Healthcare-Associated Infections _ ______________________________________________________________
Elevation of the Head of the Bed Reducing the risk of aspiration and contamination with gastric secretions also helps to prevent the development of ventilator-associated pneumonia. The risk of aspiration has been significantly reduced by positioning the patient with the head of the bed at an angle of 30 to 45 degrees [22; 204; 205]. In one randomized controlled trial, there were 18% fewer cases of ventilator-associated pneumonia among intubated patients in the group assigned to the recumbent position (45 degrees) compared with the group assigned to the supine position [205]. In another study, elevation of the head of the bed at 30 degrees was the most effective measure among a group of preventive interventions, resulting in a 52% variance in the rate of ventilator-associated pneumonia [206]. Both the ATS/ IDSA and SHEA/IDSA guidelines recommend maintaining the head of the bed at a 30- to 45-degree angle [20; 38]. Daily Oral Care with Chlorhexidine Oral care interventions have been suggested by some, in part because of an association between a high level of dental plaque and a high rate of colonization with aerobic pathogens, including S. aureus , gram-negative bacilli, and P. aeruginosa [207]. Research has shown that oral decontamination with chlorhexidine leads to a significant reduction in the coloniza- tion of pathogens in the oropharynx; in most studies, the intervention has not had a significant effect on the rate of ventilator-associated pneumonia or associated mortality, but more recent studies have shown significant decreases in the rate of ventilator-associated pneumonia [208; 209; 210]. Including tooth brushing with chlorhexidine does not seem to add benefit [211; 212]. Regular oral care with an antiseptic solution or chlorhexidine is recommended in the ATS/IDSA
breathing exercises are recommended, especially for people at high risk for pulmonary complications, as are frequent cough- ing and early movement (in bed and/or walking) [27; 143; 194]. Fair evidence supports the selective (rather than routine) use of a nasogastric tube after abdominal surgery [143]. Ventilator-Associated Pneumonia Two guidelines were developed to focus specifically on the prevention of ventilator-associated pneumonia; one was jointly developed by the SHEA and IDSA, and the other was jointly developed by the Canadian Critical Care Trials Group and the Canadian Critical Care Society [22; 38]. In addition, prevention of ventilator-associated pneumonia is addressed in the CDC’s guidelines for preventing healthcare-associated pneumonia and in the IDSA/ATS guidelines on the manage- ment of healthcare-associated pneumonias [20; 27]. All of these agencies suggest a multicomponent strategy for prevention of pneumonia. Compliance with guidelines, however, has been slow; nursing surveys demonstrate rates of adherence to specific preventive measures ranging from 15% to 50% [195; 199]. Education is beneficial, and training sessions are a proven means to enhance knowledge and practice among healthcare professionals caring for intubated patients [200]. The Institute for Healthcare Improvement (IHI) found that implementation of its ventilator bundle, a collection of five prevention strategies drawn from these guidelines, led to a 45% reduction in the incidence of VAP [201]. The bundle includes the following interventions [201]: • Assessment of readiness to extubate and daily interruptions of sedation
• Elevation of the head of the bed • Daily oral care with chlorhexidine • Prophylaxis of peptic ulcer disease • Prophylaxis of deep vein thrombosis Assessment of Readiness to Extubate
and SHEA/IDSA guidelines [20; 38]. Prophylaxis of Peptic Ulcer Disease
Prophylaxis of peptic ulcer disease has evolved with some con- flicting views. Antacids, histamine-2 antagonists, and sucralfate have been traditionally given to patients receiving mechani- cal ventilation to prevent the formation of ulcers. However, reducing the amount of gastric acid can increase the risk of colonization of gram-negative bacilli in the stomach. As a result, WHO recommended avoiding the use of these agents [18]. The CDC noted that there was insufficient evidence on the use of peptic ulcer prophylaxis and included no recommendations in this regard in its guidelines [27]. The ATS/IDSA guidelines stated that the risks and benefits of prophylaxis should be weighed carefully [20]. The most recent guidelines, developed by SHEA/IDSA, notes that histamine-2 receptor antagonists and PPIs should be avoided in patients who are not at high risk for developing a stress ulcer or stress gastritis [38].
Because of the increasing risk of infection as the duration of ventilation increases, the primary goal is to extubate patients as early as possible. Thus, assessment of the readiness for extuba- tion and weaning protocols are key aspects in the preventive approach [20; 198]. Daily interruption of sedation until the patient is awake has been shown to significantly decrease the number of days on mechanical ventilation, from 7.3 days to 4.9 days in one study [202]. There are risks to this approach, such as the potential for increased pain, anxiety, and desatu- ration. However, the use of sedation interruption has been further demonstrated to reduce the complications of prolonged mechanical ventilation [203]. The SHEA/IDSA guidelines recommend daily assessment of the readiness to wean and the use of weaning protocols [38].
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