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Sathiyabama S. Cricothyrotomy - In Unanticipated Difficult Intubation Cases with Respiratory Compromise. Int Arch Otorhinolaryngol 2024; 28:e307-e313. [PMID: 38618597 PMCID: PMC11008948 DOI: 10.1055/s-0043-1776726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/15/2023] [Indexed: 04/16/2024] Open
Abstract
Introduction Cricothyrotomy, percutaneous dilation tracheostomy, and tracheostomy are all cost-effective and safe techniques used in the management of critically ill patients who need an artificial airway other than endotracheal tube ventilation. The present study focused on enlightening on elective and emergency procedures performed on conditions present with difficult airways and also attempts to shed light on the aspects of securing an airway in anticipated and unanticipated difficult intubation. Objective The objective of the study was to compare the three procedures conducted during difficult airway/failed intubation situations. Methods The present retrospective observational study was conducted collecting data from patient files obtained at a tertiary healthcare center from 2013 to 2018. The difficult intubation cases were managed by ear, nose, and throat (ENT) surgeons. The study compared three methods: Cricothyrotomy, percutaneous dilation tracheostomy, and tracheostomy based on factors such as procedure duration, complications, and the instruments required for each procedure. Results The study enrolled 85 patients, 61 males and 24 females, aged between 30 and 70 years old. To perform cricothyrotomy, only a simple blade was required. Cricothyrotomy had the shortest operating time (4.1±3.1 minutes) and the shortest time of full oxygen saturation (3 min). Percutaneous tracheostomy had the least amount of bleeding (1%). Cricothyrotomy significantly showed the least intraoperative bleeding than percutaneous dilation, tracheostomy, and tracheostomy ( p = 0.001). Conclusion Cricothyrotomy is preferable as it takes less time to perform, causes less bleeding, and takes the least time for full oxygen saturation than tracheostomy and percutaneous dilatational tracheostomy in "can't intubate, can't oxygenate" patients.
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Affiliation(s)
- S Sathiyabama
- Department of ENT, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
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2
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Garegnani LI, Giménez ML, Escobar Liquitay CM, Franco JVA. Oral hygiene interventions to prevent ventilator‐associated pneumonia: A network meta‐analysis. Nurs Crit Care 2022. [DOI: 10.1111/nicc.12865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation. We sought to investigate factors associated with the development of VAP in critically ill trauma patients. METHODS We conducted a retrospective review of trauma patients admitted to our trauma intensive care unit between 2016 and 2018. Patients with ventilator-associated pneumonia were identified from the trauma database. Data collected from the trauma database included demographics (age, gender and race), mechanism of injury (blunt, penetrating), injury severity (injury severity score "ISS"), the presence of VAP, transfused blood products and presenting vital signs. RESULTS A total of 1403 patients were admitted to the trauma intensive care unit (TICU) during the study period; of these, 45 had ventilator-associated pneumonia. Patients with VAP were older (p = 0.030), and they had a higher incidence of massive transfusion (p = 0.015) and received more packed cells in the first 24 h of admission (p = 0.028). They had a higher incidence of face injury (p = 0.001), injury to sternum (p = 0.011) and injury to spine (p = 0.024). Patients with VAP also had a higher incidence of acute kidney injury (AKI) (p < 0.001) and had a longer ICU (p < 0.001) and hospital length of stay (p < 0.001). Multiple logistic regression models controlling for age and injury severity (ISS) showed massive transfusion (p = 0.017), AKI (p < 0.001), injury to face (p < 0.001), injury to sternum (p = 0.007), injury to spine (p = 0.047) and ICU length of stay (p < 0.001) to be independent predictors of VAP. CONCLUSIONS Among critically ill trauma patients, acute kidney injury, injury to the spine, face or sternum, massive transfusion and intensive care unit length of stay were associated with VAP.
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Michelángelo H, Angriman F, Pizarro R, Bauque S, Kecskes C, Staneloni I, García D, Espínola F, Mazer G, Ferrari C. Implementation of an experiential learning strategy to reduce the risk of ventilator-associated pneumonia in critically ill adult patients. J Intensive Care Soc 2019; 21:320-326. [PMID: 34093734 DOI: 10.1177/1751143719887285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective We evaluated the impact of an experiential learning strategy on both the adherence to the use of bundles and the incidence of ventilator-associated pneumonia in critically ill adult patients. Methods Longitudinal, quasi-experimental interrupted time-series study in a tertiary teaching hospital in Buenos Aires, Argentina. Successive measurements were made before and after the intervention was implemented between January 2016 and December 2018. Our main exposure was experiential learning, which was based on a combination of play activities, simulation models, knowledge and attitude competencies, role-playing and feedback. The adherence to the bundle for the care of mechanically ventilated critically-ill adult patients and the occurrence of ventilator-associated pneumonia were the main outcomes of interest. We used generalized linear models including time as a linear spline to estimate the effect of the experiential learning strategy both on the adherence to the bundle of care and the occurrence of ventilator-associated pneumonia during long-term follow-up. Results The overall proportion of adequate bundle use before and after the implementation of the intervention was 60.8% (95% CI: 56.9-64.7) and 85.6% (95% CI: 81.2-90.1), respectively. The incidence rate of ventilator-associated pneumonia before and after the intervention was 6.11 (95% CI: 5.82-6.40) and 3.55 (95% CI: 2.96-4.14) every 1000 days of mechanical ventilation, respectively. The estimated baseline monthly change in the adherence to the mechanical ventilation bundle was 0.4% (95%CI: -0.3-1.2%, p = 0.31) and 1.1% (95% CI: 0.2-2.2%, p < 0.01) before and after the implementation of the intervention, respectively. These results were consistent across our statistical quality control analysis. Conclusions The implementation of experiential learning strategies improves the adherence to bundles in the care of mechanically ventilated critically ill adult patients. Such strategies also decrease the incidence rate of ventilator-associated pneumonia. Both effects appear to remain constant during long-term follow-up.
