You are on page 1of 14

POST resuscitation cardiac arrest care

There is increasing recognition that systematic post cardiac arrest care after return of spontaneous circulation (ROSC) can improve the likelihood of patient survival with good quality of life. This is based in part on the publication of results of randomized controlled clinical trials as well as a description of the postcardiac arrest syndrome.13 Postcardiac arrest care has significant potential to reduce early mortality caused by hemodynamic instability and later morbidity and mortality from multiorgan failure and brain injury.3,4 This section summarizes our evolving understanding of the hemodynamic, neurological, and metabolic abnormalities encountered in patients who are initially resuscitated from cardiac arrest. The initial objectives of postcardiac arrest care are to Optimize cardiopulmonary function and vital organ perfusion. After out-of-hospital cardiac arrest, transport patient to an appropriate hospital with a comprehensive postcardiac arrest treatment system of care that includes acute coronary interventions, neurological care, goal-directed critical care, and hypothermia. Transport the in-hospital postcardiac arrest patient to an appropriate critical-care unit capable of providing comprehensive postcardiac arrest care. Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest. Subsequent objectives of postcardiac arrest care are to Control body temperature to optimize survival and neurological recovery Identify and treat acute coronary syndromes (ACS) Optimize mechanical ventilation to minimize lung injury Reduce the risk of multiorgan injury and support organ function if required Objectively assess prognosis for recovery Assist survivors with rehabilitation services when required Previous SectionNext Section

Systems of Care for Improving PostCardiac Arrest Outcomes

Postcardiac arrest care is a critical component of advanced life support (Figure). Most deaths occur during the first 24 hours after cardiac arrest.5,6 The best hospital care for patients with ROSC after cardiac arrest is not completely known, but there is increasing interest in identifying and optimizing practices that are likely to improve outcomes (Table 1).7 Positive associations have been noted between the likelihood of survival and the number of cardiac arrest cases treated at any individual

hospital.8,9 Because multiple organ systems are affected after cardiac arrest, successful post cardiac arrest care will benefit from the development of system-wide plans for proactive treatment of these patients. For example, restoration of blood pressure and gas exchange does not ensure survival and functional recovery. Significant cardiovascular dysfunction can develop, requiring support of blood flow and ventilation, including intravascular volume expansion, vasoactive and inotropic drugs, and invasive devices. Therapeutic hypothermia and treatment of the underlying cause of cardiac arrest impacts survival and neurological outcomes. Protocolized hemodynamic optimization and multidisciplinary early goal-directed therapy protocols have been introduced as part of a bundle of care to improve survival rather than single interventions.1012 The data suggests that proactive titration of postcardiac arrest hemodynamics to levels intended to ensure organ perfusion and oxygenation may improve outcomes. There are multiple specific options for acheiving these goals, and it is difficult to distinguish between the benefit of protocols or any specific component of care that is most important.

View larger version: In this page In a new window Download as PowerPoint Slide

Figure. Postcardiac arrest care algorithm.

View this table: In this window In a new window

Table 1. Multiple System Approach to PostCardiac Arrest Care A comprehensive, structured, multidisciplinary system of care should be implemented in a consistent manner for the treatment of postcardiac arrest patients (Class I, LOE B). Programs should include as part of structured interventions therapeutic hypothermia; optimization of hemodynamics and gas

exchange; immediate coronary reperfusion when indicated for restoration of coronary blood flow with percutaneous coronary intervention (PCI); glycemic control; and neurological diagnosis, management, and prognostication. Previous SectionNext Section

