Preventing VAP in your patients?

[usalsfyre]

Continuous above the cuff suction is a key feature I'd want on any patient tubed for more than just surgery.

My second to third hand understanding is the numbers on this are pretty iffy. To be fair I haven't looked at it myself.

 

[18G]

Forest for the trees. It's great that you prevented the patient from having the possibility of ambulance pathogens introduced....meanwhile they've aspirated half of what's in their stomach while you fiddle-farted around with hooking the Yaunker up.

(Yes, I've dealt with intubated ICU patients. And every ICU and CCT provider I know pre-connects this stuff. Suction is one of the few items that when you need you need in a hurry.)

Seriously, it takes 10secs to hook the stuff up when its on the action area sealed. It is sterile for a reason. Just because every ICU and CCT provider you know does it, doesn't make it right. That is a typical EMS mentality. Just saying.

I guess we should have our BVMs and Defib pads pre-connected all the time too. Just saying.

If the patient is already tubed, what is the big hurry? Take the extra time to avoid introducing pathogens and VAP and do the job right.

 

[Carlos Danger]

Continuous above the cuff suction is a key feature I'd want on any patient tubed for more than just surgery.

I have not searched the lit about this because, quite frankly, VAP is not a big interest or clinical concern of mine.

However, I have never seen this done. Considering the financial incentives that hospitals have to keep VAP rates low, I think it'd be a lot more common if it worked.

I do know that a large, tertiary hospital that I used to work at used continuous-suction ETT's for a while, and eventually stopped when they could not show that it decreased their VAP rates.

One I worked at before never used them that I know of, but at one point they had a big problem with VAP and tried everything under the sun. Again, I think if they had reason to believe that these continuous suction ETT's worked, they probably would have tried them.

My understanding is that mouth cleanliness is only a small contributing factor in the development of VAP. It is quite possible that we are worrying too much about this.

I'm all for looking at ways that our prehospital care and improve eventual outcomes, but I really don't think VAP is for us to worry about in the field.

 

[Carlos Danger]

If the patient is already tubed, what is the big hurry? Take the extra time to avoid introducing pathogens and VAP and do the job right.

How is oral suction with a non-sterile yankauer going to cause VAP?

 

[18G]

How is oral suction with a non-sterile yankauer going to cause VAP?

Because it can introduce pathogens into the mouth which then make their way down the trachea into the lungs = microaspiration.

 

[Aidey]

So should we only suction in sterile negative pressure environments?

 

[Veneficus]

Because it can introduce pathogens into the mouth which then make their way down the trachea into the lungs = microaspiration.

perhaps, have you ever seen the list of pathogens already in the mouth?

The GI tube is definately not sterile.

 

[18G]

Bacterial Growth in Secretions and on Suctioning Equipment of Orally Intubated Patients: A Pilot Study

http://ajcc.aacnjournals.org/content/11/2/141.short

 

[Veneficus]

Bacterial Growth in Secretions and on Suctioning Equipment of Orally Intubated Patients: A Pilot Study

http://ajcc.aacnjournals.org/content/11/2/141.short

lol. Did you read that?

It useda lot of words to say that the contamination was likely from the patient's own flora.

(also, it is not convincing to cite sources from nursing publications or China)

 

[18G]

lol. Did you read that?

It useda lot of words to say that the contamination was likely from the patient's own flora.

(also, it is not convincing to cite sources from nursing publications or China)

It is a very small study. My point with that is the issue deserves recognition and not to brush it off.

And where are you getting a nursing publication in China????

The AMERICAN Journal of Critical Care is from China?

 

[Veneficus]

It is a very small study. My point with that is the issue deserves recognition and not to brush it off.

And where are you getting a nursing publication in China????

The AMERICAN Journal of Critical Care is from China?

No, they are held in the same regard. Basically none.

 

[Dwindlin]

It is a very small study. My point with that is the issue deserves recognition and not to brush it off.

And where are you getting a nursing publication in China????

The AMERICAN Journal of Critical Care is from China?

If you can't see why this study isn't worth the paper it's printed on then there really is nothing to discus.

 

[Clipper1]

I
I do know that a large, tertiary hospital that I used to work at used continuous-suction ETT's for a while, and eventually stopped when they could not show that it decreased their VAP rates.

One I worked at before never used them that I know of, but at one point they had a big problem with VAP and tried everything under the sun. Again, I think if they had reason to believe that these continuous suction ETT's worked, they probably would have tried them.

My understanding is that mouth cleanliness is only a small contributing factor in the development of VAP. It is quite possible that we are worrying too much about this.

I'm all for looking at ways that our prehospital care and improve eventual outcomes, but I really don't think VAP is for us to worry about in the field.

Did you happen to find out which tubes they went to when they stopped the continuous suction ETTs? There are several on the market now which also promote the shape of the cuff and they may also have instituted a Pressure EZ device or cuff monitoring.