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Affiliation(s)
- Hernán Michelángelo
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Quality Improvement Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Federico Angriman
- Department of Critical Care, Sunnybrook Health Sciences Center, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Rodolfo Pizarro
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Susana Bauque
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Claudia Kecskes
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Inés Staneloni
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - David García
- Quality Improvement Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fidencia Espínola
- Quality Improvement Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gustavo Mazer
- Quality Improvement Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Cristina Ferrari
- Medical School, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina
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Abstract
OBJECTIVES To assess the effectiveness of the ventilator bundle in the reduction of mortality in ICU patients. DATA SOURCES PubMed, Scopus, Web of Science, Cochrane Library for studies published until June 2017. STUDY SELECTION Included studies: randomized controlled trials or any kind of nonrandomized intervention studies, made reference to a ventilator bundle approach, assessed mortality in ICU-ventilated adult patients. DATA EXTRACTION Items extracted: study characteristics, description of the bundle approach, number of patients in the comparison groups, hospital/ICU mortality, ventilator-associated pneumonia-related mortality, assessment of compliance to ventilator bundle and its score. DATA SYNTHESIS Thirteen articles were included. The implementation of a ventilator bundle significantly reduced mortality (odds ratio, 0.90; 95% CI, 0.84-0.97), with a stronger effect with a restriction to studies that reported mortality in ventilator-associated pneumonia patients (odds ratio, 0.71; 95% CI, 0.52-0.97), to studies that provided active educational activities was analyzed (odds ratio, 0.88; 95% CI, 0.78-0.99), and when the role of care procedures within the bundle (odds ratio, 0.87; 95% CI, 0.77-0.99). No survival benefit was associated with compliance to ventilator bundles. However, these results may have been confounded by the differential implementation of evidence-based procedures at baseline, which showed improved survival in the study subgroup that did not report implementation of these procedures at baseline (odds ratio, 0.82; 95% CI, 0.70-0.96). CONCLUSIONS Simple interventions in common clinical practice applied in a coordinated way as a part of a bundle care are effective in reducing mortality in ventilated ICU patients. More prospective controlled studies are needed to define the effect of ventilator bundles on survival outcomes.
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Behzadi F, Khanjari S, Haghani H. Impact of an education program on the performance of nurses in providing oral care for mechanically ventilated children. Aust Crit Care 2018; 32:307-313. [PMID: 30126677 DOI: 10.1016/j.aucc.2018.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 04/11/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Mechanically ventilated children are prone to pneumonia due to immobilization and lack of laryngeal (cough) reflex and swallowing. Nurses are directly responsible for many clinical approaches used to prevent ventilator-associated pneumonia. OBJECTIVE The research objective is to determine the effectiveness of the nurse education program on the performance of nurses in providing oral care for mechanically ventilated children. METHODS This quasi-experimental pretest-posttest design was conducted on 100 nurses (50 in each of the control and intervention groups) in pediatric intensive care units (PICU) in Tehran, 2015. The research tools included a demographic form and three checklists for evaluation of performance according to the clinical practice guidelines for the oral health status of children in PICU. Before intervention, the performance of nurses in both groups was observed at three stages and three different shifts, using an observational checklist. After one month, their performance was observed again with the same checklist at three stages and three different shifts in the PICU. The training was done in four 40-50 minute sessions in a workshop with a 4-week follow-up. The Chi-square test, Fisher's exact test, paired t-test, independent t-test, and regression analysis comprised the tools used to analyze the data. FINDINGS The mean performance scores of nurses before the education program in the intervention and control groups were 42.8 (±18.5) and 48.7 (±15.7), respectively. These scores improved to 68.6 (±31.4) and 48.6 (±15.4) four weeks after the intervention (p < 0.001). CONCLUSION The performance of nurses in providing oral care for mechanically ventilated children improved after the intervention. It is recommended to implement this program for all nurses, regardless of their ward or specialty, based on the clinical practice guidelines. The periodic refreshing in-service training program should be provided to nurses in PICU in order to enhance their performance in providing oral care.
