VENTILATOR CARE BUNDLE

VENTILATOR CARE BUNDLEWan Ahmad Asyraf bin Wan Md AdnanModerator: Dr Nik Azman bin Nik Adib

IntroductionProblems with VentilationVentilator Care BundleConclusionReferences

IntroductionIntensive care patients are almost always synonymous with ventilationIt has been proven to help in managing patients in critical care settingsUnfortunately, ventilator patients are at high risk of developing several serious complications.

Problems with VentilationMultiple serious complications may arise in ventilated patientsThese include:Ventilator associated pneumoniaVenous thromboembolism (VTE)Stress-induced gastrointestinal bleeding

Ventilator Associated PneumoniaLife threatening complications, associated in up to 50% of ventilated patientsMortality rate 2-3 times moreDefinition:Pneumonia occurring more than 48 hours after patients have been intubated and received mechanical ventilation

ComplicationsVentilator Associated PneumoniaClinical criteria for suspicionNew or persistent infiltrate on CXRPlus 2 of the followingPurulent endotracheal secretionsIncreasing oxygen requirementsCore temperature > 38.0 CTWC < 3.5 or > 11.0DiagnosisEndotracheal aspirateDiagnostic bronchoscopy

Complications

Ventilator Associated PneumoniaEarly vs late VAPBacteriologyEarly: susceptible gram negative bacteriaLate: higher chances of multiresistant organismsPrognosis: Early: less severeLate: higher mortality and morbidityRisk factorsPulmonary disease, sepsis, major surgery, multiorgan failure, enteral nutrition, GI prophylaxis, positioning, reintubation, paralytic agentComplicationsVentilator associated pneumoniaCommon mechanisms by which VAP develops:Aspiration of secretionsColonisation of the aerodigestive tractsUse of contaminated equipmentComplications

Venous thromboembolismHigh prevalence of VTEMost patients in hospital have risk factors for VTE (critical care patients have higher risks)DVT and PE are usually clinically silent in hospital settings (even more silent in ventilated patients)Difficult to predictScreening at-risk patients is not effective and will involve high costComplicationsVenous thromboembolismAdverse consequencesIncrease mortalityHigh cost of investigationsCost of treatment for DVT and PERisk of recurrenceSignificant mortality and morbidity due to VTE in critically ill patientsFor example: pulmonary embolismBetween 7 to 27% of death in ICU may have been caused or contributed by PE (based on post mortem examinations)Out of those number, only 30% has clinical suspicion of PE

Stress-induced gastrointestinal bleedingCritically ill patients are at higher risk of developing stress ulcerIn addition to premorbid risk factors which they already haveIncidence of overt gastrointestinal bleeding in ICU patients is estimated to range from 1.5-8.5%As high as 15% if no prophylaxis were givenComplicationsOthersCumulative cost of all the complicationsIncreased length of stay in intensive careHigher direct cost for treatmentIncreased bed occupancy rateComplications

Ventilator Care BundleBundle:a set of individual components, combined to make a set of quality indicators for a specific system, procedure or treatmentExamples:Ventilator care bundle, sepsis bundle, central venous line bundleIndividual components improve careEven greater improvement when applied togetherstandard of careVentilator care bundleDesigned to minimise complications which may arise when patients are on ventilatorGuidelines tend to be long policy, whilst bundle meant to be short, simple and easier to implement13Ventilator Care Bundle4 key components (according to MRIC)Head of bed% of patients nursed with the head of bed at least 30 degreesSedation vacation% of patients who have had their sedation held within the last 24 hoursPeptic ulcer (PU) prophylaxis% of patients receiving PU prophylaxis within 24 hours of admissionVTE prophylaxis% of patients receiving prophylaxis within 24 hours of admissionSome studies added an extra component to this bundle later onDaily oral care

