Title: Updates in preventative strategies in the ICU<br/>Author: Feras Khan<br/><a href='http://umem.org/profiles/faculty/1145/'>[Click to email author]</a><hr/><p>
<strong>Updates in preventative strategies in the ICU</strong></p>
<p>
<span style="font-size:14px;"><em><span style="background-color:#afeeee;">Preventing Ventilator Associated Pneumonia (VAP)</span></em></span></p>
<ul>
<li>
Traditionally ICUs use techniques such as head of bed elevation> 30 degrees, chlorhexidine mouth rinses, reduced sedation, and controlling cuff pressure between 20-30 cm H2O to reduce VAP</li>
<li>
A new trial confirms that subglottic suctioning also reduces VAP</li>
<li>
Endotracheal tubes are made with a suction line along the edge with fenestrations below the vocal cords and above the cuff</li>
<li>
This is hooked to wall suction removing secretions before they are aspirated</li>
<li>
VAP rates are very low in the US (most likely due to under-reporting)</li>
<li>
It is reported at around 15 VAPs/ 1000 ventilator days in Europe</li>
</ul>
<p>
<em>The trial</em></p>
<ul>
<li>
5 ICUs in Belgium; 352 total patients with suctioning vs control were randomized</li>
<li>
Reduced incidence of confirmed VAP <span style="background-color:#ffff00;">9% vs 18%</span>, decrease ventilator days <span style="background-color:#ffff00;">10 vs 20</span> and antibiotic use <span style="background-color:#ffff00;">7% absolute reduction</span></li>
</ul>
<p>
<em>Bottom Line</em></p>
<ul>
<li>
More expensive around $20 or more vs $1 for a regular ETT</li>
<li>
NNT around 11 to prevent one VAP: it is cost efficient</li>
<li>
Use them in patients who will remain intubated for > 48hrs (not elective surgical patients)</li>
</ul>
<p>
<em><span style="font-size:14px;"><span style="background-color:#afeeee;">Daily bathing with chlorhexidine does not reduce health care associated infections</span></span></em></p>
<ul>
<li>
It is believed that daily bathing with chlorhexidine antibiotic washes decrease rates of infection in the ICU; this is debatable</li>
</ul>
<p>
<em>The trial</em></p>
<ul>
<li>
One center, 5 ICUs, 9340 patients</li>
<li>
10 week cleaning period followed by a two week washout then crossover to the alternate treatment (non-antibiotic washes)</li>
<li>
Looking for CLABSIs, CAUTIs, VAP and C. diff infections</li>
<li>
55 infections occurred in the chlorhexidine group; 60 in the control goup.</li>
<li>
<span style="background-color:#ffff00;">2.86 per 1000 patient days</span> (chlorhexidine group) vs <span style="background-color:#ffff00;">2.9 per 1000 patient days</span> (control)</li>
</ul>
<p>
<em>Bottom Line</em></p>
<ul>
<li>
Does not appear to be helpful (perhaps specific patient groups such as bone marrow units may benefit)</li>
<li>
More expensive to use these washes and can lead to resistance</li>
<li>
Very well designed study with a variety of ICUs used (although one center)</li>
</ul>
<fieldset><legend>References</legend>
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<span id="scm6MainContent_lblArticleTitle" style="margin: 0px; padding: 0px; border: 0px; font-family: inherit; font-size: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; vertical-align: baseline;">Chlorhexidine Bathing and Health Care–Associated Infections<span class="subTitle" style="margin: 0px; padding: 0px; border: 0px; font-family: inherit; font-size: 20px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: 24px; vertical-align: baseline; display: inline;">A Randomized Clinical Trial</span></span></h1>
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<h1 style="font-size: 1.231em; margin: 0.375em 0px; line-height: 1.125em; font-family: arial, helvetica, clean, sans-serif;">
Prevention of ventilator-associated pneumonia and ventilator-associated conditions: a randomized controlled trial with subglottic secretion suctioning*.</h1>
<div class="auths" style="font-size: 0.923em; font-family: arial, helvetica, clean, sans-serif;">
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