This document discusses a case of ventilator-associated pneumonia (VAP) in a long-term ventilated patient. It provides details on the patient's history, examination findings, investigations, and treatment. VAP is a common nosocomial infection in the ICU that occurs within 48 hours of mechanical ventilation. Prolonged ventilation increases the risk of developing VAP. The document reviews risk factors, pathogenesis, diagnosis, treatment and prevention of VAP.
Using the Central Line Bundle
Hand Hygiene
Remove Unnecessary Lines
Use of Maximal Barrier Precautions
Chlorhexidine for Skin Antisepsis
Avoid femoral lines
Report CLABSI rates to the units
Celebrate success!!
Using the Central Line Bundle
Hand Hygiene
Remove Unnecessary Lines
Use of Maximal Barrier Precautions
Chlorhexidine for Skin Antisepsis
Avoid femoral lines
Report CLABSI rates to the units
Celebrate success!!
Ventilator Associated Pneumonia (VAP) causes and preventive strategiesVeera Reddy Suravaram
Ventilator associated pnemonia is a cause of concern in today's medical practice due to wide spread of Gram negative pathogens in hospitals and lack of good hygienic practices due to high occupancy rate in ICUs.
Prevention of Central Line Associated Blood Stream Infection (CLABSI )[compa...drnahla
Infection Control Guidelines for Prevention of Central Line Associated Blood Stream Infection (CLABSI )
Dr. NAHLA ABDEL KADERوMD, PhD.
INFECTION CONTROL CONSULTANT, MOH
INFECTION CONTROL CBAHI SURVEYOR
Infection Control Director, KKH.
Central-Line-Associated Bloodstream Infections (CLABSI) pause a major health problem in hospitalized patients. This disease is associated with people with a central line/tube inserted through the skin into the large vein, which can be used to give medicines, fluids, nutrients, or blood products to patients in critical conditions. The disease occurs when microbes enter through the central line invading the bloodstream.
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
Ventilator Associated Pneumonia (VAP) causes and preventive strategiesVeera Reddy Suravaram
Ventilator associated pnemonia is a cause of concern in today's medical practice due to wide spread of Gram negative pathogens in hospitals and lack of good hygienic practices due to high occupancy rate in ICUs.
Prevention of Central Line Associated Blood Stream Infection (CLABSI )[compa...drnahla
Infection Control Guidelines for Prevention of Central Line Associated Blood Stream Infection (CLABSI )
Dr. NAHLA ABDEL KADERوMD, PhD.
INFECTION CONTROL CONSULTANT, MOH
INFECTION CONTROL CBAHI SURVEYOR
Infection Control Director, KKH.
Central-Line-Associated Bloodstream Infections (CLABSI) pause a major health problem in hospitalized patients. This disease is associated with people with a central line/tube inserted through the skin into the large vein, which can be used to give medicines, fluids, nutrients, or blood products to patients in critical conditions. The disease occurs when microbes enter through the central line invading the bloodstream.
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
It is about detailed management of dengue and malaria in adults and children with brief review of clinical history and diagnosis.
reference:
-latest WHO and CDC guidelines
-Nelson 21st edition
-Ghai-Essential Paediatrics 9th edition
-Harrison
Antibiotics In Acute Respiratory Failureshabeel pn
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updated info from reliable source .
it helps in understanding complications due to covid . it is handy for interns and postgraduates to act when cases come ,
Pneumonia lecture,Describe the common pathogenesis and pathogens of pneumonia
Discuss diagnosis and initial management of community acquired pneumonia (CAP)
Understand features of the Pneumonia PORT Severity Index
Discuss the IDSA/ATS guidelines and recommendations for final antibiotic choice
Understand issues in basic management for pneumonia in children, nursing home patients, and immunocompromised patients.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
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2 Case Reports of Gastric Ultrasound
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
2. Case- 50yrs old man transferred from KKH on 26/12/1433
Mr. MIAH HASAN,
as case of RTA-head injury with Cx spine # C4-C6(operated),Infected stage 4 sacral Bed Sore
with respiratory failure (neural mediated RF).