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Affiliation(s)
- Fatemeh Behzadi
- MS in Pediatric Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran; Dept. of Biostatistics, School of Management and Information Technology, Iran University of Medical Sciences, Tehran, Iran
| | - Sedigheh Khanjari
- MS in Pediatric Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran; Dept. of Biostatistics, School of Management and Information Technology, Iran University of Medical Sciences, Tehran, Iran.
| | - Hamid Haghani
- MS in Pediatric Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran; Dept. of Biostatistics, School of Management and Information Technology, Iran University of Medical Sciences, Tehran, Iran
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A Comparison of Clinical Characteristics and Outcomes of Ventilator-Associated Pneumonias Among Burn Patients by Diagnostic Criteria Set. Shock 2018; 48:624-628. [PMID: 28614140 DOI: 10.1097/shk.0000000000000926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The National Healthcare Safety Network (NHSN) replaced its old definition for ventilator-associated pneumonia (VAP) with ventilator-associated events (VAEs) in 2013. Little data is available comparing the two definitions in burn patients. METHODS Data from 2011 to 2014 were collected on burn patients mechanically ventilated for at least 2 days. VAP was determined using two methods: (1) pneumonia as defined by the previous more clinical CDC (NHSN) definition captured in the burn registry; (2) pneumonia as defined by the recent CDC (NHSN) standard of VAEs where patients meeting the criteria for possible VAP were considered having a pneumonia. Cohen kappa statistic was measured to compare both definitions, and chi-square and ANOVA to compare admission and clinical outcomes. RESULTS There were 266 burn patients who were mechanically ventilated for at least 2 days between 2011 and 2014. One hundred patients (37.5%) met the criteria by the old definition and 35 (13.1%) met the criteria for both. The kappa statistic was 0.34 (95% confidence interval 0.23-0.45), suggesting weak agreement. Those who met both definitions were mechanically ventilated for a longer period of time (P = 0.0003), and had a longer intensive care unit (ICU) length of stay (LOS) (P = 0.0004) and hospital LOS (P = 0.0014). CONCLUSIONS There is weak agreement between the two definitions of VAP in severely burn patients. However, patients who met both VAP definitions had longer ventilator days, ICU, and hospital stays.
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Gupta R, Sharma S, Saxena S. Changing panorama for surveillance of device-associated healthcare infections: Challenges faced in implementation of current guidelines. Indian J Med Microbiol 2018; 36:18-25. [PMID: 29735821 DOI: 10.4103/ijmm.ijmm_18_50] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Healthcare-associated infections (HAI) are preventable in up to 30% of patients with evidence-based infection prevention and control (IPC) activities. IPC activities require effective surveillance to generate data for the HAI rates, defining priority areas, identifying processes amenable for improvement and institute interventions to improve patient's safety. However, uniform, accurate and standardised surveillance methodology using objective definitions can only generate meaningful data for effective execution of IPC activities. The highly exhaustive, complex and ever-evolving infection surveillance methodology pose a challenge for effective data capture, analysis and interpretation by ground level personnel. The present review addresses the gaps in knowledge and day-to-day challenges in surveillance faced by infection control team for effective implementation of IPC activities.
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Affiliation(s)
- Renu Gupta
- Department of Microbiology, Institute of Human Behavior and Allied Sciences, New Delhi, India
| | - Sangeeta Sharma
- Department of Neuro Psychopharmacology, Institute of Human Behavior and Allied Sciences, New Delhi, India
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- Department of Microbiology, Institute of Human Behavior and Allied Sciences, New Delhi, India
| | - Sonal Saxena
- Department of Microbiology, Lady Hardinge Medical College, New Delhi, India
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Burn patients with infection-related ventilator associated complications have worse outcomes compared to those without ventilator associated events. Am J Surg 2017; 215:678-681. [PMID: 29126595 DOI: 10.1016/j.amjsurg.2017.10.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 10/23/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Centers for Disease Control and Prevention (CDC) replaced its definition for ventilator-associated pneumonia (VAP) in 2013. The aim of the current study is to compare the outcome of burn patients with ventilator associated events (VAEs). METHODS Burn patients with at least two days of ventilator support were identified from the registry between 2013 and 2016. Kruskal-Wallis and Fisher's exact tests were utilized for continuous and categorical variables, respectively. A logistic regression was used for the association between VAE and in-hospital mortality. RESULTS 243 patients were admitted to our burn center, of whom 208 had no VAE, 8 had a VAC, and 27 had an IVAC or PVAP. There was no difference in hospital length of stay, ICU length of stay and ventilator support days between those with no VAE and a VAC. Those with IVAC-plus had significantly worse outcomes compared to patients with no VAEs. CONCLUSIONS Burn patients with IVAC-plus had significantly longer hospital and ICU lengths of stay, days on ventilator compared with patients with no VAEs.