Overview of PostCardiac Arrest Care

The provider of CPR should ensure an adequate airway and support breathing immediately after ROSC. Unconscious patients usually require an advanced airway for mechanical support of breathing. It may be necessary to replace a supraglottic airway used for initial resuscitation with an endotracheal tube, although the timing of replacement may vary. Methods for securing an advanced airway are discussed in Part 8.1: Airway Management, but several simple maneuvers deserve consideration. For example, rescuers and long-term hospital providers should avoid using ties that pass circumferentially around the patient's neck, potentially obstructing venous return from the brain. They should also elevate the head of the bed 30 if tolerated to reduce the incidence of cerebral edema, aspiration, and ventilatory-associated pneumonia. Correct placement of an advanced airway, particularly during patient transport, should be monitored using waveform capnography as described in other sections of the 2010 AHA Guidelines for CPR and ECC. Oxygenation of the patient should be monitored continuously with pulse oximetry. Although 100% oxygen may have been used during initial resuscitation, providers should titrate inspired oxygen to the lowest level required to achieve an arterial ox ygen saturation of 94%, so as to avoid potential oxygen toxicity. It is recognized that titration of inspired oxygen may not be possible immediately after out-of-hospital cardiac arrest until the patient is transported to the emergency department or, in the case of in-hospital arrest, the intensive care unit (ICU). Hyperventilation or overbagging the patient is common after cardiac arrest and should be avoided because of potential adverse hemodynamic effects. Hyperventilation increases intrathoracic pressure and inversely lowers cardiac output. The decrease in Pa CO2 seen with hyperventilation can also potentially decrease cerebral blood flow directly. Ventilation may be started at 10 to 12 breaths per minute and titrated to achieve a PETCO2 of 35 to 40 mm Hg or a PaCO2 of 40 to 45 mm Hg. The clinician should assess vital signs and monitor for recurrent cardiac arrhythmias. Continuous electrocardiographic (ECG) monitoring should continue after ROSC, during transport, and throughout ICU care until stability has been achieved. Intravenous (IV) access should be obtained if not already established and the position and function of any intravenous catheter verified. IV lines should be promptly established to replace emergent intraosseous access achieved during resuscitation. If the patient is hypotensive (systolic blood pressure <90 mm Hg), fluid boluses can be considered. Cold fluid may be used if therapeutic hypothermia is elected. Vasoactive drug infusions such as dopamine, norepinephrine, or epinephrine may be initiated if necessary and titrated to achieve a minimum systolic blood pressure of 90 mm Hg or a mean arterial pressure of 65 mm Hg. Brain injury and cardiovascular instability are the major determinants of survival after cardiac arrest.13 Because therapeutic hypothermia is the only intervention demonstrated to improve neurological recovery, it should be considered for any patient who is unable to follow verbal commands after ROSC. The patient should be transported to a facility that reliably provides this

therapy in addition to coronary reperfusion (eg, PCI) and other goal-directed postarrest care therapies. Overall the most common cause of cardiac arrest is cardiovascular disease and coronary ischemia.14,15 Therefore, a 12-lead ECG should be obtained as soon as possible to detect ST elevation or new or presumably new left bundle-branch block. When there is high suspicion of acute myocardial infarction (AMI), local protocols for treatment of AMI and coronary reperfusion should be activated. Even in the absence of ST elevation, medical or interventional treatments may be considered for treatment of ACS14,16,17 and should not be deferred in the presence of coma or in conjunction with hypothermia. Concurrent PCI and hypothermia are safe, with good outcomes reported for some comatose patients who undergo PCI. Patients who are unconscious or unresponsive after cardiac arrest should be directed to an inpatient critical-care facility with a comprehensive care plan that includes acute cardiovascular interventions, use of therapeutic hypothermia, standardized medical goal-directed therapies, and advanced neurological monitoring and care. Neurological prognosis may be difficult to determine during the first 72 hours, even for patients who are not undergoing therapeutic hypothermia. This time frame for prognostication is likely to be extended in patients being cooled. 18 Many initially comatose survivors of cardiac arrest have the potential for full recovery such that they are able to lead normal lives.1,2,19 Between 20% and 50% or more of survivors of out-of-hospital cardiac arrest who are comatose on arrival at the hospital may have good one-year neurological outcome.1,2,11 Therefore, it is important to place patients in a hospital critical-care unit where expert care and neurological evaluation can be performed and where appropriate testing to aid prognosis is available and performed in a timely manner. Attention should be directed to treating the precipitating cause of cardiac arrest after ROSC. The provider should initiate or request studies that will further aid in evaluation of the patient. It is important to identify and treat any cardiac, electrolyte, toxicological, pulmonary, and neurological precipitants of arrest. The clinician may find it helpful to review the H's and T's mnemonic to recall factors that may contribute to cardiac arrest or complicate resuscitation or postresuscitation care: hypovolemia, hypoxia, hydrogen ion (acidosis of any etiology), hyper-/hypokalemia, moderate to severe hypothermia, toxins, tamponade (cardiac), tension pneumothorax, and thrombosis of the coronary or pulmonary vasculature. For further information on treating other causes of cardiac arrest, see Part 12: Special Resuscitation Situations.

