROUND

Understanding patterns of environmental contamination by SARS-CoV-2 is essential for infection prevention policies.

METHODS

We screened surfaces and air samples from single bed ICU rooms of COVID-19 adult patients for SARS-CoV-2 RNA and viable viruses.

RESULTS AND DISCUSSION

We evidenced viral RNA environmental contamination in 76% of 100 surfaces samples and in 30% of 40 air samples without any viable virus detection by cell culture assays. No significant differences of viral RNA levels on surfaces and in ambient air were observed between rooms of patients with assisted mechanical ventilation and those of patients with high-flow nasal cannula system. Using an original experimental SARS-CoV-2 infection model of surfaces, we assessed that infectious viruses might have been present on benches within 15 hours before the time of sampling in patient rooms.

CONCLUSIONS

We observed that SARS-CoV-2 environmental contamination around COVID-19 patients hospitalized in single ICU rooms was extensive and that a high-flow nasal cannula system did not generate more viral aerosolization than a mechanical ventilation system in COVID-19 patients. Despite an absence of SARS-CoV-2 viable particles in study samples, our experimental model confirmed the need to apply strict environmental disinfection procedures and classical standard and droplet precautions in ICU wards.

Bioaerosol sampling of a ventilated patient with COVID-19

Bioaerosol samples were collected in an airborne infection isolation room, bathroom, and anteroom of a ventilated patient with coronavirus disease 2019. Twenty-eight samples were negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid, possibly due to the patient being on a closed-circuit ventilator or the efficiency of the air exchanges in the room.

Emergence of NDM-4-producing Klebsiella pneumoniae in a Korean hospital due to a patient hospitalized in Vietnam and case review

NDM-4-producing Klebsiella pneumoniae (NDM-4-KP) was detected from the patient who had previously been injured and hospitalized for 5 days in Vietnam in a neurosurgical intensive care unit (NSICU) of a Korean tertiary-care hospital in December 2016. He admitted with ventilator-associated pneumonia and NDM-4-KP was isolated, which was subsequently detected in two other NSICU patients. All NDM-4-KP isolates from patient and environmental surveillance cultures were sequence type 11. Colonization of three patients persisted for 5-12 months. Dedicated environmental cleaning was added to single room isolation of NDM-4-KP patients and universal chlorhexidine bathing, and no further transmission of NDM-4-KP occurred. This is the first report of NDM-4-KP in a Korean hospital where a patient with a history of hospitalization abroad was the index case initiating an outbreak involving three patients. The spread of newly introduced CPE was controlled using a bundle of infection control.

Bacterial sensitivity assessment of multifunctional polymeric coatings for airway stents

Current interventional technology for pediatric airway obstruction consists of cardiovascular stents and silicon tubes. These devices are composed of permanent materials that have limitations in biocompatibility and mechanical properties that make them controversial for used in pediatrics. Bioresorbable stents offer a temporary intervention that dissolves in the body over time and can serve as a platform for local drug delivery. Here we investigate a novel approach to use an antibiotic, ciprofloxacin, as a polymerization initiator to synthesize poly(ciprofloxacin fumaric acid) (PCFA) and then a second polymer using gadodiamide as an initiator to synthesize poly(gadodiamide ciprofloxacin fumaric acid) (PGCFA). Polymer structure, degradation, thermal properties, and rheological behavior were analyzed. Ciprofloxacin released was determined and polymer degradation extracts were used in bacterial sensitivity assessments with four common airway pathogens. PCFA and PGCFA polymers and drug release properties were compared to our previously published polymer poly(fumaric acid) (PFA). These novel polymers enable new possibilities as coatings for bioresorbable biomedical applications that require antibiotic resistance and imaging capabilities. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 2153-2161, 2017.

Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate

BACKGROUND

Ventilator-associated pneumonia (VAP) in neonates can be reduced by implementing preventive care practices. Implementation of a group, or bundle, of evidence-based practices that improve processes of care has been shown to be cost-effective and to have better outcomes than implementation of individual single practices.

PURPOSE

The purpose of this article is to describe a safe, effective, and efficient neonatal VAP prevention protocol developed for caregivers in the neonatal intensive care unit (NICU). Improved understanding of VAP causes, effects of care practices, and rationale for interventions can help reduce VAP risk to neonatal patients.

METHOD

In order to improve care practices to affect VAP rates, initial and annual education occurred on improved protocol components after surveying staff practices and auditing documentation compliance.

FINDINGS/RESULTS

In 2009, a tertiary care level III NICU in the Midwestern United States had 14 VAP cases. Lacking evidence-based VAP prevention practices for neonates, effective adult strategies were modified to meet the complex needs of the ventilated neonate. A protocol was developed over time and resulted in an annual decrease in VAP until rates were zero for 20 consecutive months from October 2012 to May 2014.

IMPLICATIONS FOR PRACTICE

This article describes a VAP prevention protocol developed to address care practices surrounding hand hygiene, intubation, feeding, suctioning, positioning, oral care, and respiratory equipment in the NICU.

IMPLICATIONS FOR RESEARCH

Implementation of this VAP prevention protocol in other facilities with appropriate monitoring and tracking would provide broader support for standardization of care. Individual components of this VAP protocol could be studied to strengthen the inclusion of each; however, bundled interventions are often considered stronger when implemented as a whole.

Impact of a Program of Intensive Surveillance and Interventions Targeting Ventilated Patients in the Reduction of Ventilator-Associated Pneumonia and Its Cost-Effectiveness

Objective:

We hypothesized that a program of prospective intensive surveillance for ventilator-associated pneumonia (VAP) and concomitant implementations of multimodal, multidisciplinary preventive and intervention strategies would result in a reduction in the incidence of VAP and would be cost-effective.

Setting:

Medical and surgical intensive care units (ICUs) in a university teaching hospital.