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Walaszek M, Gniadek A, Kolpa M, Wolak Z, Kosiarska A. The effect of subglottic secretion drainage on the incidence of ventilator associated pneumonia. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2017; 161:374-380. [PMID: 29042707 DOI: 10.5507/bp.2017.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 09/12/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Ventilator-Associated Pneumonia (VAP) is an undesired side effect of mechanical ventilation in intensive care units (ICUs). AIM We evaluated whether endotracheal tubes with subglottic secretion drainage (SSD) would reduce the incidence of VAP among patients undergoing mechanical ventilation in an ICU. METHODS The analysis of medical records of patients undergoing mechanical ventilation exceeding 48 h who were hospitalised in ICUs between 2007 and 2014 led to separating two groups of patients: those in whom no subglottic drainage was applied (NSSD) (records dating from 2007-2010) and those whose treatment involved endotracheal tubes with subglottic secretion drainage (SSD) (records dating from 2011-2014). RESULTS Analysis of 1807 patients hospitalised in ICUs (804 NSSD patients and 1003 SSD patients). A difference was found in the frequency of VAP incidence between the groups (P<0.001). In the NSSD group as many as 84 cases were reported (incidence: 10.7%), and in the SSD group - 43 cases (incidence: 5.2%). The odds ratio (OR) and relative risk (RR) was 2.5. The probability of VAP was significantly higher in the NSSD group. The risk factors of VAP incidence (P<0.001) included the correlation between reintubation (R=0.271), tracheostomy (R=0.309) and bronchoscopy (R=0.316). CONCLUSION Use of endotracheal tubes with subglottic secretion drainage in patients in the ICU on mechanical ventilation significantly reduced the incidence of VAP.
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Affiliation(s)
- Marta Walaszek
- Sw. Lukasz Provincial Hospital in Tarnow, Poland.,Department of Nursing, Institute of Health Sciences, State Higher Vocational School in Tarnow, Poland
| | - Agnieszka Gniadek
- Department of Nursing Management and Epidemiology Nursing, Faculty of Health Sciences, Jagiellonian University Medical College, Cracow, Poland
| | - Malgorzata Kolpa
- Department of Nursing, Institute of Health Sciences, State Higher Vocational School in Tarnow, Poland
| | - Zdzislaw Wolak
- Department of Nursing, Institute of Health Sciences, State Higher Vocational School in Tarnow, Poland
| | - Alicja Kosiarska
- Department of Nursing, Institute of Health Sciences, State Higher Vocational School in Tarnow, Poland
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Younan D, Griffin R, Swain T, Pittet JF, Camins B. Trauma patients meeting both Centers for Disease Control and Prevention's definitions for ventilator-associated pneumonia had worse outcomes than those meeting only one. J Surg Res 2017; 216:123-128. [PMID: 28807196 DOI: 10.1016/j.jss.2017.04.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/23/2017] [Accepted: 04/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) replaced its old definition for ventilator-associated pneumonia (VAP) with the ventilator-associated events algorithm in 2013. We sought to compare the outcome of trauma patients meeting the definitions for VAP in the two modules. METHODS Trauma patients with blunt or penetrating injuries and with at least 2 d of ventilator support were identified from the trauma registry from 2013 to 2014. VAP was determined using two methods: (1) VAP as defined by the "old," clinically based NHSN definition and (2) possible VAP as defined by the updated "new" NHSN definition. Cohen's kappa statistic was determined to compare the two definitions for VAP. To compare demographic and clinical outcomes, the chi-square and Student's t-tests were used for categorical and continuous variables, respectively. RESULTS From 2013 to 2014, there were 1165 trauma patients admitted who had at least 2 d of ventilator support. Seventy-eight patients (6.6%) met the "new" NHSN definition for possible VAP, 361 patients (30.9%) met the "old" definition of VAP, and 68 patients (5.8%) met both definitions. The kappa statistic between VAP as defined by the "new" and "old" definitions was 0.22 (95% confidence interval, 0.17-0.27). There were no differences in age, gender, race, or injury severity score when comparing patients who met the different definitions. Those satisfying both definitions had longer ventilator support days (P = 0.0009), intensive care unit length of stay (LOS; P = 0.0003), and hospital LOS (P = 0.0344) when compared with those meeting only one definition. There was no difference in mortality for those meeting both and those meeting the old definition for VAP; patients meeting both definitions had higher respiratory rate at arrival (P = 0.0178). CONCLUSIONS There was no difference in mortality between patients meeting the "old" and "new" NHSN definitions for VAP; those who met "both" definitions had longer ventilator support days, intensive care unit, and hospital LOS.
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Affiliation(s)
- Duraid Younan
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Russell Griffin
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Thomas Swain
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jean-Francois Pittet
- Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bernard Camins
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Parisi M, Gerovasili V, Dimopoulos S, Kampisiouli E, Goga C, Perivolioti E, Argyropoulou A, Routsi C, Tsiodras S, Nanas S. Use of Ventilator Bundle and Staff Education to Decrease Ventilator-Associated Pneumonia in Intensive Care Patients. Crit Care Nurse 2016; 36:e1-e7. [PMID: 27694363 DOI: 10.4037/ccn2016520] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP), one of the most common hospital-acquired infections, has a high mortality rate. OBJECTIVES To evaluate the incidence of VAP in a multidisciplinary intensive care unit and to examine the effects of the implementation of ventilator bundles and staff education on its incidence. METHODS A 24-month-long before/after study was conducted, divided into baseline, intervention, and postintervention periods. VAP incidence and rate, the microbiological profile, duration of mechanical ventilation, and length of stay in the intensive care unit were recorded and compared between the periods. RESULTS Of 1097 patients evaluated, 362 met the inclusion criteria. The baseline VAP rate was 21.6 per 1000 ventilator days. During the postintervention period, it decreased to 11.6 per 1000 ventilator days (P = .01). Length of stay in the intensive care unit decreased from 36 to 27 days (P = .04), and duration of mechanical ventilation decreased from 26 to 21 days (P = .06). CONCLUSIONS VAP incidence was high in a general intensive care unit in a Greek hospital. However, implementation of a ventilator bundle and staff education has decreased both VAP incidence and length of stay in the unit.