WHO analgesic ladder

Pain ladder

From Wikipedia, the free encyclopedia

Jump to: navigation, search "Pain ladder" is a term coined by the World Health Organization (WHO) to describe its guideline for the use of drugs in the management of pain. It was originally applied to the management of cancer pain, but is now widely used by medical professionals for the management of all types of pain. The general principle is to start with first step drugs, and then to climb the ladder if pain is still present. The medications range from household, over-the-counter drugs with minimal sideeffects at the lowest rung, to powerful opioids.


1 The Ladder 2 See also 3 References 4 External links

The Ladder[edit]
The WHO guidelines[1] recommend prompt oral administration of drugs when pain occurs, starting, if the patient is not in severe pain, with non-opioid drugs such as paracetamol (acetaminophen), dipyrone, non-steroidal anti-inflammatory drugs (NSAIDs) or COX-2 inhibitors. Then, if complete pain relief is not achieved or disease progression necessitates more aggressive treatment, a mild opioid such as codeine phosphate, dextropropoxyphene, dihydrocodeine or Tramadol are added to the existing non-opioid regime. If this is or becomes insufficient, a mild opioid is replaced by a stronger opioid, such as morphine, diamorphine (heroin), fentanyl, buprenorphine, oxymorphone, oxycodone, hydromorphone, while continuing the non-opioid therapy, escalating opioid dose until the patient is pain free or at the maximum possible relief without intolerable side effects. If the initial presentation is severe pain, this stepping process should be skipped and a strong opioid should be started immediately in combination with a non-opioid analgesic.[2] Bottom rung of ladder (mild pain): Non opioid +/- adjuvant Middle rung of ladder (moderate pain): Weak opioid +/- non opioid +/- adjuvant Highest rung of ladder (severe pain): Strong opioid +/- non opioid +/- adjuvant The usefulness of the second step (mild opioid) is being debated in the clinical and research communities. Some authors challenge the pharmacological validity of the step and, pointing to their higher toxicity and low efficacy, argue that a mild opioid, with the possible exception of Tramadol due to its unique action, could be replaced by smaller doses of a strong opioid.[2]

Not all pain yields completely to classic analgesics, and drugs that are not traditionally considered analgesics, but which reduce pain in some cases, such as steroids or bisphosphonates, may be employed concurrently with analgesics at any stage. Tricyclic antidepressants, class I antiarrhythmics, or anticonvulsants are the drugs of choice for neuropathic pain. Up to 90 percent of cancer patients, immediately preceding death, use such adjuvants. Many adjuvants carry a significant risk of serious complications.[2


Before undergoing elective surgical procedures, patients should be instructed about taking deep breaths and ambulating postoperatively (unless there is a medical contraindication to doing so). Such instruction is especially important in patients who are at high risk for pneumonia after operation. This group includes patients scheduled for abdominal aortic aneurysm repair or thoracic procedures, those older than 60 years, those undergoing general anesthesia, those whose functional status is poor, those with greater than 10% weight loss, those on long-term steroid therapy, those with COPD, smokers, those with abnormally low or high BUN levels, and those receiving more than 4 units of blood preoperatively. ,
2 62

Patients who are also at high risk but are not candidates for preoperative

respiratory instruction include those undergoing emergency surgical intervention, those with impaired sensoria, and those with a history of cerebrovascular accident with residual neurologic deficit (although, depending on the type of deficit, this patient population may benefit from preoperative teaching as well). Incentive spirometry is valuable for preventing pneumonia after operation and is a cost-effective adjunct to early ambulation. It benefits a wide range of patients but is especially effective in moderate-risk and high-risk patients, who should receive extra attention in ensuring compliance with this simple intervention. Although chest physiotherapy has been proposed as a means of potentially decreasing postoperative pneumonia, a meta-analysis of 14 published studies assessing the usefulness of this modality after upper abdominal procedures did not support its routine use.

Like many other infections in critically ill patients, VAP is often preventable. Well-designed studies have found numerous interventions to be effective in lowering the incidence of VAP.

Some of these interventions are as simple

as positioning the patient appropriately or educating health care workers about risk factors for VAP.

