perioperative infection control.pptx

Perioperative infection control and
wound healing: Role of
anesthesiologist
Moderator
Dr. Nishkarsh Gupta Dr. Hitender Gautam
Additional Professor Associate Professor
Deptt. of OAPM Deptt. of Microbiology
Dr. Brajesh Ratre
Assistant Professor
Deptt. of OAPM
Presenter- Dr. Gitartha Goswami
SR, Deptt. of OAPM
Department of Onco-Anaesthesia and Palliative Medicine
IRCH, NCI, AIIMS

Highlights
• Epidemiology
• Pathophysiology
• SSIs and Wound infection
• Microbiology
• Risk factors
• Role of anesthesiologists
• Guidelines and evidences
IRCH, National Cancer Institute, AIIMS
IRCH, NCI, AIIMS

Epidemiology
• Incidence of HCAI- developed countries- 3.5–12%, developing countries-
5.7%- 19.1%.
• The risk of HCAI in the OR is even higher.
• SSIs- 2nd most common cause of HCAIs after UTI, account for approximately
17% of all HCAI.
• SSIs are the most common perioperative infection, 38% of all infections in
surgical patients
• Prolongs hospital stay, cause morbidity, increase the cost of health care, and
lead to mortality
IRCH, NCI, AIIMS

Pathophysiology
• Tissue damage leads to the release of damage activated molecular patterns
(DAMPs) or alarmins into the circulation, eg- HMGB 1, mtDNA
• DAMPs activates pattern recognition receptors (PRRs), also independently
activate complement, neutrophils, monocytes and dendritic cells.
• Activation of PRRs → secretion of cytokines and chemokines via signalling
pathways involving NF-kB.
• Excess production of inflammatory mediators (ILs) leads to SIRS.
IRCH, NCI, AIIMS

Pathophysiology
• SIRS is associated with a compensatory increase in anti-inflammatory
cytokines (IL-10, TGF-β).
• The balance of proinflammatory (IL-6, TNF-a) and antiinflammatory factors
dictates whether inflammation return to baseline or progress to persistent
inflammation, immunosuppression, and catabolism syndrome (PICS).
• PICS increases risk of MODS and sepsis.
• Paradoxically, SIRS suppresses body’s ability to mount a defence against
invading pathogens.
IRCH, NCI, AIIMS

Pathophysiology
• Increased susceptibility to infection and sepsis, invading microbes further
stimulate immune cells via pathogen-associated molecular patterns
(PAMPs).
• A vicious cycle ensues, SIRS results in inflammation and immunoparesis,
which, in turn, leads to sepsis with furthur inflammation and risk of MODS.
• The initial complement activation leads to consumption of complement, an
imbalance ensues, rendering the host susceptible to invading pathogens.
IRCH, NCI, AIIMS

Pathophysiology
• The transfusion of blood and products along with anesthetics contribute to
this immunosuppressive environment.
• Anaesthesia suppresses the immune system, both directly and indirectly.
• Cancer recurrence and infection are intimately linked, both flourish in an
environment of T-cell exhaustion and lymphocyte anergy, observed in the
perioperative period.
• The key concern is the creation of a protumour and proinfection cytokine
and inflammatory milieu.
IRCH, NCI, AIIMS

Pathophysiology
• Natural killer cells, are suppressed by both anaesthetics and opioids.
• Anaesthetics mediate secondary effects through altered adrenocortical
function.
IRCH, NCI, AIIMS

IRCH, NCI, AIIMS

SSIs
• CDC defines SSI- infection related to an operative procedure that occurs at
or near the surgical incision within 30 days of the procedure or within 90
days if prosthetic material is implanted.
• All surgical wounds are likely to become contaminated, usually by resident
bacterial flora.
• May not be significant and contaminated wounds may go unnoticed.
• Progression from wound contamination to clinical infection is determined
by the adequacy of host defence.
IRCH, NCI, AIIMS

8-10% 12-20% 25%
IRCH, NCI, AIIMS

SSIs types
IRCH, NCI, AIIMS

MICROBIOLOGY
• Pathogens depend upon the type of wound
• Clean procedures- skin flora, including streptococcal
species, Staphylococcus aureus, and CONS.
• Clean-contaminated procedures- gram-negative and enterococci in
addition to skin flora.
• Surgical procedure involves a viscus, the pathogens reflect the
endogenous flora of the viscus or nearby mucosal surface; typically
polymicrobial.
IRCH, NCI, AIIMS

