MUDr.Pavel Štětka ARK FN U sv.anny Brno

Transkript

1 MUDr.Pavel Štětka ARK FN U sv.anny Brno

2 Definice Etiologie,bakteriologické a histologické aspekty incidence Klinická diagnoza Preventivní opatření Závěr.

3 Johanson et al. in nově vzniklý infiltrát na rtg, 2.TT nad 38,3stC, 3.leukocytoza 4. purulentní tracheální aspirát ovšem NESPECIFICKÉ Cultures of tracheal aspirates are not very useful in establishing the cause of VAP. Although such cultures are highly sensitive, their specificity is low even when they are cultured quantitatively

4 five RCTs (1367 patients) AUTHORS' CONCLUSIONS: There is no evidence that the use of quantitative cultures of respiratory secretions results in reduced mortality, reduced time in ICU and on mechanical ventilation, or higher rates of antibiotic change when compared to qualitative cultures in patients with VAP. Similar results were observed when invasive strategies were compared with non-invasive strategies.

5 VAP přesná dg. tato kritéria jsou ovšem založená na invazívních procedurách n neobvyklých klin.manifestacích n.komplikacích VAP #histopathologické vyš. vzorku plicní tkáně z otevřené plicní biopsie # rychlá kavitace plicního infiltrátu při absenci tumoru n.tbc # positivní kultivace pleuralní tekutiny # průkaz stejné bakterie se shod.antibiogramem isolované z krve a sekretu resp.traktu bez jiného zjistitelného zdroje bakteriémie# histopathologické vyš.plicní tkáně získáné při pitvě # early-onset VAP (pneumonia od 2 do 5 dne po intubaci- STPN,STAU, HAEIN # late-onset VAP po 5 až 7 dni GNB, Enterobacteriacea, MRSA, event.caalb

6 VAP Ventilator-associated associated pneumonia (VAP) je nejčast astější nosokomiáln lní infekcí na ICU Incidence 10-40% Zdvojnásobuje mortalitu pacientů na ICU Prodlužuje uje dobu hospitalizace LOStj.loenght of stay (>6 days) Zvyšuje náklady (>$10000 per episode) Safdar N, Dezfulian C, Collard HR, Saint S.Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med Oct;33(10): Shorr AF, Wunderink RG. Dollars and sense in the intensive care unit: the costs of ventilator-associated pneumonia.crit Care Med May;31(5):

7 1- kolonizace sekretu horních cest dýchacíchpodíl regurgitace žal.obsahu do hypofaryngu 2-mikroaspirace podél manžety intubační kanyly 3- překonání obranných mechanismů respiračního traktu

8 # Methany et al.,ccm 2006 Apr : :Tracheobronchial aspiration of gastric contents in critt.ill tube-fed patients # Pepsin jako marker 6000vzorků 89%poz.!!!!!

9 DIGESTIVE TRACT INTERNAL ORGANS ACQUISITION CARRIAGE OVERGROWTH >10na5/g COLONIZATION INFECTION SURVEILLANCE SAMPLES DIAGNOSTIC SAMPLES LOWER AIRWAY,BLOOD,BLADDER

10 A.NORMÁLN LNÍ STRPNEU/oro HAE INFL/oro MOR CAT/oro E COLI/gut STAU/gut i oro CAALBI/gut i oro B.ABNORMÁLN LNÍ KLEBS PROTEUS ENTEROBA MORG SP CITRO SERRA PSEU ACINET MRSA

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13 # pravidelná edukace personálu # mít protokol prevence VAP # pravidelná surveillance VAP út + čt # přísná hygiena rukou a izolace infekčních pacientů # NIV místo UPV přes OTK-Girou et al.,association of NIV with nosocomial infections and survival in critt.ill patients,jama 2000

14 # OTI místo NTI # weaning + sedation protokol tj. redukce ventilator-days # uzavřený vs. otevřený ený systém odsávání - CLOSED TRACHEAL SUCTION SYSTEMS FOR PREVENTION OF VAP Siempos II, Alfa Institute of Biomedical Sciences, Athens, Greece, Br J Anaesth Mar;100(3):

15 a meta-analysis analysis of randomized controlled trials (RCTs). Nine RCTs were included in the meta-analysis. 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) ].. Suctioning with closed systems was associated with LONGER MV DURATION (weighted mean differences: 0.65 days, 95% CI ) and HIGHER COLONIZATION OF THE RESPIRATORY TRACT (OR=2.88, 95% CI ) 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.

