UMEM Educational Pearls

Category: Critical Care

Title: Updates in preventative strategies in the ICU

Keywords: VAP, chlorhexidine baths, subglottic suctioning (PubMed Search)

Posted: 2/10/2015 by Feras Khan, MD
Click here to contact Feras Khan, MD

Updates in preventative strategies in the ICU

Preventing Ventilator Associated Pneumonia (VAP)

  • 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
  • A new trial confirms that subglottic suctioning also reduces VAP
  • Endotracheal tubes are made with a suction line along the edge with fenestrations below the vocal cords and above the cuff
  • This is hooked to wall suction removing secretions before they are aspirated
  • VAP rates are very low in the US (most likely due to under-reporting)
  • It is reported at around 15 VAPs/ 1000 ventilator days in Europe

The trial

  • 5 ICUs in Belgium; 352 total patients with suctioning vs control were randomized
  • Reduced incidence of confirmed VAP 9% vs 18%, decrease ventilator days 10 vs 20 and antibiotic use 7% absolute reduction

Bottom Line

  • More expensive around $20 or more vs $1 for a regular ETT
  • NNT around 11 to prevent one VAP: it is cost efficient
  • Use them in patients who will remain intubated for > 48hrs (not elective surgical patients)

Daily bathing with chlorhexidine does not reduce health care associated infections

  • It is believed that daily bathing with chlorhexidine antibiotic washes decrease rates of infection in the ICU; this is debatable

The trial

  • One center, 5 ICUs, 9340 patients
  • 10 week cleaning period followed by a two week washout then crossover to the alternate treatment (non-antibiotic washes)
  • Looking for CLABSIs, CAUTIs, VAP and C. diff infections
  • 55 infections occurred in the chlorhexidine group; 60 in the control goup.
  • 2.86 per 1000 patient days (chlorhexidine group) vs 2.9 per 1000 patient days (control)

Bottom Line

  • Does not appear to be helpful (perhaps specific patient groups such as bone marrow units may benefit)
  • More expensive to use these washes and can lead to resistance
  • Very well designed study with a variety of ICUs used (although one center)


Chlorhexidine Bathing and Health Care Associated InfectionsA Randomized Clinical Trial

Michael J. Noto, MD, PhD1; Henry J. Domenico, MS2; Daniel W. Byrne, MS2; Tom Talbot, MD, MPH1; Todd W. Rice, MD, MSc1; Gordon R. Bernard, MD1; Arthur P. Wheeler, MD1
JAMA. 2015;313(4):369-378. doi:10.1001/jama.2014.18400.

2015 Jan;43(1):22-30. doi: 10.1097/CCM.0000000000000674.

Prevention of ventilator-associated pneumonia and ventilator-associated conditions: a randomized controlled trial with subglottic secretion suctioning*.