Preventing VAP in your patients?
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KingCountyMedic
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Yes exactly, a extra step if time and the situation allows for it might not be a bad idea.
And when I say elective intubation, I mean making the decision to intubate before the the patient crashes requiring an emergent intubation.
:beerchug:
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I've done more than a few RSI's, so I'm pretty pretty familiar with how they should be done......if you've never seen a chest tube placed in 10 seconds with little concern for prep, then you haven't been involved in many emergent CT placements. In a true emergency, the A-B-C's really do trump concerns for infection.
I'm not suggesting shortcuts, though....quite the opposite, in fact. RSI is by far the riskiest procedure that we do in the field, and the airway deserves to be the sole focus of the intubator. He or she does not need to be worrying about anything other than assessing and then securing the airway. The bottom line is that a field RSI is a truly critical procedure which should preclude all other concerns that are not directly related to the success of securing the airway.
If there were any reason to think that this would significantly improve outcomes, then OK, maybe then it'd be worth finding a way to work it into the sequence. But I think that should be shown pretty decisively before we bring it into the field and add another step to an already task-saturated situation.
In the ICU's chlorexidine rinses are actually pretty time consuming. We didn't see much improvement in our VAP rate until we were up to 2 minutes every 2 hours with teeth brushing every 8 hours. I just do not see it being practical or wise to try to do a proper mouth rinse in the middle of an emergent intubation.
Action942Jackson
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Actually, given any situation, you have ample time. If you pre-oxygenate correctly allowing sufficient BVM ventilations with a nasal cannula cranked at 6 lpm in place providing additional oxygenation. When you build that oxygenation toilet up, you stop BVM ventilations and the oxygen delivered through a nasal cannula can replace what the body would use in that time frame. Giving additional minutes to drop the tube.
It's a trick the was taught by our medical director and during a statewide EMS conference. It truly does allow the time to take a deep breath, ensure proper preparations (suction, c-collar, additional tubes, blades, etc) and fully grasp the task at hand, instead of the "oh :censored::censored::censored::censored: I've gotta drop that tube now because their sats are dropping after 15 seconds." It's not about how fast you can drop the tube, but why your tubing, how your tubing, what benefit will the patient receive, what will their clinical course in ICU be, and what are some possible risks associated with it.
I love to see places actively evaluating what can change vs throwing stuff to the wall and seeing if it sticks.
The other factors are important. There is alot more to successful intubation than just putting the tube through the cords.
If you are truly educated and trained in RSI, then you should be in control of the airway which may allow for a few seconds to properly have all the necessary equipment in place along with being in a good position to prevent further damage to the patient.
If EMS can not improve the overall survival of the patient, then what is the point? Intubation should be alot more than just a one dimensional skill. It should be viewed as a multifactorial asset to survival. The timing of that skill is also part of that step. With the current studies on intubation and cardiac arrest, when and where intubation should be done must be considered.
EM doctors probably don't like to have their intubations and lines questioned by CM doctors but they understand the reasons behind the concerns. They know their emergently placed lines might increase a risk for infection with associated death and must be honest in their own assessment and communication to those assuming continued care for the patient. This is difficult when egos are involved but medicine is changing that as more evidence is revealed forcing changes in practice.
None of these looked at cleansing the mouth with clorhexidine. I just posted them to show proof of concept that these measure can reduce hospital acquired infections. These mainly looked at line infections.
Don't disagree with you here, only to say if I go to "pre-oxygenate" and the sat's are hanging in there and I'm effectively ventilating I'm done. If I can maintain the patient without having to do an invasive procedure in less than ideal conditions that's what I'm doing.
Very little of what we do has any impact on overall mortality. Sorry to burst anyone's bubble. . .
Although tooth brushing is effective for mechanical removal of dental plaque, there is no convincing evidence that tooth brushing reduces VAP risk. Most studies of the effectiveness of mechanical oral care have been anecdotal or used a non-experimental design, and many studies included oral care along with other interventions with proven efficacy (e.g., head of bed elevation), and tested all the interventions together as a bundle.
That is from this article:
Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care 2004;13:25–33
This may or may not have a place in prehospital medicine but should be examined in the ED and trauma centers. At least oral care should be initiated in the ED following intubation rather then just considering it an ICU nurse task. Ventilators are now being held in the ED for several hours due to lack of ICU beds.
http://www.sageproducts.com/lit/20939c.pdf
You can find the abstracts to these articles on Medscape or Pubmed.
DeRiso AJ, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Am J Respir Crit Care Med 1996;109:1556–61.
Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry LO. Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care 2002;11:567–70.
Fourrier F, Dubois D, Pronnier P, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit Care Med 2005;33:1728–35.
Koeman M, van der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilatorassociated pneumonia. Am J
Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA 2006; 296:2460–6.
Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007;334:889.
Chlebicki MP, Safdar N. Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 2007;35:595–602.
Munro CL, Grap MJ, McClish D, Sessler CN. Chlorhexidine reduces ventilator associated pneumonia (VAP) in mechanically ventilated ICU adults. Crit Care
Grap MJ, Munro CL, Elswick RK, Sessler CN, Ward KR, Higgins SM. Early, single chlorhexidine application to reduce oral flora and VAP in trauma victims. Am J Crit Care 2009;18:200.
You must be talking solely about cardiac arrest.