Interventions:

All ventilated patients in the medical and surgical ICUs were monitored for VAP from January 1997 through December 1998. Interventions including elevation of the head of the bed, use of sterile water and replacement of stopcocks with enteral valves for nasogastric feeding tubes, and prolongation of changing of in-line suction catheters from 24 hours to as needed were implemented.

Results:

The rates of VAP decreased by 10.8/1,000 ventilator-days in the medical ICU (CI95, 4.65-16.91) and by 17.2/1,000 ventilator-days in the surgical ICU (CI95> 2.85-31.56) when they were compared for 1997 and 1998. With the use of the estimated cost of a VAP of $4,947 from the literature, the reduction resulted in cost savings of $178,092 and $148,410 in the medical and surgical ICUs, respectively, for a total of $326,482. In addition, $25,497 was saved due to the lengthening of the time for the change of in-line suction catheters, resulting in a cost savings of $351,979. This total cost savings of $351,979 minus the cost of enteral valves of $2,100 resulted in total net savings of $349,899.

Conclusion:

Intensive surveillance and interventions targeted at ventilated patients resulted in reduction of VAP and appeared to be cost-effective.

Impact of closed versus open tracheal suctioning systems for mechanically ventilated adults: a systematic review and meta-analysis

PURPOSE

Whether closed tracheal suctioning systems (CTSS) reduce the incidence of ventilator-associated pneumonia (VAP) compared with open tracheal suctioning systems (OTSS) is inconclusive. We conducted a systematic review and meta-analysis of randomized controlled trials that compared CTSS and OTSS.

METHODS

PubMed, the Cochrane Central Register of Controlled Trials, the Web of Science, Google Scholar, and a clinical trial registry from inception to October 2014 were searched without language restrictions. Randomized controlled trials of CTSS and OTSS that compared VAP in mechanically ventilated adult patients were included. The primary outcome was the incidence of VAP. Secondary outcomes were mortality and length of mechanical ventilation. Data were pooled using the random effects model.

RESULTS

Sixteen trials with 1,929 participants were included. Compared with OTSS, CTSS was associated with a reduced incidence of VAP (RR 0.69; 95 % CI 0.54-0.87; Q = 26.14; I (2) = 46.4 %). Compared with OTSS, CTSS was not associated with reduction of mortality (RR 0.96; 95 % CI 0.83-1.12; Q = 2.27; I (2) = 0.0 %) or reduced length of mechanical ventilation (WMD -0.45 days; 95 % CI -1.25 to 0.36; Q = 6.37; I (2) = 5.8 %). Trial sequential analysis suggested a lack of firm evidence for 20 % RR reduction in the incidence of VAP. The limitations of this review included underreporting and low quality of the included trials, as well as variations in study procedures and characteristics.

CONCLUSIONS

Based on current, albeit limited evidence, it is unlikely that CTSS is inferior to OTSS regarding VAP prevention; however, further trials at low risk of bias are needed to confirm or refute this finding.

Ventilator-associated pneumonia in patients admitted to intensive care units, using open or closed endotracheal suctioning

Background:

Critically ill patients under mechanical ventilation require frequent suctioning of airway secretion. Closed suction permits suctioning without disconnection from ventilator; so it might decrease hypoxemia and infection rate.

Objectives:

This study aimed to evaluate the effect of closed tracheal suction system (CTSS) versus open tracheal suction system (OTSS).

Patients and Methods:

This is a prospective randomized study, which was carried on 100 patients in surgical Intensive Care Unit requiring mechanical ventilation for more than 48 hours from June 2012 to November 2013. In two groups, suction was performed based on the patients' need as well as physician's or nurses' decision on tracheal secretions. Patients randomly allocated into two groups (50 patients each): CTSS group and OTSS group. Patients were monitored for developing ventilator-associated pneumonia (VAP) during the study. Throat samples were taken on admission and two times per week from each patient. Tracheal samples were performed during endotracheal intubation, two times per week during mechanical ventilation and during extubation.

Results:

Drainage of subglottic secretions decreased the incidence of VAP (P < 0.05). Also type of the pharmacologic medicine for stress ulcer prophylaxis has significant effect on VAP incidence. Among the patients in OTSS and CTSS groups, 20% and 12% developed VAP, respectively. Use of CTSS compared with OTSS did not show statistically significant effect on VAP incidence in multivariate analysis; however, OR (odds ratio) tended to identify OTSS as an exposure factor for the development of VAP (OR = 1.92; CI = 0.45-8.30; = 0.38) compared with the CTSS. Higher levels of APACHE II score, sinusitis and tracheostomy put the patients at the risk of VAP. However, using heat and moisture exchanger (HME) instead of humidifier decreased this risk.

Conclusions:

Based on the results obtained from our study, impact of suctioning is similar between CTSS and OTSS regarding the occurrence of VAP. It seems that physicians must consider many factors such as duration of mechanical ventilation, comorbidities, oxygenation parameters, number of required suctioning, and the cost prior to using each type of tracheal suction system.

Ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia (VAP) is a type of nosocomial pneumonia that occurs in patients who receive mechanical ventilation (MV). According to the International Nosocomial Infection Control Consortium (INICC), the overall rate of VAP is 13.6 per 1,000 ventilator days. The incidence varies according to the patient group and hospital setting. The incidence of VAP ranges from 13-51 per 1,000 ventilation days. Early diagnosis of VAP with appropriate antibiotic therapy can reduce the emergence of resistant organisms.

METHOD

The aim of this review was to provide an overview of the incidence, risk factors, aetiology, pathogenesis, treatment, and prevention of VAP. A literature search for VAP was done through the PUBMED/MEDLINE database. This review outlines VAP's risk factors, diagnostic methods, associated organisms, and treatment modalities.

CONCLUSION

VAP is a common nosocomial infection associated with ventilated patients. The mortality associated with VAP is high. The organisms associated with VAP and their resistance pattern varies depending on the patient group and hospital setting. The diagnostic methods available for VAP are not universal; however, a proper infection control policy with appropriate antibiotic usage can reduce the mortality rate among ventilated patients.