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Affiliation(s)
- Maria Parisi
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Vasiliki Gerovasili
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece.
| | - Stavros Dimopoulos
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Efstathia Kampisiouli
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Christina Goga
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Efstathia Perivolioti
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Athina Argyropoulou
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Christina Routsi
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Sotirios Tsiodras
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Serafeim Nanas
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
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Abstract
BACKGROUND Hospital-acquired infections (HAIs) are a persistent concern and include surgical site infections, intravascular line-associated infections, pneumonia, catheter-associated urinary tract infections, and C. difficile infection. METHOD Review of the pertinent English-language literature. RESULTS Hospital-acquired infections result in significant increases in morbidity, mortality rates, and cost and are a focus of efforts at reduction. CONCLUSION I discuss efforts specific to each of the most common infections and a philosophical approach to prevention that strives to achieve zero potentially preventable hospital-acquired infections.
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Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, Magill SS, Maragakis LL, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol 2016; 35:915-36. [DOI: 10.1086/677144] [Citation(s) in RCA: 186] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2015; 35 Suppl 2:S133-54. [PMID: 25376073 DOI: 10.1017/s0899823x00193894] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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16
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The effect of a nurse-led multidisciplinary team on ventilator-associated pneumonia rates. Crit Care Res Pract 2014; 2014:682621. [PMID: 25061525 PMCID: PMC4100357 DOI: 10.1155/2014/682621] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Revised: 06/06/2014] [Accepted: 06/10/2014] [Indexed: 11/18/2022] Open
Abstract
Background. Ventilator-associated pneumonia (VAP) is a worrisome, yet potentially preventable threat in critically ill patients. Evidence-based clinical practices targeting the prevention of VAP have proven effective, but the most optimal methods to ensure consistent implementation and compliance remain unknown.
Methods. A retrospective study of the trend in VAP rates in a community-hospital's open medical intensive care unit (MICU) after the enactment of a nurse-led VAP prevention team. The period of the study was between April 1, 2009, and September 30, 2012. The team rounded on mechanically ventilated patients every Tuesday and Thursday. They ensured adherence to the evidence-based VAP prevention. A separate and independent infection control team monitored VAP rates.
Results. Across the study period, mean VAP rate was 3.20/1000 ventilator days ±5.71 SD. Throughout the study time frame, there was an average monthly reduction in VAP rate of 0.27/1000 ventilator days, P < 0.001 (CI: −0.40–−0.13). Conclusion. A nurse-led interdisciplinary team dedicated to VAP prevention rounding twice a week to ensure adherence with a VAP prevention bundle lowered VAP rates in a community-hospital open MICU. The team had interdepartmental and administrative support and addressed any deficiencies in the VAP prevention bundle components actively.
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Safdar N, Anderson DJ, Braun BI, Carling P, Cohen S, Donskey C, Drees M, Harris A, Henderson DK, Huang SS, Juthani-Mehta M, Lautenbach E, Linkin DR, Meddings J, Miller LG, Milstone A, Morgan D, Sengupta S, Varman M, Yokoe D, Zerr DM. The evolving landscape of healthcare-associated infections: recent advances in prevention and a road map for research. Infect Control Hosp Epidemiol 2014; 35:480-93. [PMID: 24709716 PMCID: PMC4226401 DOI: 10.1086/675821] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This white paper identifies knowledge gaps and new challenges in healthcare epidemiology research, assesses the progress made toward addressing research priorities, provides the Society for Healthcare Epidemiology of America (SHEA) Research Committee's recommendations for high-priority research topics, and proposes a road map for making progress toward these goals. It updates the 2010 SHEA Research Committee document, "Charting the Course for the Future of Science in Healthcare Epidemiology: Results of a Survey of the Membership of SHEA," which called for a national approach to healthcare-associated infections (HAIs) and a prioritized research agenda. This paper highlights recent studies that have advanced our understanding of HAIs, the establishment of the SHEA Research Network as a collaborative infrastructure to address research questions, prevention initiatives at state and national levels, changes in reporting and payment requirements, and new patterns in antimicrobial resistance.