Hand Hygiene
Appropriate hand hygiene is a simple but underused method of preventing nosocomial infection. Lack of attention to hand hygiene has been a persistent problem worldwide for decades, and physicians often have the poorest compliance. The alcohol foams and gels currently available are more effective than hand washing in killing the bacteria present on the hands and take substantially less time to use, improving compliance with hand hygiene in the ICU.


preparations now represent the hand hygiene method of choice in most cases and should be readily available throughout the ICU. Hands that are visibly dirty or are soiled with blood or body fluids should still be washed with antimicrobial soap and water, however. Appropriate hand hygiene practices should be followed both before and after contact with a patient who has an Figure 1 Recommended Approach to Antibiotic Treatment endotracheal tube or tracheostomy in place, regardless of whether gloves are worn. In addition, hand decontamination is required before and after contact with any respiratory device that is used on a mechanically ventilated patient.

Gloves should be worn for handling respiratory secretions or objects contaminated with such secretions. They should be changed between contacts with different patients, after handling respiratory secretions. In addition, gloves should be changed between contacts with a contaminated body site and the respiratory tract or any portion of the ventilator circuit on the same patient. Gowns are also recommended when soiling with respiratory secretions is anticipated; they should be removed after the soiling occurs and before any contact with other ICU patients.

Aspiration of upper airway secretions occurs in healthy adults as well as in ill ones. It is, however, a matter of much greater concern in critically ill patients with decreased host defenses, who are at increased risk for VAP. Maneuvers to reduce aspiration of gastric contents therefore have the potential to decrease the incidence of VAP. Because the supine position is associated with an increased risk of aspiration (especially if the patient is receiving tube feedings via a nasoenteric tube), placing the patient in a semirecumbent position via the simple expedient of raising the head of the bed to an angle of 30 to 45 or greater is recommended as a means of possibly preventing VAP (if not medically contraindicated). A prospective, randomized trial involving 86 patients in two ICUs (neither of them surgical) was stopped at the first interim analysis because of the significant difference in the incidence of VAP between semirecumbent patients and supine patients.

The incidence of both clinically suspected VAP and microbiologically proven VAP was drastically

reduced in patients positioned with the head of the bed at a 45 angle (from 34% to 8% and from 23% to 5%, respectively). Enteral feeding was also independently associated with the risk of VAP: supine patients receiving enteral feedings had a 50% chance of acquiring VAP. A subsequent prospective, randomized trial of 109 patients found that a target backrest elevation of 45 was not achieved 85% of the time, and the actual treatment position (28) did not prevent the development of VAP compared with the standard position (10).

The supine position has been identified as an independent risk factor for VAP in other observational studies of ICU patients as well. In addition, patients who require transport from the ICU are at substantially higher risk for VAP than

those who do not (24.2% versus 4.4%).


It is possible that the VAP rate is increased because patients requiring

transport are sicker at baseline, but it is also possible that the rate is higher in this group partly because patients are supine for much or all of their transport time. Because static bed rest is known to increase the risk of pulmonary (and nonpulmonary) complications, it has been theorized that postural oscillation and rotation may prevent VAP. Specialized kinetic beds are available that provide continuous movement and are capable of reducing pulmonary complications in surgical patients. A study of 106 blunt trauma patients in a surgical ICU demonstrated a significant decrease in VAP in patients randomly selected to undergo continuous postural oscillation.

A study of 65 surgical patients immobilized because of head injury or


traction showed a nonstatistical trend toward a decreased risk of pneumonia in patients treated with kinetic beds.

Finally, a study of 69 liver transplant patients randomly assigned to either continuous lateral rotation or a conventional bed found that the incidence of lower respiratory tract infections was decreased in the study group, as was the length of time to the development of infection; however, the duration of mechanical ventilation and length of stay were unchanged.

Overall, there appears to be a trend toward decreased VAP in surgical patients treated with kinetic beds. In addition, various accompanying nonpulmonary complications can also be prevented by this treatment (e.g., decubitus ulcers). Accordingly, kinetic beds should be used in surgical patients who are expected to have a prolonged ICU course.