Reference: MRIC (malaysian registry of intensive care)14

Head of bed Maintain patients in a semi recumbent position (minimum 30 degrees)To minimise aspiration of gastric contents, oropharyngeal or nasopharyngeal secretions (associated with VAP)67% reduction in VAP among patients maintained in semirecumbent positions during the first 24 hours of mechanical ventilationRCT published in 1999 (Drakulovic et al): significantly lower incidence of VAP in patients in semi recumbent positions (c.f. supine position)26% absolute risk reduction of clinically suspected nosocomial pneumonia18% absolute risk reduction in aspiration penumoniaImprove ventilationSpontaneous mode: diaphragm moves easier during inspiration as abdominal contents are lower in the cavityMandatory mode: minimise atelectasisVentilator care bundle67% reduction: in multivariate study published in JAMA in 199316Head of bedExclusion criteriaPatient on high dose of vasopressors/inotropesIntraaortic balloon pump Spine instability,Pelvic instability Compromised circulation (femoral lines) Agitated (risk of falling out of bed)

Ventilator care bundle

Sedation vacationSedationFundamental part intensive careEnables application of mechanical ventilationLess distressDifferent drugs used in ICU for that purposeBenzodiazepinesOpioidPropofolKetamineDexmedetomedine Ventilator care bundleSedation vacationDiscontinuation of sedation after very prolonged infusionfrequently resulted in hangover effectLonger than expected time to wake upProspective observational study (1998)Continuous IV sedation associated with prolongation of mechanical ventilation (compared to bolus IV sedation or no sedation)

Ventilator care bundleKollef et al (1998): single adult ICU, only benzodiazepines were primarily used21Sedation vacationAim: to minimise duration of mechanical ventilation (eventually reducing the risk of VAP)Periodic sedative interruptions Daily assessment of readiness to extubateRCT published in 2000 (Kress et al):Daily interruption resulted in significant reduction of mechanical ventilation time (7.3 days to 4.9 days)

Ventilator care bundleSedation vacationWithhold sedatives every morning at 8 am except in patients requiring continuous deep sedation. Analgesics should be continued for patients requiring pain relief.Exceptions:Patients on cerebral protection, severe sepsis, ARDS, prone positions, on muscle relaxant infusionsRisk:Increased potential for self extubationPain & anxietyVentilator care bundle

Peptic ulcer prophylaxisCritically ill patients on mechanical ventilation have an increased risk of stress ulcers which may progress to gastrointestinal bleedingAssociated with five-fold increase in ICU mortalityRationale for prophylaxisReduce volume of gastric juiceIncrease pH of gastric contentsAcidic content aspiration has a greater pulmonary inflammatory responseVentilator care bundlePeptic ulcer prophylaxisWhen to start?Mechanical ventilationCoagulopathyHypoperfusion state, organ dysfunctionSevere head injury, spinal cord injurySevere burnsHigh dose corticosteroidsPatients who are not fed with 2 risk factors of peptic ulcer (NSAIDs, steroids, previous history)Ventilator care bundlePeptic ulcer prophylaxisWhich medications?Sucralfate (vs H2 receptor antagonist) seems to have the upper hand initiallyLower risk of late-onset VAP4% higher risk of clinically significant bleedingMaintain normal gastric pH (lower GNB colonisation)H2 receptor antagonist has gained more popularity later onBased on double blind RCT published in 1998Lower risk of bleeding as compared to sucralfateWith no significant difference in the rates of VAP, duration of stay in ICU and mortalityProton pump inhibitorUnknown relative efficacy as prophylaxis (equivalent ability to increase gastric pH as compared to H2 receptor antagonist)Used in proven ulcers or already on PPI treatment

Ventilator care bundleNosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. A randomized controlled trial. (1994)-sucralfate: lower risk of VAP, higher risk of bleeding)Multicenter prospective study of ventilator-associated pneumonia during acute respiratory distress syndrome. Incidence, prognosis, and risk factors. ARDS Study Group.-higher risk of VAP with sucralfateNosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers. The role of gastric colonization. (1987)-GNB colonisation (associated with higher pH) more frequent in patients receiving H2 receptor antagonist and antacids (as compared to sucralfate)