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Affiliation(s)
- Nasia Safdar
- University of Wisconsin, Madison, Infectious Disease Division, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Deverick J. Anderson
- Duke University Medical Center, Department of Infectious Diseases, Durham, North Carolina
| | | | - Philip Carling
- Boston University School of Medicine, Boston, Massachusetts
| | - Stuart Cohen
- Division of Infectious Diseases, University of California Davis School of Medicine, Hospital Epidemiology and Infection Prevention, Sacramento, California
| | - Curtis Donskey
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
| | - Marci Drees
- Christiana Care Health System, Newark, Delaware
| | - Anthony Harris
- University of Maryland School of Medicine, EPH Genomic Epidemiology & Clinical Outcomes, Baltimore, Maryland
| | | | - Susan S. Huang
- University of California Irvine School of Medicine, Irvine, California
| | - Manisha Juthani-Mehta
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, Connecticut
| | - Ebbing Lautenbach
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | | | - Loren G. Miller
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California
| | | | - Daniel Morgan
- University of Maryland School of Medicine and Veterans Affairs Maryland Healthcare System, Baltimore, Maryland
| | - Sharmila Sengupta
- Department of Microbiology, BLK Super Specialty Hospital, Delhi, India
| | - Meera Varman
- Creighton University Medical Center, Omaha, Nebraska
| | - Deborah Yokoe
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Danielle M. Zerr
- Department of Pediatrics, University of Washington and Seattle Children’s Research Institute, Seattle, Washington
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18
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Oliveira J, Zagalo C, Cavaco-Silva P. Prevention of ventilator-associated pneumonia. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:152-61. [PMID: 24674617 DOI: 10.1016/j.rppneu.2014.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 01/06/2014] [Accepted: 01/08/2014] [Indexed: 12/29/2022] Open
Abstract
Invasive mechanical ventilation (IMV) represents a risk factor for the development of ventilator-associated pneumonia (VAP), which develops at least 48h after admission in patients ventilated through tracheostomy or endotracheal intubation. VAP is the most frequent intensive-care-unit (ICU)-acquired infection among patients receiving IMV. It contributes to an increase in hospital mortality, duration of MV and ICU and length of hospital stay. Therefore, it worsens the condition of the critical patient and increases the total cost of hospitalization. The introduction of preventive measures has become imperative, to ensure control and to reduce the incidence of VAP. Preventive measures focus on modifiable risk factors, mediated by non-pharmacological and pharmacological evidence based strategies recommended by guidelines. These measures are intended to reduce the risk associated with endotracheal intubation and to prevent microaspiration of pathogens to the lower airways.
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Affiliation(s)
- J Oliveira
- CIIEM, Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal; TechnoPhage S.A., Lisbon, Portugal
| | - C Zagalo
- CIIEM, Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal; Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - P Cavaco-Silva
- CIIEM, Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal; TechnoPhage S.A., Lisbon, Portugal.
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19
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Schwarz C, Usemann J, Stephan V, Kaiser D, Rothe K, Rückert J, Neudecker J. Bilateral pneumothorax following a blunt trachea trauma. Respir Med Case Rep 2013; 10:56-9. [PMID: 26029515 PMCID: PMC3920364 DOI: 10.1016/j.rmcr.2013.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 08/23/2013] [Indexed: 11/30/2022] Open
Abstract
A-13 year old boy had an accident with his bike with a blunt thorax trauma and presented shortly after with facial swelling. Due to respiratory insufficiency, intubation was done during the transport to the clinic. First, a chest radiograph was performed, which showed a unilateral pneumothorax. Later a CT scan revealed bilateral pneumothorax and pneumomediastinum. Bilateral chest tube insertions improved the respiratory situation. Bronchoscopy showed a tracheal lesion two cm posterior to the main carina. After good wound healing, the patient was dismissed after 21 days in good health. Conservative treatment can be recommended in selected patients with a tracheal lesion when having a stable respiratory situation. If the patient does not improve after 48 h or if the clinical condition worsens, surgical management should be considered.
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Affiliation(s)
- C. Schwarz
- Charité University Hospital Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany
| | - J. Usemann
- Charité University Hospital Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany
| | - V. Stephan
- Sana Hospital Lichtenberg, Gotlinderstr. 2-20, 10365 Berlin, Germany
| | - D. Kaiser
- Helius Klinikum Walthöferstr., 14165 Berlin, Germany
| | - K. Rothe
- Charité University Hospital Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany
| | - J.C. Rückert
- Charité University Hospital Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany
| | - J. Neudecker
- Charité University Hospital Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany
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20
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Suys E, Nieboer K, Stiers W, De Regt J, Huyghens L, Spapen H. Intermittent subglottic secretion drainage may cause tracheal damage in patients with few oropharyngeal secretions. Intensive Crit Care Nurs 2013; 29:317-20. [PMID: 23727136 DOI: 10.1016/j.iccn.2013.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 02/16/2013] [Accepted: 02/25/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Injurious prolapse of tracheal mucosa into the suction port has been reported in up to 50% of intubated patients receiving continuous aspiration of subglottic secretions. We investigated whether similar injury could be inflicted by automated intermittent aspiration. METHODS Six consecutive patients, intubated with the Mallinckrodt TaperGuard Evac™ endotracheal tube, were studied. A flow sensor was placed between the vacuum regulating system and the mucus collector. Intermittent suctioning was performed at a pressure of -125 mmHg with a 25s interval and duration of 15s. After 24h, a CT scan of the tracheal region was performed. RESULTS Excessive negative suction pressure, a fast drop in aspiration flow to zero, and important "swinging" movements of secretions in the evacuation line were observed in all patients. Oral instillation of antiseptic mouthwash restored normal aspiration flow and secretion mobility. CT imaging showed marked entrapment of tracheal mucosa into the suction port in all patients. CONCLUSION In patients with few oropharyngeal secretions, automated intermittent subglottic aspiration may result in significant and potential harmful invagination of tracheal mucosa into the suction lumen. A critical amount of fluid must be present in the oropharynx to assure adequate and safe aspiration.