DAY-148 in ICU/hospital
DAY 1468 on ventilator(tracheostomy) SIMV mode Vt-500ml, RR-12/min, Fio2 45%,
PEEP-3mbar, PS-16mbar
Since five days Fio2- 65-75% ,PEEP -8, to maintainSpo2 above 95% and
Pco2 -78mmHg , ABG-RES. ACIDOSIS WITH HYPOXIEMIA
O/E- Temp38.9 degree celcius HR-102b/min ,BP-98/58mmHg ,RR-28breaths/min,
pallor, emaciated, on noradrenaline & dopamine
BED SORES partially clean with health granulation tissue
Diarrhea since 10 days
S/E -RS- mucopurulent resp secretion B/L crackles Rt>Lt ,
P/A and CVS-unremarkable CNS- conscious, vague response to vc, Quadriplegic
LAB. R - Wbc-22,Hb-9.5g/dl , plt- 93 alb-2.46mg/dl TP-5.9mg/dl wbc-41(4/5)
Sputum analysis- Candida, GPC-++ Pus cells-+++, Stool analysis –NBF
Sputum-c/s(4/5/33)-pseu.auerginosa, klebsiella pneumonia. Sensitive to Ceftazidime,
Tienam. CXR– will review
TREATMENT- Antibiotics,zantac, iron folic acid, clexan and supportive treatment NGT
FEEDING partially supported by parenteral . Antibiotic- tienam and cipro
5. case-- ABDUL BADER 55yrs lady transferred from KKH on
Mrs. FARIYAL
6/4/1433 as a case of POST-CPR, BRAIN ANOXIA ,DCM.
DAY 29th in ICU and on VENTILATOR
SIMV mode(Tracheostomy) Vt- 500ml, RR-6/min, PS- 7mbar, Pinsp- 20,
Fio2-30% consistent on same parameters with Sp02>97%
O/E: Temp.38.5degree celcius, RR-14/min HR-70/min,
BP -98/60mmHg, Spo2 -99%
S/E : RS- mucoid secretion, conducted sounds
CVS/PER ABD- Unremarkable, CNS- unconscious GCS- 5T/15
Wbc-8, Hg-8.9,alb-3.4mg/dl , ABG- Met. Alkalosis, CXR-will review
Blood c/s –CONS sen to vanco, Sputum c/s-NBG Urine c/s-NGB
Urine analysis(20/4/33)-pus cells-15-20/hpf, Rbcs 10-15/hpf, epith. Cells-
6-8 (11/4/33, 17/4/33—consistant pus cells and Rbcs)on 3/5- 2-3 pus cel
TREATMENT-Aspirin, Plavix, Clexan, Captopril, Zocar, Amiodarone,
Depakin, Adol, Zantac, NGT feeding and supportive treatment.
Received Vancomycin.
7. INTRODUCTION
Mechanical ventilator is one of the important life
saving devices used in conditions like
Respiratory failure (main indication)
Protection of airways
Head injury
Post operative
Shock
However, as like any other devices/ medications
MV also associated with complications like
Hemodynamic instability, Pneumothorax, VALI and
VENTILATOR ASSOCIATED PNEUMONIA
8. What is VAP?
A Nosocomial pneumonia associated with
mechanical ventilation (either by
Endotracheal tube or Tracheostomy) that
develops within 48 hours or more of
hospital admission and which was not
present at the time of admission.
National institute of health excellence (NICE)-2007
center for disease control and prevention
9. TYPES--
EARLY ONSET:
-within 3-4days of MV
less virulent, community acquired
organism- Str.pneumonia, H. influenzae
LATE ONSET:
-After 3-4 days of MV
More virulent, hospital acquired organism-
Pseudomonas, Acinetobacter, MRSA, Enterobacteriaceae
10. EPIDEMIOLOGY
•Hospital acquired pneumonia (HAP) is the
second most common hospital infection.