Choice of Feeding Route

Although elevation of the head of the bed reduces aspiration, it does not prevent gastroesophageal reflux. Because gastric overdistention is also associated with an increased risk of aspiration, there has been considerable interest in identifying a route of feeding that is associated with a decreased incidence of VAP. This issue is directly relevant to the postoperative setting, in which many patients, as a consequence of the surgical procedure, experience ileus, which is often exacerbated by narcotics given for pain relief. The generally appropriate reluctance to feed a patient with a large gastric residuum in the ICU setting should be balanced against the desire to provide adequate nutrition as soon as is practicable after an operation, as well as against the multiple advantages of enteral feeding over parenteral feeding. Accordingly, the timing for initiating feedings postoperatively must be individualized on the basis of each patient's situation and condition. In addition, whereas feeding a supine patient greatly increases the risk of VAP, there is no documented benefit to postpyloric feeding or to using smaller nasogastric tubes recommendations can be made regarding how best to feed a postoperative patient enterally.

and no clear

Minimization of Endotracheal Intubation

Extended mechanical ventilation is a major risk factor for VAP; it follows, then, that decreasing or eliminating the need for an endotracheal tube has the potential to lower the incidence of VAP. There are two major strategies by which this goal can be accomplished: (1) earlier extubation (i.e., removing an endotracheal tube when it is no longer needed) and (2) noninvasive ventilation (i.e., continuing ventilatory support without the presence of an endotracheal tube). In addition, the route of intubation (oral versus nasal) can influence the development of pneumonia.

Although the optimal mode of weaning has not been definitively determined, it is clear that many patients are kept intubated even when they no longer require mechanical ventilation. The use of a weaning protocol, a sedation

protocol, or both has been shown to reduce the duration of mechanical ventilation. In addition, daily interruption of sedation until a patient is awake has been demonstrated to decrease the number of ventilator days in a medical ICU population.

Importantly, a randomized, controlled trial of 336 patients demonstrated that the combination of a

spontaneous awakening trial and a spontaneous breathing trial led to decreased time on the ventilator and ICU length of stay as well as decreased mortality for 1 year compared with a spontaneous breathing trial with sedation per usual care.

This approach has not been extensively studied in the surgical ICU, where the issue is complicated by the

greater need for postoperative narcotics. Regardless of the technique or protocol employed, patients should be assessed daily to determine whether ventilatory support is still necessary. Extubated patients have a substantially lower incidence of postoperative pneumonia than patients with an endotracheal tube in place. The presence of an endotracheal tube in itself, independent of the need for mechanical ventilation, also appears to be a risk factor for VAP. The tube hinders both airway reflexes and coughing, allowing secretions that accumulate above the tube to enter the airways over time and serve as a nidus of infection. This problem is eliminated in patients who are ventilated noninvasively with bilevel positive airway pressure (BiPAP). Multiple studies have found noninvasive ventilation to be associated with lower pneumonia rates and mortalities than conventional ventilation. However, these studies were done in medical ICUs, predominantly on patients with COPD exacerbations, and it is unclear whether similar results are achievable in patients with postoperative respiratory failure. Reintubation is also an independent risk factor for the development of VAP.

However, fear of the potential adverse

consequences of reintubation should not prevent an awake patient who passes a spontaneous breathing trial from being extubated. Many postoperative patients who are extubated and have unexpected ventilatory problems can be managed without reintubation on BiPAP. In addition, although it is unclear what the correct percentage of extubation attempts that require reintubation would be, it is clear that the number is not zero. The decision to extubate is, in a way, comparable to the decision to perform an appendectomy. If every patient on whom an appendectomy is done has appendicitis, it is likely that too few operations are being done and that some patients are being allowed to experience a ruptured appendix needlessly. Similarly, if every patient who is extubated postoperatively does well, it is likely that too few extubations are being done and that some patients are being kept intubated inappropriately and thus experiencing preventable morbidity. Nasal intubation increases the risk of sinusitis, which, even though only 10% of patients with opacified sinuses have recoverable bacteria, is associated with an increased incidence of VAP.

It is not clear whether sinusitis causes VAP

or merely represents a marker of patients who are at higher risk for pneumonia. In either case, given the association between nasotracheal intubation and increased infection rate and mortality, nasotracheal intubation should not be considered a first-line method of obtaining airway control.

Ventilator Management
Although, in theory, ventilator tubing, suction catheters, and humidification systems could all play a role in the development of pneumonia, none of them have been convincingly shown to have an impact on VAP rates. Condensate in the ventilator tubing can become contaminated, but multiple randomized trials have demonstrated that routinely changing ventilator circuits in patients with respiratory failure does not lower the VAP rate. periodically be drained and discarded.