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Affiliation(s)
- E Suys
- Intensive Care Department, University Hospital, Vrije Universiteit Brussel, Laarbeeklaan, 101, B-1090 Brussels, Belgium(1).
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21
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Matar DS, Pham JC, Louis TA, Berenholtz SM. Achieving and sustaining ventilator-associated pneumonia-free time among intensive care units (ICUs): evidence from the Keystone ICU Quality Improvement Collaborative. Infect Control Hosp Epidemiol 2013; 34:740-3. [PMID: 23739079 DOI: 10.1086/670989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Our retrospective analysis of the Michigan Keystone intensive care unit (ICU) collaborative demonstrated that adult ICUs could achieve and sustain a zero rate of ventilator-associated pneumonia (VAP) for a considerable number of ventilator and calendar months. Moreover, the results highlight the importance of adjustment for ventilator-days before comparing VAP-free time among ICUs.
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Affiliation(s)
- Dany S Matar
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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22
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Gupta D, Agarwal R, Aggarwal AN, Singh N, Mishra N, Khilnani GC, Samaria JK, Gaur SN, Jindal SK. Guidelines for diagnosis and management of community- and hospital-acquired pneumonia in adults: Joint ICS/NCCP(I) recommendations. Lung India 2012; 29:S27-62. [PMID: 23019384 PMCID: PMC3458782 DOI: 10.4103/0970-2113.99248] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - G. C. Khilnani
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - J. K. Samaria
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - S. N. Gaur
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - S. K. Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - for the Pneumonia Guidelines Working Group
- Pneumonia Guidelines Working Group Collaborators (43) A. K. Janmeja, Chandigarh; Abhishek Goyal, Chandigarh; Aditya Jindal, Chandigarh; Ajay Handa, Bangalore; Aloke G. Ghoshal, Kolkata; Ashish Bhalla, Chandigarh; Bharat Gopal, Delhi; D. Behera, Delhi; D. Dadhwal, Chandigarh; D. J. Christopher, Vellore; Deepak Talwar, Noida; Dhruva Chaudhry, Rohtak; Dipesh Maskey, Chandigarh; George D’Souza, Bangalore; Honey Sawhney, Chandigarh; Inderpal Singh, Chandigarh; Jai Kishan, Chandigarh; K. B. Gupta, Rohtak; Mandeep Garg, Chandigarh; Navneet Sharma, Chandigarh; Nirmal K. Jain, Jaipur; Nusrat Shafiq, Chandigarh; P. Sarat, Chandigarh; Pranab Baruwa, Guwahati; R. S. Bedi, Patiala; Rajendra Prasad, Etawa; Randeep Guleria, Delhi; S. K. Chhabra, Delhi; S. K. Sharma, Delhi; Sabir Mohammed, Bikaner; Sahajal Dhooria, Chandigarh; Samir Malhotra, Chandigarh; Sanjay Jain, Chandigarh; Subhash Varma, Chandigarh; Sunil Sharma, Shimla; Surender Kashyap, Karnal; Surya Kant, Lucknow; U. P. S. Sidhu, Ludhiana; V. Nagarjun Mataru, Chandigarh; Vikas Gautam, Chandigarh; Vikram K. Jain, Jaipur; Vishal Chopra, Patiala; Vishwanath Gella, Chandigarh
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Abstract
PURPOSE OF REVIEW The increasing number of hospitals reporting ventilator-associated pneumonia (VAP) rates at or close to zero begs the question of whether zero should become the national benchmark for VAP. This article explores the significance of very low VAP rates, reviews differences in surveillance and clinical rates, proposes reasons for their discrepancies, and suggests possible objective alternatives for surveillance. RECENT FINDINGS Surveillance rates of VAP are decreasing, whereas clinical diagnoses and antibiotic prescribing remain prevalent. This growing discrepancy reflects the lack of objective and definitive signs to diagnose VAP. External reporting pressures may be encouraging stricter interpretation of subjective signs and other surveillance initiatives that can artifactually lower rates. It is impossible to disentangle the relative contribution of care improvements versus surveillance effects to currently observed low VAP rates. SUMMARY The increasing mismatch between surveillance rates and clinical diagnoses limits the utility of official VAP rates to estimate disease burden and guide quality improvement. Advocates are advised to consider objective alternatives such as average duration of mechanical ventilation, length of stay, mortality, and antibiotic prescribing. Emerging surveillance definitions that use more objective criteria may better reflect and inform future clinical practice.