MICROBIOLOGY
• The causative pathogens associated with SSIs have changed over time.
• SSIs caused by gram-negative bacilli decreased, with emergence MRSA.
• MRSA associated were higher mortality rates, longer hospital stays, and
higher costs.
• During the past decade the proportion of SSI due to MRSA declined.
• Fungal SSIs- widespread use of prophylactic and empiric antibiotics,
increased severity of illness, and immunocompromised patients.
IRCH, NCI, AIIMS

MICROBIOLOGY
• Exogenous sources of contamination- OR environment or
personnel.
• Anal, vaginal, or nasopharyngeal carrier of group A streptococci by
OR personnel, led to several SSI outbreaks.
• Gram-negative organisms is commonly seen on the hands with
artificial nails.
• Rare outbreaks or clusters of SSIs caused by unusual pathogen-
traced to contaminated dressings, bandages, irrigants, or
disinfection solution
IRCH, NCI, AIIMS

RISK FACTORS FOR SSI
IRCH, NCI, AIIMS

Why cancer patients are at increased risk?
• Effects of Cancer
- Impaired cellular and humoral immunity
- Bone marrow infiltration
• Effects of CT/RT
- Disruption of skin and mucosal barriers
- Neutropenia/impaired neutrophil function
• Functional hyposplenism or asplenia after HSCT
• Poor nutritional status, TPN
IRCH, NCI, AIIMS

What is the role of anesthesiolgist?
• Role both outside and inside the OR.
• Infection prevention in the OR anesthesia work area is important
but very challenging owing to the work flow of anesthesia
providers.
• Policies and procedures for HH, safe injection practises, and
environmental cleaning and disinfection.
• Individuals involved in these procedures require training, as well as
regular skills assessments.
IRCH, NCI, AIIMS

Factors controlled by anesthetists
 Hand hygiene
 Aseptic technique during invasive
procedures
 Face masks and sterile barriers
 OR characteristics- Limit traffic
through operating room, Use of
laminar airflow
 Surgical antibiotic prophylaxis
 Glycaemic control
 Perioperative thermoregulation
Perioperative drugs management
 Inspired oxygen concentration
 Perioperative fluid management
 Minimizing blood transfusions
 ERAS
Nutrition
 Anesthetic technique
- Avoidance of selected drugs
- Regional anaesthesia techniques
- Effect of PPV
IRCH, NCI, AIIMS

Factors controlled by Surgeon and Surgical techniques
1. Skin antisepsis, Hair removal
2. Bowel preparation
3. Gentle traction
4. Effective hemostasis
5. Removal of devitalized tissues
6. Minimization of electrocautery to avoid thermal spread
7. Obliteration of dead space
8. Irrigation of tissues with saline to avoid excessive drying
9. Wound closure without tension
10. Judicious use of closed suction drains
11. Topical and local antibiotic delivery
12. Antibiotic-impregnated implants, antibiotic sutures
13. Wound dressings, wound protectors

Guidelines
• Several guidelines available regarding prevention of SSI- CDC, WHO,
APSIC, IDSA, NICE.
• SHEA Expert Guidance on Infection prevention in the operating
room anesthesia work area.
IRCH, NCI, AIIMS

Infection prevention in the OR anesthesia
work area
• Contamination in the anesthesia work area include the anesthesia cart,
stopcocks, LMAs, laryngoscope blades, touchscreens, keyboards,
providers’ hands.
• Anesthesia work area bioburden- both commensal and pathogenic
bacteria, including CONS, Bacillus spp, streptococci, Staph aureus,
Acinetobacter spp etc.
• High risk practises- use of multi-dose vials for >1 patient, <100% use of
gloves during airway management, failure to perform HH after removing
gloves, entry into anesthesia cart drawers without performance of HH.
IRCH, NCI, AIIMS

Hand hygiene
• Ideally performed according to the WHO 5 Moments for Hand Hygiene.
• HH performed- before aseptic tasks, after removing gloves, when hands are
soiled or contaminated, before touching the contents of the anesthesia cart,
and when entering and exiting the OR.
• Indications in the OR can be as high as 54/hr, logistically unfeasible, leading to
non adherence rates of 83%,.
• Increasing access to ABHR led to an increase in HH practises by anesthesiology
staff during a surgical procedure
IRCH, NCI, AIIMS

