UMEM Educational Pearls

Title: Updates in preventative strategies in the ICU

Category: Critical Care

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)

References

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*.

Damas P1, Frippiat F, Ancion A, Canivet JL, Lambermont B, Layios N, Massion P, Morimont P, Nys M, Piret S, Lancellotti P, Wiesen P, D'orio V, Samalea N,Ledoux D.