If you need to intubate a 20 y/o asthma or OD patient, there is no reason to give up on them. Weekend college drunk binges are nasty but they can survive. COPD and CHF exacerbations which are beyond CPAP can also survive with short term intubation. So can many sepsis patients but might require a few days on a ventilator in ICU. Trauma is another area which can be survived. Sometimes intubation is needed for pain and seizure control. That does not mean it is a death sentence.
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Anyone heard of ET tube lubricant with selenium added? A friend of mine is the PI on a study they are doing in Lubbock where they are using selenium coated airways and selenium added lubricant in their procedures.
Supposedly it has significantly reduced the biofilm build up along with the VAP rate.
Not sure about the commercial availability, but it peaked my interest.
Supposedly it has significantly reduced the biofilm build up along with the VAP rate.
Not sure about the commercial availability, but it peaked my interest.
The ICUs here are looking at antimicrobial coating as an alternative to silver for a more cost effective method if they produce the same results.
There are several studies available online which have taken place over the past decade.
KingCountyMedic
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Maybe this is the case where you work. Not so in many other progressive parts of the world, mine included. Please tell me you don't rely on a patients O2 Sats to determine your course of treatment?
Have y'all looked through these studies and the dates on them? Some of them are 20 years old. I can't bear to look through the whole laundry list of pointless and inapplicable studies. Did any of them deal with chlorhexidine rinse prior to ETT? If not, they're absolutely worthless in proving the point you're trying to prove. If you have such a study, please post it, by itself, instead of a list of unrelated chlorhexidine skin prep and nosocomial infection articles. (one was from Nursing Economics for god's sake!) Evidence based medicine - and there is no evidence for this.
Sorry to be blunt - but I put ETT's in for a living, many times, every single working day, both electively and emergently. Someone would have to come up with absolute solid evidence that this is helpful, and I can tell you, it's nowhere in the anesthesia literature, much less coming close to making a change in clinical practice.
Nosocomial infections are a serious problem, but they're a problem largely of the environment patients find themselves in. But if ETT-acquired infections were really a problem, we'd be seeing a lot more of it. We simply don't. It's not even a blip on the radar. Most patients, even critically ill ones, don't keep them that long, because if long-term intubation is anticipated, a trach will come sooner rather than later.
And BTW - most of those in my profession never lubricate their ETT's.
Sorry to be blunt - but I put ETT's in for a living, many times, every single working day, both electively and emergently. Someone would have to come up with absolute solid evidence that this is helpful, and I can tell you, it's nowhere in the anesthesia literature, much less coming close to making a change in clinical practice.
Nosocomial infections are a serious problem, but they're a problem largely of the environment patients find themselves in. But if ETT-acquired infections were really a problem, we'd be seeing a lot more of it. We simply don't. It's not even a blip on the radar. Most patients, even critically ill ones, don't keep them that long, because if long-term intubation is anticipated, a trach will come sooner rather than later.
And BTW - most of those in my profession never lubricate their ETT's.
Well of course you do. Are you serious?
If there is not such thing as ETT acquired infections, why have there been so many studies on these infections and why have there been improvements since different tubes have been used along with other bundle considerations?
VAP has been around and studied for many years. This is nothing new and it is impossible to post every article on the topic. The articles just show how long this has been researched. No one just discovered it and much can be learned from past studies to move forward with new studies.
The point is, care does not stop with just the insertion of the ETT nor is just putting the tube through the cords all there is to the intubation process.
Hospitals do have a goal of decreasing vent days and not making a trach patient out of everyone who comes into the ICUs. LTC is not the way to go and should not be used as an excuse not prevent poor outcomes.
The reason VAP is of economic concern is that CMS will not pay for hospital acquired infections. Regardless of whether the actual incident began in the prehospital phase, the hospital will be held accountable and must do what they can.
Because of the past research and awareness of VAP or VAE, incidences have decreased. After well over 20+ years of research and improving policies, it would be stupid to continue making the same mortality rate occur over and over. To say not to initiate such things like a oral hygiene or other prophylactic as soon as possible would not be doing the patients any favor for a chance at reducing their vent days or death.
Check with you local hospital's ICU and see if they have a VAP bundle in place and see if it has oral care to be initiated when the ET tube is present.
You should post this in every thread on the site.
This should be the case were everyone works. Again, just because we can do something doesn't mean we should.
Yes I rely on sats, as well as a host of other things to guide what I do.
Did you read the articles or just the abstracts. I just spent too much of my morning going over all of those articles and most of them aren't impressive. Many of them have pretty significant flaws. Many of the studies lost more than half their enrolled patients, most are using a diagnostic tool that has been called into question (CPIS), none of them demonstrated any mortality benefit or decreased vent time. And only one showed (a small) dcreased LOS. And the one that showed decreased LOS was in one subset of patients.
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That is a good question. Has pre-hospital intubation even been shown to improve survival? If we're really worried about contaminating the airway, why not stick to SGA's?
You seem to be assuming that this will improve survival, while there is no proof of that. People once assumed that hard spine boards and intra-cardiac epi would improve survival, too.
As I wrote before, IF there were some indication that this might significantly improve outcomes, then I would be all for finding a way to work it into an RSI protocol. But no such indication exists. I do not see a reason to add an additional step to an already critical, task-saturated sequence.
If you guys were more familiar with how VAP is managed in the ICU's, you would see exactly what I mean. The only things that have been shown to reduce VAP incidence in the ICU's are things that require consistent effort and frequent interventions......so I just don't see why we think a single, quick treatment in the field is going to make any difference at all.
I'm not saying this shouldn't be looked at, I'm just saying I don't think pre-hospital is the appropriate forum for the initial investigations.
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