• VAP is the most common intensive care unit
(ICU) infection.
• 90% of all nosocomial infections occurring
in ventilated patients are pneumonias.
11. INCIDENCE
VAP occurs in 10 - 65% of all ventilated
patients Crit Care Clin (2002)
Incidence increases with duration of MV
3% /day for first 5days, 2%/day for 6-10days
and 1%/day after 10 days.
The incidence of VAP is highest in the
following groups:
Trauma, Burns, Neurosurgical pts. Postop.
Mortality rate is 27% &43%with antibiotic
resistant organism.
critical care societies collaborative(CCSCs)
Mortality rate in VAP caused by Pseudomonas
or Acinetobacter is as high as 76%
Crit Care Med (2004)
12. Cont…
VAP
Increases ventilatory support requirements
and ICU stay by 4.3 days
Increases hospital LOS by 4 to 9 days
Increases medical cost
Chest 2002;122:2115
Critical Care Medicine 2005;33:2184-93
13. Causative Organisms
Early onset:
Hemophilus influenza
Streptococcus pneumoniae
Staphylococcus aureus (methicillin sensitive)
Escherichia coli
Klebsiella
Late onset:
Pseudomonas aeruginosa
Acinetobacter
Staphylococcus aureus (methicillin resistant)
Most strains responsible for early onset VAP are
antibiotic sensitive. Those responsible for late onset
VAP are usually multiple antibiotic resistant
Am J Resp Crit Care (1995)
15. RISK FACTORS FOR VAP
Host related:
-Underlying medical conditions-
COPD, obesity, ARDS, gastro esophageal disease,
burn, trauma, MODS etc--
-Immunosuppression, Malnutrition(S.Albumin<2.2g/dl)
-Advanced age
-Patients’ body position
-Level of consciousness- impaired LOC, delirium,
coma.
-Number of intubations- Reintubations
-Medications (Antibiotics, sedation, NM blockers)
16. Cont..
• Device related:
- MV with Endotracheal tube, trcheostomy
-Prolonged MV
-Number of intubations- reintubation
-Use of humidifier
-Nasogastric or orogastric tubes
• Personnel related:
-Improper hand washing
-Failure to change gloves between contacts with pts
-Not wearing personal protective equipment when
17. PATHOGENESIS
Bacteria enter the lower respiratory tract via
following pathways:
Aspiration of organisms from the oropharynx
and GI tract (most common cause)
Direct inoculation
Inhalation of bacteria
Haematogeneous spread
18. ASPIRATION- Primary Route of
Bacterial Entry into LRT
ENDOTACHEAL TUBE
Holds the vocal cords
open-predispose to micro & macro aspiration
of colonized bacteria from oropharynx to LRT.
Leakage of secretion containing bacteria
around the ETT cuff.
NGT OR OROGASTRIC TUBE
Interrupt gastro-esophageal sphincter
leading GI reflux and aspiration.
Increase oropharyngeal colonization, stagnation
of oropharyngeal and nasal secretion.
19. Cont..
Inhalation of aerosols containing bacteria :
-Contaminated RT equipment
-from other patients/ healthcare personnel's
-Inadequate disinfection/sterilization technique
-Contaminated solutions/water
Direct contact:
-Cross Contamination (Hands)
20. HOW DO WE DIAGNOSE? 2-1-2
Radiographic evidence x 2 consecutive days
New, progressive or persistent infiltrate
Consolidation, opacity, or cavitation
Clinical sings
At least 1 of the following:
Fever (> 38 degrees C) with no other recognized cause
Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000
WBC/mm3)
At least 2 of the following:
New onset of purulent sputum or change in character of
secretions
New onset or worsening cough, dyspnea, or tachypnea
Rales or bronchial breath sounds
Worsening of gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)
21. CONT…
Microbiological criteria (optional)
At least one of the following:
• Positive growth in blood culture not related to another
source of infection.
