Preventing ventilator-associated complications

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Many patients in hospital intensive care units have been weakened by serious illness or the ordeal of complicated surgery and are unable to breathe without the aid of mechanical ventilators. While often essential in sustaining life, ventilators can turn become a risk to patients if the tubes delivering air allow bacteria or secretions to enter the lungs. The aim of this intervention is to prevent complications associated with mechanical ventilation by implementing the components known as the ‘ventilator bundle’.

The power of the ‘ventilator bundle’ is that it brings together scientifically grounded concepts that improve the clinical outcome. The focus is the application of the entire bundle as a single intervention, rather than applying the individual components.

Toolkit

Preventing ventilator associated complications toolkit (660kb, pdf)

Tools

Safer Systems Saving Lives Protractor (204kb, pdf)

VAC audit summary (73kb, MS Word)

VAC audit tool (83kb, MS Word)

FAQs

Safer Systems Saving Lives FAQs - February 2006 (327kb, pdf)

Could you comment on the issue of angle of elevation of head of bed in VAC and evidence for 30-40 degrees? It has been suggested there is evidence to support 20 degree elevation.

A recent meta-analysis by Hess concluded that the semi recumbent position was the most effective position for preventing ventilator associated pneumonia (VAP). Semi recumbent has been defined as elevation of the head of the bed to 45 degrees. A study by Grap et al published at the same time as Hess suggested that elevation of the head of the bed at <30 degrees did not result in a statistically significant increase in the incidence of VAP.

A most recent prospective muliticentred trial tested elevations of 45 degrees and 10 degrees. The authors concluded that elevation of 45 degrees is not feasible, finding the mean elevation for patients nursed at 45 degrees was in fact closer to 30 degrees. The editorial of the publication noted that the trial failed to answer the question of whether a strict semi recumbent position of 45 degrees will significantly decrease VAP.

On this basis the SSSL project continues to recommend elevation of the head of the bed to ~30 degrees.

Is it correct that we audit every ventilated patient three times per week?

The toolkit does suggest that audits be performed three times a week for VAC patients. This is suggested because some ICUs may have difficulty gaining an ample sample if audits are not done regularly. On the other hand, the project is not seeking to create a burdensome workload, so sites should determine how frequently they need to audit to establish compliance, and gain an adequate sample.

References

• Collard HR, Saint S, and Matthay MA. Prevention of Ventilator-Associated Pneumonia: An Evidence-Based Systematic Review, Ann Intern Med. 2003(138):494-501.

• Combes A. Backrest elevation for the prevention of ventilator-associated pneumonia: back to the real world? Crit Care Med 2006(34): 2:559-561.

• Grap MJ, Munro CL, Hummel RS 3rd, et al. Effect of backrest elevation on the development of ventilator-associated pneumonia, Am J Crit Care 2005(14);4:325-32.

• Hess DR. Patient Positioning and Ventilator-Associated Pneumonia, Respiratory Care 2005(50);7:892-897.

• Kress, JP, Pohlman, AS, O'Connor, MF, et al., 2000, 'Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation’, New England Journal of Medicine, Volume 342, Number 20, pp 1471-1477.
  Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation (External link)
  http://content.nejm.org/cgi/content/abstract/342/20/1471

• The Victorian Quality Council, 2004, ‘Pressure Ulcer point prevalence survey’, The Victorian Quality Council, 2004, ‘Pressure Ulcer point prevalence survey’
  Pressure Ulcer point prevalence survey
  http://www.health.vic.gov.au/qualitycouncil/downloads/pupps2/pupps2_report.pdf

• vanNieuwenhoven CA, Vandenbroucke-Grauls C, vanTiel FH, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: A randomized study, Crit Care Med 2006(34);2:396-402.

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