27Peptic ulcer prophylaxisDosageRanitidineIV 50mg tds (bd dose in renal failure)Oral 150mg bd (od dose in renal failure) once enteral feeding establishedPantoprazoleActive UGIB: Loading IV 80mg, then infusion 8mg/hr (over 48-72H)Unclear associations between peptic ulcer prophylaxis and decreasing rates of VAPBased on experience, VAP rates decrease precipitously when PUD prophylaxis is applied as part of interventions for ventilator careVentilator care bundleVTE prophylaxisRationale for prophylaxis:High prevalencePreventable adverse consequencesEfficient and effectiveRisk factorsBefore admissionSurgery, trauma, burns, malignancy, sepsis, immobilisation (stroke, cord injury), pregnancy, previous VTEAcquired in ICUCVL, sepsis, sedation and paralysis, mechanical ventilationVentilator care bundleVTE prophylaxisSystematic review in 2001:Within 1st week of ICU admission, about 10-30% develop DVTUnfractionated heparin (UFH) reduces incidence of DVT by 20%Low molecular weight heparin (LMWH) decrease the incidence by a further 30%

Ventilator care bundleAttia et al (2001): DVT and its prevention in critically ill adults30VTE prophylaxis

VTE prophylaxisPharmacological modalitiesLow dose UFHLMWHFondaparinux sodium (pentasaccharide Factor Xa inhibitor)Withhold...Significant decrease in platelet count (30 50%)Thrombocytopenia (< 50,000/mm3)INR / aPTT ratio > 1.5Ventilator care bundleVTE prophylaxisMechanical prophylaxisEnhance effectiveness of pharmacological useConside when pharmacological use is contraindicatedUnclear associations between VTE prophylaxis and decreasing rates of VAPVAP rates decrease precipitously when VTE prophylaxis is applied as part of interventions for ventilator care

Ventilator care bundle

Daily oral careChlorhexidine has long been proven as an inhibitor of dental plaque formation and gingivitisImportant adjunct to oral hygieneMeta-analysis published in 2007Oral decontamination using chlorhexidine in ventilated adults is associated with lower risk of VAPRationale:Reduces bacteria in oral mucosa, thus decreasing the potential of bacterial colonisation in the upper respiratory tractVentilator care bundleVentilator care bundleCompilations of measuresWhen applied together, can potentially minimise rates of VAP and other complications associated with ventilationConsidered as standard of care for every patients on mechanical ventilatorFailure of which will be considered as being negligent towards patients care

SummaryWhat do I want if that ICU patient is me?If you decide to intubate and ventilate me, please keep head of bed elevated (at least 30 degrees)No unnecessary sedation for meKindly prescribe IV ranitidine Do not make me starve, start early feedingPlease give me some kind of DVT prophylaxisGently wash my mouth with chlorhexidine rinseExtubate me as soon as possible, when Im readyAnd do not forget to wash your hand before/after touching me

ReferencesMalaysian Registry of Intensive Care, http://www.mric.org.my Management Protocols in ICU 2012, Malaysian Society of Intensive Care, August 2012.Institute for Healthcare Improvement, http://www.ihi.org Reducing Harm in Critical Care, http://www.patientsafetyfirst.nhs.uk Zap the VAP Initiative. http://www.zapthevap.com Susan et al, Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals, Infection Control and Hospital Epidemiology. October 2008Steven et al, Ventilator-Associated Pneumonia: Diagnosis, Treatment and Prevention, Clinical Mirobiology Reviews. October 2006The Canadian Critical Care Trials Group, A Randomized Trial of Diagnostic Techniques for Ventilator-Associated Pneumonia, The New England Journal of Medicine. December 2006.Mitra et al, Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial, Lancet. 2009John et al, Daily Interruptions of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation, The New England Journal of Medicine. December 2000.Deborah et al, A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation, The New England Journal of Medicine. December 1998.Paul et al, Stress ulcer prophylaxis in the new millenium: A systematic review and meta-analysis, Critical Care Medicine. 2010