Comparison of open and closed suction on safety, efficacy and nursing time in a paediatric intensive care unit

BACKGROUND

Endotracheal suctioning (ETS) is one of the most common procedures performed in the paediatric intensive care. The two methods of endotracheal suctioning used are known as open and closed suction, but neither method has been shown to be the superior suction method in the Paediatric Intensive Care Unit (PICU).

PURPOSE

The primary purpose was to compare open and closed suction methods from a physiological, safety and staff resource perspective.

METHODS

All paediatric intensive care patients with an endotracheal tube were included. Between June and September 2011 alternative months were nominated as open or closed suction months. Data were prospectively collected including suction events, staff involved, time taken, use of saline, and change from pre-suction baseline in heart rate (HR), mean arterial pressure (MAP) and oxygen saturation (SpO2). Blocked or dislodged ETTs were recorded as adverse events.

FINDINGS

Closed suction was performed more often per day (7.2 vs 6.0, p<0.01), used significantly less nursing time (23 vs 38 min, p<0.01) and had equivalent rates of adverse events compared to open suction (5 vs 3, p<0.23). Saline lavage usage was significantly higher in the open suction group (18% vs 40%). Open suction demonstrated a greater reduction in SpO2 and nearly three times the incidence of increases in HR and MAP compared to closed suction. Reductions in MAP or HR were comparable across the two methods.

CONCLUSIONS

In conclusion, CS could be performed with less staffing time and number of nurses, less physiological disturbances to our patients and no significant increases in adverse events.

Foreign body blocking closed circuit suction catheter: An unusual cause of retained tracheal secretions in a mechanically ventilated patient

Closed circuit suction system (CCSS) has become a standard of care for the tracheal suctioning of mechanically ventilated patients. The advantages of CCSS over the open suction system include decreased environmental, personnel and patient contamination, preservation of lung volumes and oxygenation especially in the severely hypoxemic patients. On the other hand, CCSS has lower efficacy in removal of secretions and it may have certain other disadvantages due to the invisibility of its tip. We report an unusual case of an airway foreign body causing blockage of the CCSS leading to retained secretions and deterioration of patient. Timely changing over to open suction system helped in its detection and improvement of patient.

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

BACKGROUND

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

End-expiratory lung volume recovers more slowly after closed endotracheal suctioning than after open suctioning: a randomized crossover study

PURPOSE

Endotracheal suctioning causes significant lung derecruitment. Closed suction (CS) minimizes lung volume loss during suction, and therefore, volumes are presumed to recover more quickly postsuctioning. Conflicting evidence exists regarding this. We examined the effects of open suction (OS) and CS on lung volume loss during suctioning, and recovery of end-expiratory lung volume (EELV) up to 30 minutes postsuction.

MATERIAL AND METHODS

Randomized crossover study examining 20 patients postcardiac surgery. CS and OS were performed in random order, 30 minutes apart. Lung impedance was measured during suction, and end-expiratory lung impedance was measured at baseline and postsuctioning using electrical impedance tomography. Oximetry, partial pressure of oxygen in the alveoli/fraction of inspired oxygen ratio and compliance were collected.

RESULTS

Reductions in lung impedance during suctioning were less for CS than for OS (mean difference, -905 impedance units; 95% confidence interval [CI], -1234 to -587; P < .001). However, at all points postsuctioning, EELV recovered more slowly after CS than after OS. There were no statistically significant differences in the other respiratory parameters.

CONCLUSIONS

Closed suctioning minimized lung volume loss during suctioning but, counterintuitively, resulted in slower recovery of EELV postsuction compared with OS. Therefore, the use of CS cannot be assumed to be protective of lung volumes postsuctioning. Consideration should be given to restoring EELV after either suction method via a recruitment maneuver.

Investigation into the effect of closed-system suctioning on the frequency of pediatric ventilator-associated pneumonia in a developing country

OBJECTIVE

To investigate the effect of closed-system vs. open endotracheal suctioning on the frequency of ventilator-associated pneumonia and outcome in a pediatric intensive care unit in a developing country.

DESIGN

Prospective observational and nonrandomized controlled clinical study.

SETTING

A 20-bed pediatric intensive care unit in a tertiary pediatric hospital.

PATIENTS

Infants and children mechanically ventilated for >24 hrs.

INTERVENTION

: Pediatric intensive care unit suctioning systems were alternated monthly. An 8-month interim analysis was planned with a priori efficacy and futility study termination boundaries set at p < .006 and p > .52, respectively.

MEASUREMENTS AND MAIN RESULTS

Demographic, clinical, and laboratory data were prospectively recorded. Ventilator-associated pneumonia was diagnosed using the Clinical Pulmonary Infection Score, and the results were confirmed retrospectively using Centers for Disease Control criteria. A total of 250 patients (median [interquartile range] age of 3.8 [1.2-15.0] months) in 263 pediatric intensive care unit admissions were included. Fifty-nine admissions developed ventilator-associated pneumonia, with a calculated rate of 45.1 infections per 1000 ventilated days. There was no difference in characteristics or outcome between patients on closed-system suctioning (n = 83) and those on open endotracheal suctioning (n = 180). The frequencies of ventilator-associated pneumonia for patients on closed-system suctioning and open endotracheal suctioning were 20.5% and 23.3%, respectively (p = .6), reaching the a priori set limit of futility. Patients who developed ventilator-associated pneumonia spent a median (interquartile range) of 22 (13-37) and 11 (8-16) days in the hospital and pediatric intensive care unit, respectively, compared to 14.5 (10-24) and 6 (4-8) days for those without ventilator-associated pneumonia (p < .001). A 22% proportion of patients who developed ventilator-associated pneumonia died compared to 11.3% of those without ventilator-associated pneumonia (p = .03). Risk factors for ventilator-associated pneumonia identified on multiple logistic regression were duration of mechanical ventilation, transport out of the pediatric intensive care unit, and blood transfusion.