16 # otk polyurethanová manžeta redukující mikroaspirace,která normálně až v 9/10 případů Influence of an endotracheal tube with polyurethane cuff and subglottic secret drainage on pneumonia Lorente l,. am j respir crit care med dec 1;176: to compare the incidence of VAP, using an endotracheal tube with polyurethane cuff and subglottic secretion drainage (ett-puc-ssd) versus a conventional endotracheal tube (ett-c) with polyvinyl cuff, without subglottic secretion drainage.

17 METHODS: Clinical randomized trial in a 24-bed medicalsurgical intensive care unit. Patients expected to require mechanical ventilation for more than 24 hours were randomly assigned to one of two groups: one was ventilated with ETT-PUC-SSD and the other with ETT-C. RESULTS: Tracheal aspirate samples were obtained during endotracheal intubation, then twice per week and finally on extubation. VAP was found in 31 of 140 (22.1%) patients in the ETT-C group and in 11 of 140 (7.9%) in the ETT-PUC-SSD group (P = 0.001) CONCLUSIONS: The use of an endotracheal tube with polyurethane cuff and subglottic secretion drainage helps prevent early- and late-onset VAP.

18 Oblast bez záhybz hybů (Těsnící zóna)mimořádné utěsnění bez záhybů a kanálků > posílené těsnící schopnosti Ultra-tenká manžeta (< 15 mikronů) eliminuje kapilární síly Tvar manžety zajišťuje optimální utěsnění pro téměř všechny typy a rozměry trachey

19 Stěna trachey Záhyby manžety

20 Cardiac surgery patients are at risk for postoperative pneumonia. Peri-operative micro-aspiration of oropharyngeal content is a possible cause of the pathofysiology of postoperative pneumonia. We speculated that the use of a poly-urethane cuffed endotracheal tube (PUC ETT) (Seal-Guard Guard ) could be protective due to enhanced sealing of the pharyngotracheal barrier. Results 59 patients were included, 30 patients received poly-urethane cuffed ETT, patients received conventional PVC ETT, Conclusions: Use of a poly-urethane cuffed ETT was associated with a lower rate of early postoperative pneumonia in cardiac surgery patients

21 # Subglotická drenáž =odsávání nad balónkem, frekvence kolikrát denně? Cameron Dezfulian, MD-Subglottic secretion drainage for preventing VAP: a meta-analysis AmJMed snížení early-onset VAP, LOS 3 dny, UPV 2 dny

22 # udržování stálého tlaku v manžetě otk dnes i speciální přístroje # neprovádět pravidelnou výměnu okruhu ventilátoru u jednoho pacienta!! ale nyní nedělat vůbec # HME místo aktivního zvlhčování? neprokázán rozdíl, výměna až po 72 hodinách, určitá skupina až týden

23 RESULTS: Thirteen randomized controlled trials, studying 2,580 patients, were included. HMEs were cheaper than HHs in each of the randomized controlled trials. CONCLUSION: The available evidence does not support the preferential performance of either passive or active humidifiers in mechanical ventilation patients in terms of ventilator- associated pneumonia incidence, mortality, or morbidity

24 CONCLUSION: The LoTrach system has been designed to facilitate the provision of a number of evidence-based interventions that have been shown to reduce VAP. Pulmonary aspiration is ubiquitous with conventional cuffs but prevented by the cuff of the LoTrach system when held at a constant and safe pressure against the tracheal wall with a cuff pressure controller. Other aspects incorporated in the ETT are aimed at clearing the secretions from the subglottic space, preventing tube occlusion and accidental extubation, and avoiding damage to the airway. In this way the LoTrach system employs a multifactorial approach to the prevention of VAP and the cost savings from LoTrach rather than a standard ETT will be considerable because of an average 3 day reduction in ICU length of stay related to this. It thus has the potential to be a very useful tool in the ICU setting in the prevention of VAP.