Hand hygiene
• ABHR dispensers at the entrances to ORs and near anesthesia providers.
• Double gloves during airway management, removal of outer gloves
immediately after airway manipulation and inner gloves ASAP and
perform HH.
• Current data inadequate to either support or discourage use of ABHR on
gloved hands, application might be better when doffing and donning are
not feasible
IRCH, NCI, AIIMS

ASEPTIC PRECAUTIONS FOR VARIOUS
PROCEDURES AND USE OF PPE
• Objective- reduce endogenous and exogenous sources of infection to patients
and HCWs.
• Indications for aseptic practices-
1. During care and nursing of patients : Barrier nursing
2. During therapeutic procedures: i.m. injections, CVP line access, Arterial lines.
3. During airway and endoscopic procedures: Intubation, mechanical
ventilation, suctioning, Bronchoscopy.
4. During various diagnostic procedures
5. Others- foley’s catheterization.
IRCH, NCI, AIIMS

USE OF PERSONAL PROTECTIVE
EQUIPMENT
• Use of PPE appropriate for the procedure.
• PPE interrupt the chain of transmission of organisms from the patient to the
HCW and from the HCW to the patient.
• Correct donning and doffing practises.
IRCH, NCI, AIIMS

OR Environmental disinfection
• Direct laryngoscope or video-laryngoscope handles and blades should
undergo high-level disinfection or sterilization prior to use.
• Otherwise, replace with single-use ones.
• Clean blades and handles to be stored in packaging appropriate for
semicritical items.
• Infectious disease outbreaks have been associated with contaminated
laryngoscopes.
• Laryngoscope handles not able to undergo high-level disinfection should
not be used.
IRCH, NCI, AIIMS

• Inadequate data to make recommendations regarding the use of disposable
covers to prevent contamination of anesthesia machines.
• High-touch surfaces on the anesthesia machine and anesthesia work area
should be disinfected between OR uses.
• Use EPA-approved hospital disinfectant that is compatible with the
equipment and surfaces.
• Reusable monitoring equipment and cables in physical contact with patients
should be cleaned.
IRCH, NCI, AIIMS

• i.v. access ports- disinfected before each use, scrubbing the port with a
sterile alcohol-based disinfectant or use sterile isopropyl alcohol
containing caps to cover ports continuously.
• The act can be challenging in anesthesia practice, particularly during
induction and emergence of anesthesia.
• Maximal sterile barrier precautions- All CVCs and axillary and femoral
arterial lines.
• Other peripheral arterial lines- a minimum of a cap, mask, sterile gloves,
and a small sterile fenestrated drape.
IRCH, NCI, AIIMS

• Rubber stoppers of vials and necks of ampules- wiped with 70%
alcohol prior to use.
• Bacterial contamination of medication syringes can occur with skin
microorganisms.
• Needleless syringes should be capped with a sterile cap that
completely covers the Luer connector on the syringe
• Storage of supplies on the top surface of the cart should be
avoided, should be removed between cases to facilitate cleaning.
IRCH, NCI, AIIMS

• Provider-prepared sterile injectable drugs should be used as soon as
practicable, USP recommends use within 1hr
• Commercially prefilled syringes or syringes prepared by the hospital
pharmacy have a relatively long life.
• Discard provider-prepared sterile injectable drugs and i.v. solutions at the
end of each case, whether used or not.
• Unused prefilled syringes with intact locks can be returned to stock.
IRCH, NCI, AIIMS

• Use Single-dose medication vials and flushes whenever possible.
• Multi-dose vials- used for only 1 patient and accessed with a new sterile
syringe and needle for each entry.
• Syringes and needles are single patient devices and should never be
reused for another patient.
• Both CDC and AAGBI have issued safe injection practices.
• Minimize the time between spiking IV bags and patient administration.
• No specific time limit has been identified in the literature.
IRCH, NCI, AIIMS

• Computer keyboards and touchscreen- cleaned and disinfected after each
anesthesia case using a hospital-approved disinfectant.
• Use of Plastic keyboard shields, or washable keyboards and touchscreens
facilitate thorough disinfection.
IRCH, NCI, AIIMS