CONCLUSION

Closed-system suctioning did not affect the frequency of ventilator-associated pneumonia or patient outcome in this setting.

Comparing influence of intermittent subglottic secretions drainage with/without closed suction systems on the incidence of ventilator associated pneumonia

CONTEXT

Intermittent subglottic drainage (ISD) of secretions is recommended for prevention of ventilator-associated pneumonia (VAP) as it reduces microaspiration from the area around the cuff. Poor suction techniques can contribute to VAP, hence closed suction system (CSS) may have theoretical benefit in VAP prevention. Combination of these two techniques may provide added advantage.

AIMS

To study the influence of ISD with/without CSS on the incidence of VAP.

MATERIALS AND METHODS

Data from 311 patients requiring mechanical ventilation (MV) for more than 72 hours were collected retrospectively. They were divided into four groups as follows: group A, no intervention; group B, only CSS; group C, only ISD; and group D, ISD with CSS. These groups were compared with respect to incidence of VAP, duration of MV, length of ICU and hospital stay and ICU mortality.

RESULTS

Patients in the four groups were comparable with respect to age, sex ratio and admission Acute Physiology and Chronic Health Evaluation (APACHE) II scores. Incidence of VAP per 1000 ventilator days in groups A, B, C, and D were 25, 23.9, 15.7 and 14.3, respectively (P=0.04). There was no significant difference in the duration of MV (P=0.33), length of ICU (P=0.55) and hospital stay (P=0.36) and ICU mortality (P=0.9) among the four groups.

CONCLUSIONS

ISD of secretions reduces the incidence of VAP. CSS alone or in combination with ISD has no significant effect on VAP incidence. Hence, ISD may be recommended for VAP prevention, but indications other than VAP prevention should determine the type of the suction system.

Influence of tracheal suctioning systems on health care workers' gloves and equipment contamination: a comparison of closed and open systems

The impact of tracheal suctioning with an open or a closed system on equipment and health care workers contamination with multidrug-resistant pathogens was compared. Only the closed system reduced hand and equipment contamination during tracheal suctioning. This equipment could be systematically used to reduce risk of cross contamination in the intensive care unit.

Perioperative care following complex laryngotracheal reconstruction in infants and children

Laryngotracheal reconstruction (LTR) involves surgical correction of a stenotic airway with cartilage interpositional grafting, followed by either placement of a tracheostomy and an intraluminal stent (two-stage LTR) or placement of an endotracheal tube with postoperative sedation and mechanical ventilation for an extended period of time (singlestage LTR). With single-stage repair, there may be several perioperative challenges including the provision of adequate sedation, avoidance of the development of tolerance to sedative and analgesia agents, the need to use neuromuscular blocking agents, the maintenance of adequate pulmonary toilet to avoid perioperative nosocomial infections, and optimization of postoperative respiratory function to facilitate successful tracheal extubation. We review the perioperative management of these patients, discuss the challenges during the postoperative period, and propose recommendations for the prevention of reversible causes of extubation failure in this article. Optimization to ensure a timely tracheal extubation and successful weaning of mechanical ventilator, remains the primary key to success in these surgeries as extubation failure or the need for prolonged postoperative mechanical ventilation can lead to failure of the graft site, the need for prolonged Pediatric Intensive Care Unit care, and in some cases, the need for a tracheostomy to maintain an adequate airway.

Comparing influence of intermittent subglottic secretions drainage with/without closed suction systems on the incidence of ventilator associated pneumonia

CONTEXT

Intermittent subglottic drainage (ISD) of secretions is recommended for prevention of ventilator-associated pneumonia (VAP) as it reduces microaspiration from the area around the cuff. Poor suction techniques can contribute to VAP, hence closed suction system (CSS) may have theoretical benefit in VAP prevention. Combination of these two techniques may provide added advantage.

AIMS

To study the influence of ISD with/without CSS on the incidence of VAP.

MATERIALS AND METHODS

Data from 311 patients requiring mechanical ventilation (MV) for more than 72 hours were collected retrospectively. They were divided into four groups as follows: group A, no intervention; group B, only CSS; group C, only ISD; and group D, ISD with CSS. These groups were compared with respect to incidence of VAP, duration of MV, length of ICU and hospital stay and ICU mortality.

RESULTS

Patients in the four groups were comparable with respect to age, sex ratio and admission Acute Physiology and Chronic Health Evaluation (APACHE) II scores. Incidence of VAP per 1000 ventilator days in groups A, B, C, and D were 25, 23.9, 15.7 and 14.3, respectively (P=0.04). There was no significant difference in the duration of MV (P=0.33), length of ICU (P=0.55) and hospital stay (P=0.36) and ICU mortality (P=0.9) among the four groups.

CONCLUSIONS

ISD of secretions reduces the incidence of VAP. CSS alone or in combination with ISD has no significant effect on VAP incidence. Hence, ISD may be recommended for VAP prevention, but indications other than VAP prevention should determine the type of the suction system.

An open-labelled randomized controlled trial comparing costs and clinical outcomes of open endotracheal suctioning with closed endotracheal suctioning in mechanically ventilated medical intensive care patients

PURPOSE

Closed endotracheal suctioning (CES) may impact ventilator-associated pneumonia (VAP) risk by reducing environmental contamination. In developing countries where resource limitations constrain the provision of optimal bed space for critically ill patients, CES assumes greater importance.

MATERIALS AND METHODS

In this prospective, open-labeled, randomized controlled trial spanning 10 months, we compared CES with open endotracheal suctioning (OES) in mechanically ventilated patients admitted to the medical intensive care unit (ICU) of a university-affiliated teaching hospital. Patients were followed up from ICU admission to death or discharge from hospital. Primary outcome was incidence of VAP. Secondary outcomes included mortality, cost, and length of stay.