Circuits should

be changed when they are visibly soiled with vomit or blood or are malfunctioning. In addition, condensate should

Heat moisture exchangers (HMEs) are frequently used instead of heated water humidification systems because HMEs are relatively inexpensive and require neither electricity nor active heating elements. HMEs minimize the formation of condensate within ventilator circuits, thereby, in theory, potentially decreasing VAP rates. One study found HMEs to yield lower infection rates than humidification systems,

but at present, there is no clear consensus in

favor of either type of device. Either an open single-use catheter system or a closed multiuse catheter system may be used for suctioning. Although open systems are associated with increased environmental contamination, current evidence suggests that the incidence of VAP is not significantly affected by the type of suctioning system used. VAP,
81 80


addition, when closed systems are used, routine changing of inline suction catheters does not reduce the incidence of nor is there convincing evidence that more frequent suctioning prevents VAP.

Ventilator Weaning
Given that the rate of VAP increases with increasing duration of mechanical ventilation, it is imperative to provide all attempts at ventilator weaning in the ICU as a VAP preventive strategy. Daily interruption of sedation, that is, spontaneous awakening trials, and daily spontaneous breathing trials are therefore recommended. ,
75 82

It has been

documented that a wake up and breathe protocol that pairs daily spontaneous awakening trials (i.e., interruption of sedatives) with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in the ICU.

Prevention of Oropharyngeal Colonization

Oropharyngeal colonization can be decreased by means of either antiseptic therapy or a comprehensive oral hygiene program. Oral chlorhexidine gluconate (0.12%), given before and after cardiac procedures, has proved effective in preventing postoperative pneumonia.

In a prospective, randomized, blinded trial, patients receiving a chlorhexidine

rinse, which has documented activity against both aerobes and anaerobes, experienced a 69% decrease in the incidence of postoperative pneumonia. This decrease was not associated with a change in antibiotic resistance patterns after operation and was accompanied by a reduction in postoperative antibiotic use. Similar results were demonstrated in a study in the surgical ICU that demonstrated that an oral care protocol combining tooth brushing and twice-daily application of chlorhexidine gluconate decreased the VAP rate from 5.2 per 1,000 ventilator days to 2.4 per 1,000 ventilator days.

These results are consistent with a recent meta-analysis demonstrating that topical

chlorhexidine is beneficial in preventing VAP, with the most significant benefit present in cardiac surgery patients.

An additional randomized trial with 2% chlorhexidine solution four times daily versus normal saline ( n = 207) confirmed a VAP reduction (7 versus 21 per 1,000 ventilator days, p = .04), and a meta-analysis of two studies using 2% chlorhexidine revealed an overall relative risk of VAP for patients in the chlorhexidine group of 0.53 (95% CI 0.31 to 0.90; p = .02).

Interestingly, the addition of electric tooth brushing to oral care with 0.12% chlorhexidine was not

effective for VAP prevention.

Drainage of Subglottic Secretions

Secretions that pool above an inflated endotracheal cuff may be a source of aspirated material that results in VAP. Specially designed endotracheal tubes are available that have a separate opening above the cuff of the tube to allow either continuous or intermittent suctioning and drainage of secretions that accumulate in the subglottic space.

A meta-analysis of five prospective, randomized trials evaluating the role of subglottic secretion drainage in 896 patients demonstrated that subglottic secretion drainage shortened the duration of mechanical ventilation and ICU stay and delayed the onset of pneumonia by 6.8 days and suggested that this could be an effective strategy in patients intubated for more than 72 hours.

Subsequent to the publication of this meta-analysis, however, the largest


randomized trial of subglottic secretion drainage was performed in 714 cardiac surgery patients.

No statistically

significant decrease in overall VAP rates was noted with continuous aspiration of subglottic secretions, although there was a decrease in hospital antibiotic use in the experimental group. For patients who required mechanical ventilation for more than 48 hours, VAP rates, ICU length of stay, and hospital antibiotic use were all decreased in patients treated with continuous aspiration of subglottic secretion, although this was not associated with an improvement in mortality. In addition, a randomized trial of 280 patients in a medical-surgical ICU combining subglottic secretion drainage with an endotracheal tube with a polyurethane cuff demonstrated a decrease in both early and late VAP compared with a conventional endotracheal tube with a polyvinyl cuff without subglottic secretion drainage.