OR ventilation
• Laminar flow allows particle-free air movement over the aseptic operating
field at a uniform velocity (vertically or horizontally).
• Reduces the burden of microorganisms in the OR during implantation of
prosthetic material
• However, insufficient evidence supporting its routine use
• A systematic review that included 12 observational studies (between 1987
and 2011) did not find any benefit in reducing the incidence of deep
incisional SSI following hip and knee arthroplasty, and abdominal/open
vascular surgeries.
IRCH, NCI, AIIMS

Order of patients
• Common routes for transmission of infection in the OR are airborne or
fomite borne.
• Accurate printed theatre lists to be available prior to the scheduled date.
• ‘Dirty cases’ should be identified beforehand, theatre staffs notified and
scheduled last on an operating list.
• If not possible, Hospital Infection Society advises that a plenum-ventilated
OR should require a minimum of 15 min before proceeding to the next case.
IRCH, NCI, AIIMS

Order of patients
• Appropriate cleaning of the OR between all patients should be
undertaken.
• Visible contamination with blood or body materials disinfected with
sodium hypochlorite and then cleaned with detergent and water.
• Floors of the OR should be disinfected at the end of each session.
IRCH, NCI, AIIMS

Implementation
• Regular monitoring and evaluation of infection prevention
practices.
• Use of measures to improve performance.
• Both overt and covert observation of behaviors can improve
practice.
• Regular feedbacks, surveillance measures.
• Interventions like checklists and simulation for education and
evaluation of different aspects of anesthesia practice
IRCH, NCI, AIIMS

Surgical antibiotic prophylaxis
CDC WHO IDSA
Timing In a way that bactericidal
concentration of the
agents is established in
the serum and tissues
when the incision is
made
within the 120 min
before the incision,
while considering the
half-life of the
antibiotic (cefazolin,
penicillins)
Within 1 hour,
2 hours for
Vancomycin and
Fluoroquin.
Repeat
doses
No statement At intervals of 2 half-
lives or if there is
excessive blood loss
At intervals of 2
half-lives
• Postoperatively, CDC recommends antibiotic therapy to continue only in
contaminated and dirty cases.
• Antibiotic stewardship programmes should be practised.
IRCH, NCI, AIIMS

Glycaemic control
• Surgery causes a neuroendocrine stress response with release of counter-
regulatory hormones (Epi, glucagon, cortisol, GH).
• Hyperglycaemia increases risk of morbidity and mortality, even in non-
diabetics.
• DM increases susceptibility to infection by altering both the innate and the
adaptive immune systems
• Hyperglycaemia reduces vasodilation, impairs endothelial nitric oxide
generation, decreases complement function, impairs neutrophil
chemotaxis and phagocytosis.
IRCH, NCI, AIIMS

Glycaemic control
• Nonenzymatic glycosylation of Ig, reducing complement fixation and
opsonization of microbes.
• Short-term hyperglycemia increases oxidative stress and systemic
inflammatory responses.
• Also impairs CD8+ T cell mediated immunity.
• Hyperglycaemia alters the critical balance between inflammatory and
antiinflammatory cytokines; increase adverse outcomes.
IRCH, NCI, AIIMS

Glycaemic targets
• CDC guidelines advise perioperative glycemic control, and blood glucose
target levels <200 mg/dL in patients with and without DM to prevent SSIs.
• NICE-SUGAR trial demonstrates conventional glucose control (target of
180 mg/dL) had better outcomes (less mortality) than patients managed
with intensive glucose control (target of 81–108 mg/dL).
IRCH, NCI, AIIMS

Perioperative thermoregulation
• Mild perioperative hypothermia (34°–36°C) is common in surgical patients.
• Heat loss during the first hour of anesthesia- redistribution of core to
peripheral temperature gradients caused by an anesthetic-induced
vasodliation.
• Causes of continued heat loss in the OR are radiation and convection.
• The most effective means of preventing ongoing heat loss are forced air
warming and administration of warmed fluids.
IRCH, NCI, AIIMS

Perioperative thermoregulation
• Complications- increased LOS, increased intraoperative blood loss,
transfusion requirements, adverse cardiac events
• Mild hypothermia also increases incidence of SSIs.
• Hypothermia triggers thermoregulatory vasoconstriction, thereby
decreasing subcutaneous tissue oxygen tension
• The major relation between hypothermia and increased SSI.
IRCH, NCI, AIIMS