• Positive growth culture pleural fluid.
• Bronchoaleveolar lavage
> 105colony forming units/ml.
sensivity &specificity 42-93% &45-100%
Protected
specimen brushing >103cfu/ml (33-100% & 50-
100%) chest.Apr2000;117(4suppl2):198-2002)
•Histopathological evidence of pneumonia
22. Cont--
•RADIOLOGICAL FINDING AND 2 CLINICAL
CRITERIA SENCIVITY OF DIAGNOSING VAP
IS 69% AND THE SPECIFICITY IS 75%
• SAMPLING OF RESPIRATORY SECREATION
can be obtained from distal or proximal airway however
the sensivity and specificity is more with distal airway
sample(Bronchoalveolar lavage(BAL) , Protected specimen
brush sampling(PAB).
•ABSENCE OF RADIOLOGICAL FINDING
HELPFUL FOR EXCLUDING THE DIAGNOSIS
OF VAP
23. A new streamlined surveillance defintion for
ventilator-associated pneumonia
Any one of the following
1. Opacity, infiltrate, or consolidation that appears, evolves, or persists over 72 hrs
2. Cavitation
Any one of the following
1. Temperature 100.4°F within past 24 hrs
2. White blood cell 4,000 or 12,000 white blood cells/mm3 within past 24 hrs
Both of the following
1. Two days of stable or decreasing daily minimum FIO2 followed by increase in
daily minimum FIO2 15 points sustained for 2 calendar days OR 2 days of stable or
decreasing daily minimum positive end-expiratory pressure followed by increase in
daily minimum positive end-expiratory pressure by 2.5 cm H2O sustained for 2
calendar days
2. Gram-negative stain of respiratory secretions with moderate (2+) or more
neutrophils per low power field within 72 hrs.
Critical care med 2012 vol.40,no.1
24. TREATMENT PROTOCAL
• Initial therapy is empiric
• Start when VAP is suspected, Don’t delay
• Individualize to institution-
-Hospital epidemiologic data
-Drug cost and availability
• Individualize to patient-
-Early onset versus Late onset of VAP
-Prior antibiotic use
-Underlying disease Renal, liver disease etc
-Surveillance cultures
-Use gram stain results if possible
25. TREATMENT
• GENERAL APPROACH FOR INFECTION CONTROL
• ANTIBIOTICS-
Selection of antibiotics:
Early onset of VAP and no risk for MDR -
Cefrioxone, fluroquinolones, ampicillin-sublactum
Late onset of VAP and risk for MDR-
Antipseudomonal cephalosporin(cfepime,ceftazidime)
Carbapenems(imipenem,meronem),
Beta lactam/betalactamase inhibitors-
piperacillin-tazobactam
Amonoglycocides with vancomycine,linezoid
ANTIBIOTCS TO BE ADJUSTED FURTHER ON THE
26. Risk Factors for drug resistance
ABX in last 14 days
Prior culture with MRO
Immunocompromised
Chronic primary lung pathology
Acute or long term care hospitalization within
14 days
Tracheostomy for > 5 day
27. DURATION OF TREATMENT
- Depends on severity,
- Time to clinical response and micro organism response
- Isolation of microorganism
- Longer duration >14-21days risk of toxicity and resistance
- Shorter duration<7days- risk of recurrence
-standard duration of treatment 7-14 days
- Longer durtion 14-21 days may be indicated in
Multilobular involvement, cavitation, gram-ve
necrotising pneumonia, isolation of Pseudomonas,
Acnetobacter
29. PREVENTION
Specific practices have been shown to decrease
VAP
Strong evidence that a collaborative,
multidisciplinary approach incorporating many
interventions is paramount
Intensive education directed at nurses and
respiratory care practitioners resulted in a 57%
decrease in VAP
Crit Care Med (2002)
30. PREVENTION
Conventional Infection control Aproach
•DESIGN OF ICU-
Adequate space, lighting, proper function of ventilatory
system, facilities for hand washing, Isolation room.