RESULTS

Two hundred patients were recruited, 100 in each arm. The incidence of VAP was 23.5%. Closed endotracheal suctioning was associated with a trend to a reduced incidence of VAP (odds ratio, 1.86; 95% confidence interval, 0.91-3.83; P = .067). A significant benefit was, however, observed with CES for late-onset VAP (P = .03). Mortality and duration of ICU and hospital stay were similar in the 2 groups. The cost of suction catheters and gloves was significantly higher with CES (Rs 272 [US $5.81] vs Rs 138 [US $2.94], P < .0001). Nine patients need to be treated with CES to prevent 1 VAP (95% confidence interval, -0.7 to 22).

CONCLUSIONS

In the ICU setting in a developing country, CES may be advantageous in reducing the incidence of VAP, particularly late-onset VAP. These results mandate further studies in this setting before specific guidelines regarding the routine use of CES are proposed.

Closed suctioning system: critical analysis for its use

AIM

To determine the efficacy and effectiveness of the closed suctioning system.

METHOD

Literature review articles were accessed from the following databases: PubMed, EMBASE, CINAHL, and Cochrane Library. The literature review criteria included: all publication styles except meta-analysis, participants that were > or =18 years, written in English, and published between 1973 and 2008.

RESULTS

This literature review revealed that the efficacy and effectiveness of the closed suctioning system remains to be demonstrated. The device manufacturers' studies focused on cost reduction, cross-contamination, and preservation of the oxygen saturation of patients during endotracheal suctioning; however, the clinical studies focused on the use of closed suctioning systems to prevent ventilator-associated pneumonia. The reviewed studies had small sample sizes with heterogeneous demographics and non-randomized controls. Recent studies suggest that closed suctioning systems are no better than open suctioning systems in terms of mortality, morbidity, or the cost-benefit ratio. A few studies did indicate that the closed suctioning system might reduce the loss of lung volume and oxygen desaturation.

CONCLUSION

The studies reviewed in this article suggest that the evidence on the efficacy and effectiveness of closed suctioning systems is inconclusive. Only limited populations will benefit clinically from the use of this device. There is a need for further studies with randomized controlled trials to explore the use of closed suction systems and to update current clinical practise guidelines.

Nosocomial outbreak of carbapenem-resistant Acinetobacter baumannii in intensive care units and successful outbreak control program

Acinetobacter baumannii has been increasingly reported as a significant causative organism of various nosocomial infections. Here we describe an outbreak of carbapenem-resistant A. baumannii (CRAB) in the ICUs of a Korean university hospital, along with a successful outbreak control program. From October 2007 through July 2008, CRAB was isolated from 57 ICU patients. Nineteen patients were diagnosed as being truly infected with CRAB, four of whom were presumed to have died due to CRAB infection, producing a case-fatality rate of 21.1%. In surveillance of the environment and the healthcare workers (HCWs), CRAB was isolated from 24 (17.9%) of 135 environmental samples and seven (10.9%) of 65 HCWs. The pulsed field gel electrophoresis patterns showed that the isolates from patients, HCWs, and the environment were genetically related. Control of the outbreak was achieved by enforcing contact precautions, reducing environmental contamination through massive cleaning, and use of a closed-suctioning system. By August 2008 there were no new cases of CRAB in the ICUs. This study shows that the extensive spread of CRAB can happen through HCWs and the environmental contamination, and that proper strategies including strict contact precautions, massive environmental decontamination, and a closed-suctioning system can be effective for controlling CRAB outbreaks.

A comprehensive review of pediatric endotracheal suctioning: Effects, indications, and clinical practice

OBJECTIVE

To provide a comprehensive, evidence-based review of pediatric endotracheal suctioning: effects, indications, and clinical practice.

METHODS

PubMed, Cumulative Index of Nursing and Allied Health Literature, and PEDro (Physiotherapy Evidence Database) electronic databases were searched for English language articles, published between 1962 and June 2007. Owing to the paucity of objective pediatric data, all reports dealing with this topic were examined, including adult and neonatal studies.

RESULTS

One hundred eighteen references were included in the final review. Despite the widespread use of endotracheal suctioning, very little high-level evidence dealing with pediatric endotracheal suctioning exists. Studies of mechanically ventilated neonatal, pediatric, and adult patients have shown that suctioning causes a range of potentially serious complications. Current practice guidelines are not based on evidence from controlled clinical trials. There is no clear evidence that endotracheal suctioning improves respiratory mechanics, with most studies pointing to the detrimental effect it has on lung mechanics. Suctioning should be performed when obstructive secretions are present rather than routinely. There is no clear evidence for the superiority of closed- or open-system suctioning, nor is there clear evidence for appropriate vacuum pressures and suction catheter size. Sterility does not seem to be necessary when suctioning. Preoxygenation has short-term benefits, but the longer-term impact is unknown. Routine saline instillation before suctioning should not be performed. Recruitment maneuvers performed after suctioning have not been shown to be useful as standard practice.

CONCLUSIONS

Endotracheal suctioning is a procedure used regularly in the pediatric intensive care unit. Despite this, good evidence supporting its practice is limited. Further, controlled clinical studies are needed to develop evidence-based protocols for endotracheal suctioning of infants and children, and to examine the impact of different suctioning techniques on the duration of ventilatory support, incidence of nosocomial infection, and length of pediatric intensive care unit and hospital stay.