Preop. temp Management
<36°C Active warming in ward
>/=36°C Active warming at least 30 minutes before induction
Begin induction only when temperature is 36.0°C or above
Active warming throughout the intraoperative phase if-
having anaesthesia for more than 30 minutes or
less than 30 minutes and are at higher risk of inadvertent perioperative
hypothermia
Introp. temp Maintain at >/= 36.5°C
Postop. temp
<36°C Warmed using forced-air warming until comfortably warm
NICE guidelines

SSIs risk with FAW devices
• The waste air from FAW is not simply benign waste air.
• The waste heat and air escapes from under the surgical drape near the
floor, where it warms the contaminated air near the floor.
• The contaminated warm air forms convection currents that rise along the
sides of the surgical table
• It mobilizes the floor bacteria into the sterile surgical field above the
patient.
• Studies have shown mixed results, larger RCTs needed.
IRCH, NCI, AIIMS

Perioperative drug management
• Immunosuppressive agents like glucocorticoids, MTX, AZT,
cyclosporine, and tacrolimus.
• Glucocorticoids- major concerns are: (1) the risk of SSIs and (2) the
risk of hemodynamic instability (secondary adrenal insufficiency).
• Ideally, the lowest possible dose of glucocorticoids should be used in
the perioperative setting.
• If patients require >10 mg prednisone (or equivalent) daily, it implies
that the disease activity is not adequately controlled and that elective
surgery should be postponed.
IRCH, NCI, AIIMS

Perioperative drug management
• Stopping DMARDs prior to surgery may result in a flare-up of disease
activity, may adversely affect rehabilitation.
• Biologic DMARDs can be continued till day of surgery.
• Non- biologic DMRDs- Stop for atleast 2 weeks each for etanercept
and adalimumab while 6 months for rituximab before elective surgery
IRCH, NCI, AIIMS

Inspired oxygen concentration
• Postulated to improve the oxidative bactericidal activity of neutrophils.
• Adequate wound PO2 also helps in the development of collagen and
epithelium, instrumental factors in wound healing.
• Evidence that giving 80% FIO2 rather than 30% reduces wound infections
in colorectal surgeries.
• In vitro analysis of neutrophil function reveals that a higher PO2 promotes
the production of reactive oxygen intermediates.
• Current guidelines to prevent SSIs recommend only giving the required
FIO2 to maintain oxygen saturations above 95%.
IRCH, NCI, AIIMS

Perioperative fluid management
• Wound healing is critically dependent on adequate perfusion to deliver
oxygen.
• Mild to moderate hypovolemia is well tolerated as interstitial fluid moves
into the intravascular space to preserve cardiac output.
• However, this leaves the subcutaneous tissue relatively hypovolemic.
• The optimal type of fluid (colloid or crystalloid) or strategy of fluid
management (goal directed, liberal, or restrictive) remain controversial.
IRCH, NCI, AIIMS

Perioperative fluid management
• Difficult to assess volume status in both liberal and restrictive strategy
• GDFT has gained evidence for improved outcomes, does not specifically
relate to a reduction in postoperative infection.
• WHO recommednations (2016) on prevention of SSIs- GDFT in intraop.
and postop. period is associated with decreased incidence of SSIs.
• However, restrictive therapy and preoperative GDFT were not associated
with reduction of SSI compared with standard therapy.
• When considering SSIs as endpoint, GDFT may be considered if available.
IRCH, NCI, AIIMS

Minimizing blood transfusions
• Immunomodulation and immunosuppression (TRIM) are known
consequences of allogeneic blood transfusion.
• The incidence of postoperative bacterial infection is higher in
transfused patients.
• This effect is greater in trauma patients- established fact.
• The effect appears to be dose-related, older units (>2weeks)
• Consider risk benefit ratios before transfusion, use fresh units.
• Platelet transfusions are associated with bacterial sepsis.
IRCH, NCI, AIIMS

Enhanced recovery after surgery
(ERAS)
• Initiated by Professor Henrik Kehlet in the 1990s
• ERAS or enhanced recovery programs (ERPs) or fast-tracking.
• Initially started for colorectal surgeries, aim to achieve early
recovery after surgery by maintaining preoperative organ function
and reducing the surgical stress response.
• Implemented in other surgeries and has shown a decrease in the
incidence of HAIs.
IRCH, NCI, AIIMS