•STAFFING-
Education, Adequate number, quality, importance of personal
cleanliness and attention to asceptic procedures.
•Hand washing and Hand rubbing with alcohol based solution.
•PERIODICAL BACTERIAL MONITORING POLICY.
• SPECIFIC PROPHYLAXIS- Use Gloves, Gown, Mask.
Use of NIPPV
Minimize duration of MV, checking daily for readiness to
weaning/extubation (Text book of criti care med. 5 the Edit.
32. VAP BUNDLE (VAP reduction rate44.5%)
VAP bundle(4) originated in 2005 from INSTITUTE
OF HEALTH CARE IMPROVEMENT(IHI) & CDC
1. Elevation of the head of the bed (HOB) to between 30 and
45 degrees.
2. Daily sedative interruptional and daily assessment of
readiness to extubate.
3. Stress ulcer disease prophylaxis.
4. Deep venous thrombosis (DVT) prophylaxis (unless
contraindicated)
5.IN 2010 FIFTH COMPONENT DAILY ORAL CARE
WITH CHLORHEXIDINE IS ADDED.
(criti. care 2012 vol. 40,no.1)
33. HANDWASHING
Hand washing is the single most important
(and easiest!!!) method for reducing the
transmission of pathogens
Use of waterless antiseptic preparations is also
acceptable and may increase compliance.
Remember to wash your hands
Before and after patient contact
Beginning and end of work day
Before and after using gloves
After touching contaminated surface
34. HOB 30 - 45 Degrees
The supine position is an independent risk
factor for death in all ICU patients
HOB elevation to 30-45 degree especially during
feeding prevent aspiration and 34% reduction
in VAP (Lancet.nov.1999;354,1851-1858)
CDC recommends HOB 30-45° unless
contraindicated
35. Contraindications
- Hypotension MAP <70
-Tachycardia >150
-CI <2.0
-Central line procedure
-Posterior circulation strokes
-Cervical spine instability use reverse trendelenburg
-Some femoral lines i.e.: IABP no higher than 30
degrees use reverse trendelenburg
-Increased ICP, No higher than 30 degrees avoid
hip flexion
-Proning
36. Reverse Trendelenburg
In full reverse Trendelenburg the foot of bed
will read -12 degrees
Angle of head elevation is approximately 20
degrees (not 30 degrees) when at -12
Evaluate the individual clinical situation to assess
if the patient can tolerate the addition of a small
amount of Fowlers angle which may flex the hip
37. Daily Sedative Interruption and Daily
Assessment of Readiness to Extubate
OVERSEDATION
Predisposes patients to:
Thromboemboli
Pressure ulcers
Gastric regurgitation and aspiration
VAP
Sepsis
Consequences include:
Difficulty in monitoring neuro status
Increased use of diagnostic procedures
Increase ventilator days
Prolonged ICU and hospital stay
38. Daily Wake Up
Every patient must be awakened daily unless
contraindicated!
Daily weaning assessments reduce the duration of
mechanical ventilation.
Wean infusion to off in increments of 10-25% daily in
order to perform a clinical assessment
Rebolus and restart infusion if the patient becomes
symptomatic. Your new continuous IV dose should be
lower than what you began with
Consider implementation of a sedation scale such as the
Richmond Agitation Sedation Scale (RASS) scale to avoid
over sedation.
Goal is to decrease sedation
39. STRESS ULCER PROPHYLAXIS
SUCRALFATE, H2 RECEPTOR BLOCKER,
PROTON PUMP INHIBITOR
Increases gastric ph and minimize bacterial colonization that
reduces the risk of VAP and GI bleeding
SUCRALFATE-
Decreases the VAP rate but increases the risk of GI bleeding by 4%.