Closed tracheal suction systems for prevention of ventilator-associated pneumonia

We have assessed the evidence that closed tracheal suction systems (TSS) prevent ventilator-associated pneumonia (VAP), using a meta-analysis of randomized controlled trials (RCTs). We searched PubMed and Cochrane databases to identify RCTs that compared closed with open TSS for the management of mechanically ventilated (MV) patients. Nine RCTs were included in the meta-analysis. There was no difference in the incidence of VAP between patients managed with closed and open TSS [odds ratio (OR)=0.96, 95% confidence intervals (CI) 0.72-1.28]. There was no heterogeneity among the eligible trials (I2=0, 95% CI 0-0.65). The compared groups did not differ with respect to mortality (OR=1.04, 95% CI 0.78-1.39) or intensive care unit (ICU) length of stay [two RCTs: 12.3 (sd 1.1) vs 11.5 (1.4) days and 15.6 (13.4) vs 19.9 (16.7) days]. Suctioning with closed systems was associated with longer MV duration (weighted mean differences: 0.65 days, 95% CI 0.28-1.03) and higher colonization of the respiratory tract (OR=2.88, 95% CI 1.50-5.52) than open TSS. The available evidence suggests that closed as opposed to open TSS usage did not provide any benefit on VAP incidence, mortality, or ICU stay of MV patients.

Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients

BACKGROUND

Ventilator-associated pneumonia is a common complication in ventilated patients. Endotracheal suctioning is a procedure that may constitute a risk factor for ventilator-associated pneumonia. It can be performed with an open system or with a closed system. In view of suggested advantages being reported for the closed system, a systematic review comparing both techniques was warranted.

OBJECTIVES

To compare the closed tracheal suction system and the open tracheal suction system in adults receiving mechanical ventilation for more than 24 hours.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2006, Issue 1) MEDLINE, CINAHL, EMBASE and LILACS from their inception to July 2006. We handsearched the bibliographies of relevant identified studies, and contacted authors and manufacturers.

SELECTION CRITERIA

The review included randomized controlled trials comparing closed and open tracheal suction systems in adult patients who were ventilated for more than 24 hours.

DATA COLLECTION AND ANALYSIS

We included the relevant trials fitting the selection criteria. We assessed methodological quality using method of randomization, concealment of allocation, blinding of outcome assessment and completeness of follow up. Effect measures used for pooled analyses were relative risk (RR) for dichotomous data and weighted mean differences (WMD) for continuous data. We assessed heterogeneity prior to meta-analysis.

MAIN RESULTS

Of the 51 potentially eligible references, the review included 16 trials (1684 patients), many with methodological weaknesses. The two tracheal suction systems showed no differences in risk of ventilator-associated pneumonia (11 trials; RR 0.88; 95% CI 0.70 to 1.12), mortality (five trials; RR 1.02; 95% CI 0.84 to 1.23) or length of stay in intensive care units (two trials; WMD 0.44; 95% CI -0.92 to 1.80). The closed tracheal suction system produced higher bacterial colonization rates (five trials; RR 1.49; 95% CI 1.09 to 2.03).

AUTHORS' CONCLUSIONS

Results from 16 trials showed that suctioning with either closed or open tracheal suction systems did not have an effect on the risk of ventilator-associated pneumonia or mortality. More studies of high methodological quality are required, particularly to clarify the benefits and hazards of the closed tracheal suction system for different modes of ventilation and in different types of patients.

Open and closed endotracheal suction systems in mechanically ventilated intensive care patients: a meta-analysis

BACKGROUND

Closed suction systems (CSS) are increasingly replacing open suction systems (OSS) to perform endotracheal toilet in mechanically ventilated intensive care unit patients. Yet effectiveness regarding patient safety and costs of these systems has not been carefully analyzed.

OBJECTIVE

To review effectiveness of CSS and OSS, with respect to patient outcome, bacterial contamination, and costs in adult intensive care unit patients.

DATA SOURCE

Search of MEDLINE, CINAHL, EMBASE, and Cochrane databases and a manual review of article bibliographies.

STUDY SELECTION

Randomized controlled trials comparing CSS and OSS in adult intensive care unit patients were retrieved.

DATA EXTRACTION/SYNTHESIS

Assessment of abstracts and study quality was performed by two reviewers. Data were combined in meta-analyses by random effect models. Fifteen trials were identified. No significant differences were found in incidences of ventilator-associated pneumonia (eight studies, 1,272 patients) and mortality (four studies, 1,062 patients). No conclusions could be drawn with respect to arterial oxygen saturation (five studies, 109 patients), arterial oxygen tension (two studies, 19 patients), and secretion removal (two studies, 37 patients). Compared with OSS, endotracheal suctioning with CSS significantly reduced changes in heart rate (four studies, 85 patients; weighted mean difference, -6.33; 95% confidence interval, -10.80 to -1.87) and changes in mean arterial pressure (three studies, 59 patients; standardized mean difference, -0.43; 95% confidence interval, -0.87 to 0.00) but increased colonization (two studies, 126 patients; relative risk, 1.51; 95% confidence interval, 1.12-2.04). CSS seems to be more expensive than OSS.

CONCLUSIONS

Based on the results of this meta-analysis, there is no evidence to prefer CSS more than OSS.

Impact of the suctioning system (open vs. closed) on the incidence of ventilation-associated pneumonia: Meta-analysis of randomized controlled trials

OBJECTIVE

Ventilation-associated pneumonia (VAP) is a serious complication of patients in intensive care units (ICU) who require mechanical ventilation. The choice of suctioning system (open vs. closed) remains unresolved in evidence-based guidelines. This meta-analysis was carried out to analyze the effect of the type of suctioning system on the incidence of VAP.

DESIGN

A search of the literature was used to identify randomized controlled trials addressing this question. A meta-analysis was then performed to calculate the relative risk of ventilation-associated pneumonia acquisition with the two suctioning systems.

RESULTS

Nine trials were included, with 648 patients in the open suctioning group and 644 in the closed suctioning group. VAP occurred in 128 (20%) of the open suctioning group and in 120 (19%) in the closed suctioning group (relative risk 0.95).

CONCLUSIONS

At a given pneumonia prevalence of 20% in ICU patients there was no significant advantage for the use of either suctioning system in this meta-analysis. The choice of suctioning system should therefore be based on handling, cost, and individual patient's disease until more data are available.