ERAS
• Goals- maintenance of normal physiology in the perioperative period,
decreasing surgical stress.
• Key principles of the ERAS protocol
 pre-operative counselling
 preoperative nutrition
 avoidance of prolonged perioperative fasting and carbohydrate
loading up to 2 hours preoperatively
 standardized anesthetic and analgesic regimens
 early mobilization
IRCH, NCI, AIIMS

Nutrition
• Malnutrition is associated with a number of negative consequences
 Increased susceptibility to infection
 Poor wound healing
 Increased frequency of decubitus ulcers
 Overgrowth of bacteria in the gastrointestinal tract
 Abnormal nutrient losses through the stool
• Malnutrition leads to immune system dysfunction by impairing
complement activation, bacterial opsonization, and the function of
neutrophils, macrophages, and lymphocytes
IRCH, NCI, AIIMS

Preoperative nutrition support
• Adequately nourished or mild-to-moderate malnutrition, surgery need not
be delayed for preoperative parenteral or enteral supplementation.
• Patients with severe malnutrition- some benefit from delaying surgery to
be fed only if catabolism is not due to the disease itself.
• Benefit more from enteral than parenteral feeding; TPN increases risk for
infectious complications.
• However, parenteral nutrition was found beneficial in patients with upper
gastrointestinal malignancies and hepatocellular carcinoma.
IRCH, NCI, AIIMS

Postperative nutrition support
• Enteral nutrition (oral or tube feeds) rather than parenteral, whenever
possible.
• Postoperative parenteral nutrition-if return of bowel function is not
anticipated for more than 10 days, severe malnutrition at baseline, or who
have a complicated postoperative course.
• Role for immune-enhancing nutritional supplements(arginine, glutamine,
nonessential fatty acids, branched chain fatty acids), remains unclear.
• There is insufficient high-quality evidence.
IRCH, NCI, AIIMS

Decrease in infectious comlications including pneumonia, sepsis, wound infection,
UTI etc were seen
A 45% reduction on both infectious and non infectious complications were seen.
IRCH, NCI, AIIMS

Anesthetic technique
• Anaesthetic agents
– Iv agents
– Inhalational agents
– Opioids
• The role of Regional anesthesia
• Effect of Positive pressure ventilation.
• Several literature on association of anesthetic technique on cancer
recurrence.
• Perioperative events leading to cancer recurrence may be intimately
related to perioperative infections.
IRCH, NCI, AIIMS

Agent NK cell
no./activity
T-lymphocyte Others
Propofol Increase Do not inhibit Antioxidant effect
Ketamine/
Thiopentone
/ Etomidate
Decrease Decrease T helper cells
Midazolam - - inhibitory efect on innate
immunity,
inhibit neutrophil adhesion by
inhibiting the level of IL-8
Volatile
anesthetics
Decrease Decrease T helper cell
activity
IRCH, NCI, AIIMS

Agent NK cell
no./activity
T-lymphocyte Others
Morphine suppresses NK
cell activity
Suppresses T-cell
differentiation,
promotes lymphocyte
apoptosis
Inhibit macrophage activity
Fentanyl Decrease Increase regulatory T
cells
Sufentanil Decrease Increase regulatory T
cells
Inhibits leukocyte migration
Tramadol May have protective effects
on cellular immunity
NSAIDs Reverses NK
cell
suppression
IRCH, NCI, AIIMS

Role of regional anesthesia
• Reduces perioperative stress response.
• Serum levels of the stress hormone cortisol are lower.
• Reducing the need for opioids or volatile anesthetics,
• Orthopedic knee surgery conducted under neuraxial anesthesia led to a
significant lower postoperative infections compared with general
anesthesia.
• A reduced duration of T-cell anergy and disturbances in T lymphocyte
subsets (Th1 and 2)
• However, high-quality evidence is lacking.
IRCH, NCI, AIIMS

Effect of Positive pressure ventilation
• Positive pressure ventilation appears to impair mucociliary motility in the
airways.
• Stress and shear forces exerted during the cyclic opening and closing of
alveoli result in increased cytokine production and white cell
sequestration, as does over-distension of alveoli
• PPV induce inflammation, decrease surfactant production, VILI.
• May promote translocation of tracheal bacteria into the bloodstream.
• ETT can serve as a conduit between the environment and LRT.
IRCH, NCI, AIIMS

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