They may have tried to cuts costs since these tubes are very expensive. It all depends on their other protocols and monitoring systems in place. The type of unit and the education of the staff is important.

VAP protocols do not consist of just one thing. If you read anything about it you will see this.

For EMS, it is just not rational to not see where so much of what you do could affect the patient. To think the patient's vomit or a dirty ETT will affect the patient less if it is done in the field is not even rational.

 

[VFlutter]

For EMS, it is just not rational to not see where so much of what you do could affect the patient. To think the patient's vomit or a dirty ETT will affect the patient less if it is done in the field is not even rational.

I do not think anyone is trying to argue we should intubate with dirty ET tubes or not suction gross aspirate. Not sure where that came from.

 

[Carlos Danger]

And where are you getting a nursing publication in China????

The AMERICAN Journal of Critical Care is from China?

He is saying that only MD's and DO's are capable of producing research worth reading.

The rest of us lack the intelligence to formulate, execute, and interpret a study of any type.

 

[Veneficus]

He is saying that only MD's and DO's are capable of producing research worth reading.

The rest of us lack the intelligence to formulate, execute, and interpret a study of any type.

Not quite.

I am saying that because nursing is a collaborative profession, mostly because of social reasons, that their research is so often biased towards the results they want in order to generate evidence what they are doing or want to do is correct, that they have lost considerable credibility in the scientific community.

The same happens to places where plagiarizing or falsifying research is common, like China.

I have actually been approached by research nurses who recognize the problems with research in their profession in order to help those individuals improve nursing research for the benefit of their profession. If they recognize there is a problem, why can't we be honest and admit it and talk about it?

As Dwindlin pointed out and after I read it I did. That paper was garbage. It said something that was already commonly known in medicine to publish something, anything, and as you can see, was directly aimed at promoting nursing procedures. Though at least they concluded it was inconclusive. If they had the forsight to even look in a medical text, they probably could have saved themselves a lot of trouble because the sources would even be cited for them.

I will point out that using the scientific method to demonstrate a point does not add credibility to that point. It can also cause considerable problems.

If research is something you are interested in, I highly suggest:

http://www.amazon.com/The-Mismeasur...2049256&sr=8-1&keywords=the+mismeasure+of+man

It details the pitfalls of using the scientific method for politcal purposes, as well as how it happens by people with the best intentions.

It was written by one of the most respected scientists of all time.

Spare me the "nurses are great too" nonsense. There are great individuals in all professions. Just as there are dregs. But the individual does not reflect the credit of the whole, for good or ill.

Edit: and for the record, some groups of MDs are perhaps just as bad. But what you see in medicine that you don't see in nursing, is other calling them on the carpet for it.

 

[Carlos Danger]

Not quite.

I am saying that because nursing is a collaborative profession, mostly because of social reasons, that their research is so often biased towards the results they want in order to generate evidence what they are doing or want to do is correct, that they have lost considerable credibility in the scientific community.

If they recognize there is a problem, why can't we be honest and admit it and talk about it?

That's fair. I'm the first to admit that their is a TON of BS in nursing.

Much of the reason why you don't see much "calling each other out" is because 95% of RN's have no interest in research. They don't do it, read it, or understand how to evaluate it.

That is a problem in itself, but it is not a conspiracy to help each other get away with shoddy research.

Considering how much of an impact nursing interventions have on outcomes, research into nursing care should be extremely robust. The best medicine can be rendered pretty much worthless if the patient suffers from poor nursing care. We've all seen patients recover from whatever landed them in the ICU initially, only to suffer from sepsis or other complications 2° to VAP, pressure sores, or poor IV injection procedures, etc.

 

[Veneficus]

That is a problem in itself, but it is not a conspiracy to help each other get away with shoddy research.

I don't think it is a conspiracy or even intentional.

But in western society, females are raised to a collaborative environment. Because nursing is still a female dominated environment, coupled with an overzealous esprit de corps, I think there is just a serious problem with objectivity and self critique.

I agree nursing research should be done, but it should be from the perspective of "what should be done" not "look how good we do."

 

[Dwindlin]

He is saying that only MD's and DO's are capable of producing research worth reading.

The rest of us lack the intelligence to formulate, execute, and interpret a study of any type.

I could give two :censored::censored::censored::censored:s what the title behind thier name is, garbage research is garbage. This thread has highlighted the importance of actually tracking down the paper and reading it as opposed to just reading abstracts.

 

[Carlos Danger]

Getting back to the original topic:

The idea that pre-intubation oral cleansing may reduce VAP incidence seems to hinge on the theory that the act of intubation itself (through a non-cleansed oral cavity) is a significant risk factor for VAP. Right?

But if intubation itself causes VAP, then why don’t any of the tens of thousands of people who are intubated annually for same-day surgery develop VAP?

And why does VAP typically only occur in patients who are intubated for more than 48 hours? Why doesn’t it occur in patients who are intubated for 24 hours, if it is the intubation itself that causes VAP?