Tracheal suction by closed system without daily change versus open system

BACKGROUND

Tracheal suctioning costs are higher with a closed tracheal suction system (CTSS) than with an open system (OTSS), due to the need for complete daily change as recommended by the manufacturer. However, is it necessary to change the closed system daily?

OBJECTIVE

To evaluate the tracheal suctioning costs and incidence of ventilator-associated pneumonia (VAP) using closed system without daily change vs OTSS.

DESIGN

Prospective and randomised study.

SETTING

An Intensive Care Unit in a university hospital.

PATIENTS

Patients requiring mechanical ventilation.

INTERVENTIONS

Patients were randomly assigned to CTSS without daily change or OTSS. We used a CTSS that allowed partial or complete change.

MEASUREMENTS AND RESULTS

There were no significant differences between both groups of patients (236 with CTSS and 221 with OTSS) in gender, age, diagnosis, APACHE-II score, mortality, number of aspirations per day, percentage of patients who developed VAP (13.9 vs 14.1%) or the number of ventilator-associated pneumonia per 1000 days of mechanical ventilation (14.1 vs 14.6). There were not significant differences in tracheal suctioning costs per patient/day between CTSS vs OTSS (2.3+/-3.7 vs 2.4+/-0.5 Euros; p=0.96); however, when length of mechanical ventilation was lower than 4 days, the cost was higher with CTSS than with OTSS (7.2+/-4.7 vs 1.9+/-0.6 Euros; p<0.001); and when length of mechanical ventilation was higher than 4days, the cost was lower with CTSS than with OTSS (1.6+/-2.8 vs 2.5+/-0.5 Euros; p<0.001).

CONCLUSION

CTSS without daily change is the optimal option for patients needing tracheal suction longer than 4 days.

Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia

The aim of this study was to compare the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia (VAP). A prospective, randomized, controlled trial was performed in a medical intensive care unit (MICU) of a university hospital in patients who received mechanical ventilation for more than 48 h. Patients were randomized to receive endotracheal suction with either closed catheters (closed suction group; N-41) or single-use catheters (open suction group; N=37). Cultures were taken from the ventilator tubing of 42 patients to determine the rate of colonization. There was no difference between the groups in terms of the frequency of development of VAP, mortality in the MICU, length of MICU stay and duration of mechanical ventilation. Thirteen patients in the open suction group and 16 patients in the closed suction group became colonized (P=0.14). The colonization rates by Acinetobacter spp. and Pseudomonas aeruginosa were more frequent in the closed suction group than in the open suction group (P<0.01 and P=0.04, respectively). In conclusion, closed endotracheal suction resulted in increased colonization rates of ventilator tubing with multi drug-resistant micro-organisms but did not increase the development of VAP and MICU outcome compared with open endotracheal suction.

Effectiveness and side effects of closed and open suctioning: an experimental evaluation

OBJECTIVE

To compare the effectiveness of closed system suctioning (CSS) and open system suctioning (OSS) and the side effects on gas exchange and haemodynamics, during pressure-controlled ventilation (PCV) or continuous positive airway pressure (CPAP).

DESIGN

Bench test and porcine lung injury model.

PARTICIPANTS

Twelve bronchoalveolar saline-lavaged pigs.

SETTING

Research laboratory in a university hospital.

INTERVENTIONS

In a mechanical lung, the efficacy of OSS and CSS with 12 and 14 Fr catheters were compared during volume-control ventilation, PCV, CPAP 0 or 10 cmH(2)O by weighing the suction system before and after aspirating gel in a transparent trachea. Side effects were evaluated in the animals with the same ventilator settings during suctioning of 5, 10 or 20 s duration.

MEASUREMENTS AND RESULTS

Suctioning with 12 and 14 Fr catheters was significantly more efficient with OSS (1.9+/-0.1, 2.8+/-0.9 g) and with CSS during CPAP 0 cmH(2)O (1.8+/-0.2, 4.2+/-0.5 g) as compared to CSS during PCV (0.2+/-0.2, 0.8+/-0.3 g) or CPAP 10 cmH(2)O (0.0+/-0.1, 0.7+/-0.4 g), p<0.01 (means +/- SD). OSS and CSS at CPAP 0 cmH(2)O resulted in a marked decrease in SpO(2), mixed venous oxygen saturation and tracheal pressure, p<0.001, but the side effects were considerably fewer during CSS with PCV and CPAP 10 cmH(2)O, p<0.05.

CONCLUSIONS

Irrespective of catheter size, OSS and CSS during CPAP 0 cmH(2)O were markedly more effective than CSS during PCV and CPAP 10 cmH(2)O but had worse side effects. However, the side effects lasted less than 5 min in this animal model. Suctioning should be performed effectively when absolutely indicated and the side effects handled adequately.

Epidemiology and risk factors for nosocomial pneumonia. Emphasis on prevention

VAP is a complex nosocomial infection, the disease expression and resulting patient outcome of which is dependent on host factors, the causative organism, the timing and adequacy of treatment, and the presence of intrinsic or inducible antibiotic resistance. Significant improvements have been achieved in our ability to reduce the occurrence of VAP in the hospital setting. Clinicians caring for mechanically ventilated patients should strive to develop focused programs for the prevention of VAP, other nosocomial infections, and the occurrence of antibiotic-resistant infections at their institutions. The benefits of such programs are well demonstrated. The components of a PDSA (Plan-Do-STUDY-Act) model that can be simply employed to develop a VAP prevention program are as follows: Stages Plan: 1. Identify potentially modifiable risk factors for VAP at the institutional level. 2. Develop a strategy to modify or prevent the occurrence of these risk factors. [figure: see text] Do: 1. Carry out the planned intervention strategy. 2. Identify problems in the implementation of the designed intervention. 3. Update the intervention with solutions for the identified problems. 4. Collect basic data (e.g., VAP rates, severity of illness).

