Ventilator associated pneumonia (VAP) was defined as per the Center of Disease Control (CDC) as a pneumonia that occurs in a patient who was intubated and ventilated at the time of or within 48 h before the onset of the event. Pneumonia was identified using a combination of radiological, clinical, and laboratory criteria

1. PATIENT SAFETY
BUNDLES
FOR CRITICAL CARE
PANKAJ SINGH RANA
NURSE PRACTITIONER
CRITICAL CARE

2. DEFINATION
A "bundle" is a group of evidence-
based care components for a given
disease that, when executed
together, may result in better
outcomes than if implemented
individually.

3. Bundles
In a bundle, the individual elements are built
around best evidence-based practices.
The science supporting the individual
treatment strategies in a bundle is sufficiently
mature such that implementation of the
approach should be considered either best
practice or a reasonable and generally
accepted practice.

4. VAP BUNDLE

5. VENTILATOR ASSOCIATED
PNEUMONIA
• Ventilator associated pneumonia (VAP) was
defined as per the Center of Disease Control
(CDC) as a pneumonia that occurs in a patient
who was intubated and ventilated at the time
of or within 48 h before the onset of the
event. Pneumonia was identified using a
combination of radiological, clinical, and
laboratory criteria

6. Presence of any two of the following was
considered as diagnostic of VAP.
(1)Significant heavy growth reported in the culture from
tracheal aspirates.
(2)Temp.: >38 °c or < 35 °c.
(3)Development of progressive new infiltrate on X-ray.
(4)Leukocytosis WBC >10 × 109/L or leucopenia WBC
<3 × 109/L.
(5)Ten leucocytes per HPF in gram stain of tracheal
aspirates.

7. Ventilator-Associated Pneumonia
(VAP)Bundle:
– Oral hygiene every 6 hourly
–DVT prophylaxis
–GI prophylaxis
–Head elevated to 30-45
–Daily Sedation Vacation

9. ORAL HYGIENE AND SUBGLOTTIC
SECRETION DRAINAGE
• The use of the oral antiseptic chlorhexidine
gluconate has been definitively demonstrated
to be an effective VAP prevention strategy,
and its use has been advocated in the most
recent evidence-based VAP prevention clinical
practice guidelines. Furthermore, safety,
feasibility, and cost considerations for this
intervention are all very favorable.

10. • Provide endotracheal tubes with subglottic
secretion drainage ports for patients likely to
require greater than 48 or 72 hours of
intubation helps in prevention of VAP.
• Extubating patients to place a subglottic
secretion drainage endotracheal tube is not
recommended.

11. Subglottic suction

12. GASTROINTESTINAL PROPHYLAXIS
This is not a specific strategy for VAP prevention. It
was included in the Ventilator Bundle as a strategy to
prevent stress related mucosal disease, as
mechanical ventilation is a significant risk factor.
A prospective multicenter cohort study evaluated
potential risk factors for stress ulceration in ICU
patients and documented the occurrence of clinically
important gastrointestinal bleeding

13. DVT PROPHYLAXIS
• Include deep venous prophylaxis as part of your
ICU order admission set and ventilator order set.
• Similar to stress ulcer prophylaxis, DVT
prophylaxis has not been demonstrated to
reduce the risk of VAP. It remains part of the
Ventilator Bundle in order to prevent other
serious complications that could increase the
morbidity and mortality of these patients and
should be retained

15. HEAD OF BED ELEVATION
• The semi recumbent position, achieved by
elevation of the head of the bed, is an integral
portion of the VAP bundle. It has been
speculated that the semi recumbent position
may decrease VAP by reduction in
gastroesophageal reflux and subsequent
aspiration of gastrointestinal, oropharyngeal,
and nasopharyngeal secretions.

16. • Aspiration of colonized or infected
oropharyngeal or gastrointestinal contents is a
potential contributing cause of VAP, and
evidence that aspiration of the gastric
contents occurs to a greater degree when
patients are in the supine position has been
confirmed in clinical studies.

17. DAILY SEDATION VACATION/
SPONTANEOUS BREATHING TRIALS
• Implement a protocol to lighten sedation daily at
an appropriate time to assess for neurological
readiness to extubate.
– Include precautions to prevent self-extubation such
as increased monitoring and vigilance during the trial.
• Include a sedation vacation strategy in overall
plan to wean the patient from the ventilator.
‘Sedation vacations’ are an integral component of
the VAP bundle and can have major implications
in that patients who are extubated early are at
decreased risk of VAP.

18. • Most recently, a protocol that pairs
spontaneous awakening trials (SATs), that is,
daily interruption of sedatives, with SBTs has
been confirmed to be effective.

19. Thanks for listening….