25 Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in ICU-Outcomera study group.anaesthesiology 2002,Jul, Res. 8% incidence Relative risk of VAP 5,3

26 # Orofaryngeáln lní dekontaminace chlorhexidinem SYSTEMATIC LITERATURE REVIEW OF ORAL HYGIENE PRACTICES FOR INTENSIVE CARE PATIENTS RECEIVING MEC VEN Berry AM, Am J Crit Care Nov;16(6):552-62; 62; quiz 563. BACKGROUND: Oropharyngeal colonization with pathogenic organisms contributes to the development of ventilatorassociated pneumonia in intensive care units. Although considered basic and potentially nonessential nursing care, oral hygiene has been proposed as a key intervention for reducing ventilator-associated pneumonia. Nevertheless, evidence from randomized controlled trials that could inform best practice is limited.

27 METHODS: Articles published from 1985 to 2006 RESULTS: The search yielded 55 articles: 11 prospective controlled trials, 20 observational studies, and 24 descriptive reports. CONCLUSIONS: Despite the importance of providing oral hygiene to intensive care patients receiving mechanical ventilation, high-level evidence from rigorous randomized controlled trials or high-quality systematic reviews that could inform clinical practice is scarce.

28 The one intervention not included in the IHI bundle is oral hygiene. The The one intervention not included in the IHI bundle is The purpose of this project is to support the premise that oral care,, including timed toothbrushing,, combined with the VAP bundle can mitigate and prevent the occurrence of VAP. mechanically ventilated patients on a 24-bed stroke, neurologic, and medical ICU. Patients were randomized into a control group that performed usual oral care or an intervention group that brushed teeth every 8 hours. The results were immediate and startling, as the VAP rate dropped d to zero within a week of beginning the every-8-hours toothbrushing regimen in the intervention group. The study was so successful that the control group was dropped after 6 months, and all intubated patients' teeth were brushed every 8 hours, maintaining the zero rate until the end of the study.

29 The patients were randomized to receive oral decontamination with 2% chlorhexidine solution or normal saline solution 4 times per day until their endotracheal tubes were removed. The outcome measures were the development of VAP and oropharyngeal colonization with gram-negative bacilli. Meta-analysis analysis was performed by combining the results of the present study with those from another randomized controlled trial that also used a 2% chlorhexidine formulation for oral decontamination. RESULTS: The characteristics of the patients in the chlorhexidine e group and the normal saline group were not significantly different. The incidence nce of VAP in the chlorhexidine group was 4.9% (5 of 102), and the incidence in the normal saline group was 11.4% (12 of 105). The rate of VAP in the chlorhexidine group was 7 episodes per 1,000 ventilator-days, and the rate in the normal saline group was 21 episodes per 1,000 ventilator-days. Irritation of the oral mucosa was observed in 10 (9.8%) of the patients in the chlorhexidine group and in 1 (0.9%) of the patients in the normal saline group. Oropharyngeal colonization with gram- negative bacilli was either reduced or delayed in the chlorhexidine group. Overall mortality of the patients did not differ significantly between the groups. Meta- analysis of 2 randomized controlled trials revealed an overall relative risk of VAP for patients in the chlorhexidine group of 0.53 (95% confidence interval,

30 # poloha pacienta 30st elevace horní -VAP IHI Bundle # analgosedace- 1x denně probuzení pacienta= dailly stop sedation návrh dělat denně u každého v hodin # prevence TEN heparinem -mechanismus? # punkční TS místo chirurgické TS = tracheostomie

31 RESULTS: Among patients intubated for 24 hours or longer, rates of microbiologically confirmed VAP were 4.8% (37/766 patients; 95% confidence interval [CI], 3.4%-6.6%) in the group receiving the silver-coated tube and 7.5% (56/743; 95% CI, 5.7%-9.7%) (P =.03) in the group receiving the uncoated tube (all intubated patients, 3.8% [37/968; 95% CI, 2.7%-5.2%] and 5.8% [56/964; 95% CI, 4.4%-7.5%] [P =.04]), with a relative risk reduction of 35.9% (95% CI, 3.6%-69.0%; 69.0%; all intubated patients, 34.2% [95% CI, 1.2%-67.9%]). The silver-coated endotracheal tube was associated with delayed occurrence of VAP (P =.005). No statistically ically significant between-group differences were observed in durations of intubation, intensive care unit stay, and hospital stay; mortality; ty; and frequency and severity of adverse events. CONCLUSION: Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube.

32 Incidenci VAP lze prevencí redukovat Mít na ICU guidelines prevence VAP Edukovat personál a dbát na dodržování guidelines Nové OTK s polyuretanovou manžetou a ods.nad balonkem Opět otevřený systém odsávání?