STUDY

1. Analyze data. 2. Summarize the results. Act: 1. Determine the overall success or failure of the intervention. 2. Identify potential modifications to improve the intervention strategy. 3. Prepare for next PDSA cycle. Inherent in the development and application of such programs is the concept that they are continuous processes striving to improve clinical performance over time (Fig. 3). At any given institution, the most likely approach to the prevention of NP and VAP will be a multifaceted one, employing interventions aimed at reducing the occurrence of aerodigestive tract colonization with pathogenic bacteria and aspiration. To be successful, such quality improvement programs must be embraced at the institutional level. Only in this way can hospitals hope to successfully reduce their rates of VAP and sustain or improve upon those efforts over time.

The practice and perception of intensive care staff using the closed suctioning system

Tracheobronchial suctioning using the closed suctioning system (CSS) has physiological benefits for critically ill patients. Despite these benefits, nurses have raised concerns about the CSS. The aims of this study were to identify concerns, count how frequently they occurred and examine the relationship between the concerns and the experience of the operators. Experience was defined as length of time working in an intensive care unit (ICU) and length of time using the CSS. Using a field research approach, six major concerns were identified: showering of condensate from the flush port over the hands of staff; difficulty cleansing the inner tube after use; ineffective secretion removal; disconnecting the CSS to use conventional catheters; 'sticking' of the CSS in the endotracheal tube; and possible tracheal trauma as observed by blood stained secretions. Based on these findings, a data collection form was developed and over an 8-week period, 75 staff completed 923 forms. The findings indicated that although these concerns occurred frequently (up to 66% of the time), there was no relationship between their frequency and the experience of the operator. The study concludes that, if used appropriately, the advantages of CSS outweigh the disadvantages. Policies and guidelines should be developed to redress issues of secretion removal and infection risks to maximize effectiveness of the CSS for critically ill patients.

Closed tracheal suctioning systems and infection control in the intensive care unit

Closed tracheal suction catheters offer a number of microbiological advantages over the conventional single-use suction catheters. Intensive care staff, however, have experienced difficulties such as pooling of the catheter irrigation saline within the connectors, and hand contamination from condensate which escapes via the irrigation port. Using a descriptive survey design we quantified how frequently these problems occurred. Over an eight-week period, staff completed 923 survey forms. Hand contamination from condensate was reported in 61% of responses. Rinsing the catheter after use was ineffective in 39% of responses, and 70% reported pooling of the saline in the swivel and ventilator connectors. Forty-five percent of responses reported ineffective secretion removal. The infection implications for clinical practice are discussed.

Mechanical ventilation with or without daily changes of in-line suction catheters

The purpose of this study was to determine the safety and cost-effectiveness of not routinely changing in-line suction catheters for patients requiring mechanical ventilation. Patients were randomly assigned to receive either no routine in-line suction catheter changes (n = 258) or in-line suction catheter changes every 24 h (n = 263). The main outcome measure was the incidence of ventilator-associated pneumonia. Other outcomes evaluated included hospital mortality, acquired organ system derangements, duration of mechanical ventilation, lengths of intensive care and hospital stay, and the cost for in-line suction catheters. Ventilator-associated pneumonia was seen in 38 patients (14.7%) receiving no routine in-line suction catheter changes and in 39 patients (14.8%) receiving in-line suction catheter changes every 24 h (relative risk, 0.99; 95% CI, 0.66 to 1.50). No statistically significant differences for hospital mortality, lengths of stay, the number of acquired organ system derangements, death in patients with ventilator-associated pneumonia, or mortality directly attributed to ventilator-associated pneumonia were found between the two treatment groups. Patients receiving in-line suction catheter changes every 24 h had 1,224 catheter changes costing a total of $11,016; patients receiving no routine in-line suction catheter changes had a total of 93 catheter changes costing $837. Our findings suggest that the elimination of routine in-line suction catheter changes is safe and can reduce the costs associated with providing mechanical ventilation.

Nursing care of the mechanically ventilated patient in ITU: 1

The mechanically ventilated patient often represents the ultimate in vulnerability and demands the highest standards of nursing care. Not only may the patient be unconscious but also the artificial airway is an unnatural invasion of the most innate physiological mechanism--breathing, and the nurse must safeguard this during all aspects of care. Nursing these patients is immensely satisfying and varied. It ranges from caring for the patient's activities of daily living to carrying out the highly technical and invasive monitoring and interventions which require specialist knowledge and skills. This article, the first in a two-part series, covers the types of ventilation, suction therapy, oral and eye care, elimination, body position, physiotherapy and the physiological effects of mechanical ventilation.

Microbial colonization of closed-system suction catheters used in liver transplant patients

The microbial colonization and the associated risk of respiratory infection during the application of a multiple-use closed-system suction catheter (CSSC) and a single-use open-system suction catheter (OSSC) on liver transplant patients was evaluated in this preliminary study. The cost differential for the two systems was also compared. Twenty post-orthotopic liver transplant (OLTx) patients who were mechanically ventilated via an endotracheal (ET) tube were studied. Ten subjects were randomly allocated ET suction by the CSSC and 10 with OSSC. Both groups were similar according to age, sex, clinical severity, presence of a naso-gastric tube, use of H2 antagonists and antibiotics used. Standard protocols were followed to intubate and suction the patients and to change ventilatory equipment. Suctioning performed with the CSSC did not significantly increase the risk of microbial colonization of the respiratory tract. Similarly there was no apparent difference in the incidence of nosocomial pneumonia between the two suction systems, based on the microbiological and clinical data. The mean daily cost of using the CSSC compared to the OSSC was 11.6 times higher. This may be balanced by a reduction in nursing time and reduced risk of spread of infection associated with the CSSC.

Suction apparatus and the suctioning procedure: reducing the infection risks

Serious infection has been related to the use of suction apparatus and to the suctioning procedure. Prevention of infection focuses on aseptic technique, handwashing, decontamination and sterilization of apparatus where appropriate. This article considers the infection risks arising from use of suction apparatus, the suctioning procedure and sets out recommendations for infection prevention.