Most recently, a

prospective trial at four French centers randomized adult patients intubated with a tracheal tube allowing drainage of subglottic secretions to undergo intermittent subglottic secretion drainage (SSD) (n = 169) or not (n = 164). VAP, diagnosed by quantitative culture of distal airways, occurred in 14.8% of SSD patients versus 25.6% of control patients (p = .02, relative risk reduction 42.2%, 95% CI 10.4 to 63.1) but had no impact on the duration of mechanical ventilation or ICU mortality.

At present, use of subglottic secretion drainage is hindered by logistical difficulties. These specialized tubes require routine maintenance in the ICU to ensure that the suction lumen remains patent. In addition, any decision to place the tubes in patients undergoing surgery must also be made preoperatively and communicated to the anesthesiologist or emergency department physician before the patient is intubated.

Silver-coated Endotracheal Tubes

There are significant data on preventing catheter-related bloodstream infection with antiseptic or antibioticimpregnated catheters; however, until recently, there were no data as to whether a similar approach would be beneficial in preventing VAP. Silver has broad-spectrum antimicrobial activity and has been used topically to prevent infections after thermal injury. Both animal and in vitro studies demonstrate that silver-coated endotracheal tubes are effective in decreasing bacterial colonization and adherence compared with standard tubes.

Based on the antimicrobial efficacy of silver

and an extensive clinical history without significant toxicity, a recent prospective, randomized trial compared the efficacy of silver-coated endotracheal tubes with that of conventional endotracheal tubes for the prevention of VAP in patients requiring mechanical ventilation for more than 24 hours (NASCENT trial).

A total of 766 patients received

endotracheal tubes coated on the inner and outer lumen with silver, whereas 743 patients were randomized to receive control endotracheal tubes. Patients who had emergency surgery or trauma made up 10% of the enrolled patient population, and over 30% of patients had their endotracheal tube placed in the operating room. Patients who received the silver-coated tubes had decreased incidence of VAP (7.5% versus 4.8%) and delayed occurrence of VAP. No statistically significant differences were noted in the duration of ICU or hospital stay or mortality. It should be noted that one controversial aspect of the study is the fact that 30% of positive BALs recovered organisms not

typically considered to be pathogenic, and when the data were analyzed without these organisms, the p value between the silver-coated endotracheal tubes and control tubes increased to .06.

Despite this, an accompanying editorial to this trial suggested that silver-coated endotracheal tubes should probably be used in trauma patients, in light of the fact that the benefit seen with the tubes occurred during the first 10 days of mechanical ventilation and that they would most likely be effective in a high-risk patient population.

In addition, a

cost-effectiveness analysis concluded that despite the increased cost of routinely placing silver-coated endotracheal tubes, their efficacy more than outweighed the cost, and they could potentially be a cost-saving strategy for preventing VAP.

Pharmacologic Approaches
Widely varying study results and significant infection control concerns have made SDD an extremely controversial practice. The term is actually a misnomer in that successful SDD protocols employ a combination of systemic antibiotics and nonabsorbable antibiotics given both orally and via a nasogastric tube. This is an important point: meta-analyses of SDD studies generally show that SDD is not effective if systemic antibiotics are not included. , Multiple recent meta-analyses examining the effect of SDD show decreased mortality in patients receiving SDD. demonstrated a 26% decrease in overall mortality.
99 96 97


A 2007 meta-analysis of 3,331 patients who received SDD including both parenteral and enteral antibiotics A follow-up meta-analysis from the same group examining 9,473 patients demonstrated a marked decrease in gram-negative respiratory tract infections with an odds ratio of 0.11 (95% CI 0.06 to 0.20) and a small decrease in gram-positive respiratory tract infections with an odds ratio of 0.52 (95% CI 0.34 to 0.78).
101 100

These findings were consistent with a Cochrane meta-analysis that included 36 trials In a subgroup analysis of 17 trials of 4,295 patients receiving both topical and systemic

involving 6,922 patients.

antibiotics, SDD decreased mortality with an odds ratio of 0.78 (95% CI 0.68 to 0.89), and respiratory infection was markedly decreased with an odds ratio of 0.35 (95% CI 0.29 to 0.41). There is significant concern, however, that even if SDD is effective in ICUs with low endemic rates of vancomycinresistant enterococcus, MRSA, and multidrug-resistant gram-negative bacteria (as is common in Europe), it might lead to enhanced selection of these and other resistant organisms in ICUs where they are endemic (as is common in the United States).