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Ventilator-associated pneumonia–in the eyes of the beholder*. Crit Care Med 2012; 40:352-3. [DOI: 10.1097/ccm.0b013e318232665b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Zolfaghari PS, Wyncoll DLA. The tracheal tube: gateway to ventilator-associated pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:310. [PMID: 21996487 PMCID: PMC3334734 DOI: 10.1186/cc10352] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a major healthcare-associated complication with considerable attributable morbidity, mortality and cost. Inherent design flaws in the standard high-volume low-pressure cuffed tracheal tubes form a major part of the pathogenic mechanism causing VAP. The formation of folds in the inflated cuff leads to microaspiration of pooled oropharyngeal secretions into the trachea, and biofilm formation on the inner surface of the tracheal tube helps to maintain bacterial colonization of the lower airways. Improved design of tracheal tubes with new cuff material and shape have reduced the size and number of these folds, which together with the addition of suction ports above the cuff to drain pooled subglottic secretions leads to reduced aspiration of oropharyngeal secretions. Furthermore, coating tracheal tubes with antibacterial agents reduces biofilm formation and the incidence of VAP. In this Viewpoint article we explore the published data supporting the new tracheal tubes and their potential contribution to VAP prevention strategies. We also propose that it may now be against good medical practice to continue to use a 'standard cuffed tube' given what is already known, and the weight of evidence supporting the use of newer tube designs.
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Affiliation(s)
- Parjam S Zolfaghari
- London Deanery, Guy's and St Thomas' NHS Trust, Lambeth Palace Road, London SE1 7EH, UK.
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26
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Bailey JL, Yeung SY. Probiotics for disease prevention: a focus on ventilator-associated pneumonia. Ann Pharmacother 2011; 45:1425-32. [PMID: 21954447 DOI: 10.1345/aph.1q241] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To summarize published data regarding the safety and efficacy of probiotics in the prevention of ventilator-associated pneumonia (VAP). DATA SOURCES PubMed databases (January 2000-August 2011) were searched and a bibliographic review of published articles was performed to identify original reports of probiotic administration for the prevention of VAP using the search terms probiotics, synbiotics, and ventilator-associated pneumonia. STUDY SELECTION AND DATA EXTRACTION Two pilot studies, 2 randomized controlled trials (RCTs), and 1 meta-analysis have addressed probiotic use for VAP prevention and were included in the review. DATA SYNTHESIS VAP frequently occurs in mechanically ventilated patients. Given the lack of new antimicrobial agents, probiotics have been studied for their ability to modify human microflora colonization. Two studies examining pathogen colonization rates favored probiotics, with reduced incidence and increased duration until the emergence of new species. One prospective RCT found significant reduction in the incidence of VAP and colonization rates, but no significant difference in patient disposition outcomes. Another RCT examining 28-day mortality found no overall benefit with probiotic use and no reduction in colonization rates. CONCLUSIONS Clinical trials have failed to demonstrate a consistent beneficial effect of probiotics in mechanically ventilated patients; thus, they are not recommended for routine clinical use. However, heterogeneity among study designs may hinder this assessment and the designs should be unified in future research.
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Sundar KM, Nielsen D, Sperry P. Comparison of ventilator-associated pneumonia (VAP) rates between different ICUs: Implications of a zero VAP rate. J Crit Care 2011; 27:26-32. [PMID: 21737241 DOI: 10.1016/j.jcrc.2011.05.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 04/11/2011] [Accepted: 05/08/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Ventilator-associated pneumonia (VAP) is associated with significant morbidity and mortality. Measures to reduce the incidence of VAP have resulted in institutions reporting a zero or near-zero VAP rates. The implications of zero VAP rates are unclear. This study was done to compare outcomes between two intensive care units (ICU) with one of them reporting a zero VAP rate. DESIGN, SETTING AND PATIENTS This study retrospectively compared VAP rates between two ICUs: Utah Valley Regional Medical Center (UVRMC) with 25 ICU beds and American Fork Hospital (AFH) with 9 ICU beds. Both facilities are under the same management and attended by a single group of intensivists. Both ICUs have similar nursing and respiratory staffing patterns. Both ICUs use the same intensive care program for reduction of VAP rates. ICU outcomes between AFH (reporting zero VAP rate) and UVRMC (VAP rate of 2.41/1000 ventilator days) were compared for the years 2007-2008. MEASUREMENTS AND MAIN RESULTS UVRMC VAP rates during 2007 and 2008 were 2.31/1000 ventilator days and 2.5/1000 ventilator days respectively compared to a zero VAP rate at AFH. The total days of ventilation, mean days of ventilation per patient and mean duration of ICU stay per patient was higher in the UVRMC group as compared to AFH ICU group. There was no significant difference in mean age and APACHE II score between ICU patients at UVRMC and AFH. There was no statistical difference in rates of VAP and mortality between UVRMC and AFH. CONCLUSIONS During comparisons of VAP rate between institutions, a zero VAP rate needs to be considered in the context of overall ventilator days, mean durations of ventilator stay and ICU mortality.
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Affiliation(s)
- Krishna M Sundar
- Department of Medicine, Utah Valley Regional Medical Center and University of Utah, Provo, UT 84604, USA.
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