A recent study in 13 ICUs demonstrated that even though SDD was effective,



colonization with gram-negative bacteria resistant to ceftazidime, tobramycin, or ciprofloxacin increased from 5, 7, and 7%, respectively, prior to the institution of SDD or selective oropharyngeal decontamination to 15, 13, and 13%, respectively, after treatment.

Furthermore, resistance levels in the respiratory tract were not more than 6% for all

three antibiotics prior to the study but were greater than 10% for all three after initiating SDD. In addition, a study in a surgical ICU in Austria demonstrated an increase in oxacillin resistance in S. aureus isolates from 17 to 81% over a 5-year period where SDD was practiced.

A 6-year study of 360 trauma patients receiving SDD also reported a


moderate increase in the development of resistant organisms.

Owing to infection control concerns, SDD is not widely accepted in the United States. It is noteworthy that routine use of SDD to prevent VAP is not recommended in most guidelines for preventing pneumonia or sepsis. , ,
21 58 104

Another pharmacologic approach that has been proposed as a means of preventing VAP is avoidance of drugs that raise stomach pH, on the assumption that these agents may lead to bacterial overgrowth and, eventually, to VAP. The available data, however, indicate that this assumption is incorrect. A prospective, randomized trial involving 1,200 patients in 16 ICUs that compared the H2 receptor antagonist ranitidine with sucralfate found no difference in the VAP rate between the ranitidine group and the sucralfate group. not be avoided for infection control reasons.

Notably, the rate of clinically important GI

bleeding was higher in the sucralfate group. On the basis of this definitive study, drugs that raise stomach pH should

Education of Health Care Workers

Obviously, to implement interventions that prevent VAP, health care workers must be aware that such interventions exist. Although ICU directors clearly play a major role in the overall direction of care, direct daily care of patients undergoing mechanical ventilation is provided by respiratory therapists and nurses, and these professionals stand to benefit most from educational efforts. Multiple recent publications attest to the efficacy of educational programs in preventing VAP. academic center.
106 106108

In one of these, a

program was initiated that was directed toward respiratory care practitioners and nurses in five ICUs at a single Initially, 114 respiratory therapists and 146 nurses took a 20-question pretest to determine their level of knowledge about methods of preventing VAP. They then received a 10-page self-study module that provided information about VAP and outlined prevention strategies. Both immediately after the intervention and 6 months later, participants took a posttest that was identical to the original test. Test scores improved at both time points, demonstrating that the information taught was both learned and retained. In the 12 months before implementation of the education program, 191 episodes of VAP were identified (12.6 per 1,000 ventilator days). In the 12 months following completion of the program, however, only 81 episodes of VAP (5.7 per 1,000 ventilator days) were identified [ see Figure 2]. The greatest success in VAP prevention was achieved in the surgical/trauma/burn ICU, where VAP rates decreased from 18.1 to 6.6 per 1,000 ventilator days. These results highlight the importance of disseminating information on VAP prevention to the health care workers who are providing the day-to-day care for patients at risk for VAP.

VAP Bundles
Pneumonia in the postoperative setting cannot be eliminated, but its incidence can be Figure 2 Influence substantially decreased by following evidence-based prevention guidelines. Unfortunately, of an Education compliance with such guidelines is far from uniform. Program Although multiple interventions have been demonstrated to prevent VAP, it is logical to assume that a strategy that stresses compliance with multiple evidence-based practices would be superior to a strategy focusing on a single intervention. This has led to the increasingly common practice of using bundles to prevent VAP. A recent review of VAP bundles analyzed four publications that included at least three components of the Institute for Healthcare Improvement (IHI) ventilator bundle (head of the bed elevation, sedation holiday, daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep vein thrombosis prophylaxis).

Each article

examining VAP bundles included a mix of surgical and medical patients. Each successfully brought down VAP rates.

Although the authors could not rule out publication bias (because all studies showed an improvement with VAP bundles), implementing VAP bundles appears to be an effective method of decreasing VAP rates. It should be recognized, however, that not all of the elements of the IHI ventilator bundle are associated with VAP reduction, and some methods that have been definitively demonstrated to be effective in VAP reduction are not included in the current ventilator bundle.

A European care bundle for VAP prevention was recently developed and includes the

following: nonventilatory circuit changes unless specifically indicated, alcohol hand hygiene, appropriately educated and trained staff, incorporation of sedation control and weaning protocols into patient care, and oral care with chlorhexidine.