H2 receptor blockers/PP inhibitors-
Increase rate of VAP by increasing gastric Ph leading to colonization of
bacteria and decreases the risk of GI bleeding.
H2 receptor blocker, PP inhibitor preferred over sucralfate
.
Am J Respir Crit Care Med. 2005;171(4):388-416
40. Deep Venous Thrombosis
(DVT) Prophylaxis
There is increase risk of thomboembolism in
mechanically ventilated patient.
There is no any data association between DVT
prophylaxis and decreasing rates of VAP.
VAP rates decreased most dramatically in hospitals
where all elements of the Ventilator Bundle were
implemented, including this one.
Chest. 2004;126(3 Suppl):338S-400S.
41. DAILY ORAL CARE
Dental plaque- due to absence of mechanical chewing
and the saliva and they are reservoir for potential
pathogens that causes VAP.
MECHANICAL INTERVENTION
Tooth brushing , Rinsing of oral cavity to remove dental plaque
PHARMACOLOGICAL INTERVENTION
0.12% CHLORHEXIDINE ORAL RINSE
Am J Crit Care. 2009 Sep;18(5):428-437
Oral decontamination- 2%genta+2%Collistin+2%Vanco paste QID
Selective decontamination of digestive tract(SDD)-
2%polymyxin+tobra+Amphotericine paste oral application QID.
Solution 100mg poly+80mg tobra+500mg ampho QID throu NG.
I/V Cefuroxime 1.5g TID first 4days.
42. DAILY ORAL CARE
Best Practice??
Daily assessment to determine oral health
Brush q 12 hours to prevent plaque
Oral cleansing q 2-4 hours to promote healing
and maintain integrity of oral tissues
Use of an alcohol-free, antiseptic oral rinse to
prevent or reduce bacterial load of oropharynx
Routine suctioning of mouth to manage oral
secretions and minimize risk of aspiration
Use of a moisturizer
Am J Crit Care (2005)
43. PREVENTION
NIPPV
Subglottic suction
Maintaining ETT/TT cuff pressure 20- 30cmH20
Orotracheal rather than nasotracheal intubation
Avoid unnecessary disconnection of MV circuit.
Closed inline suctioning.
Avoid saline instillation for suctioning thick secretion.
Appropriate Humidification of inspired air.
Early Enteral feeding
Turning patient every 2 hrly.
44. Airway Management
Mechanical ventilation
Avoidance of Endotracheal intubation
Mask ventilation trials , NIPPV
Minimize duration on MV
Orotracheal intubation
Nasotracheal intubation slightly increase the risk for VAP
Avoid Reintubations- increases risk of VAP 6 fold
(Am resp.criti car med.1995;152(1):137-141)
Cuff management
HVLP ETT cuff VAP rate 20% , LVHP ETT cuff VAP rate 20%
(Text book of criti. Care. 5 th Edit. Mitchell P.Fink SHOEMAKER)
Maintain at 25-30 cm H2O
45. Airway Management
Suctioning
In-line suctioning using closed technique than open
technique
Normal saline
Should not be routinely used to suction pts
Causes desaturation
Does not increase removal of secretions
Can potentially dislodge bacteria from ETT to LRT
Should be used to rinse the suction catheter after suctioning
Maintaining adequate hydration, proper humidification of
ventilatory circuit, nebulizer, mucolytic agent can help to
decrease the viscosity and eliminate the need for saline lavage
(Am. jour.crical care
46. Suctioning
Oral suction devices (Yankauer)
Policies for use and storage not written
Harbor potentially pathogenic bacteria within 24 hours
71% of nurses store the device in its packaging (STAMP)
Best practice???
Change q day
Rinse with sterile water or NS
Allow to air dry
47. SUBGLOTTAL SUCTIONING
Should be done using a 14 Fr sterile suction catheter:
Prior to ETT rotation
Prior to lying patient supine
Prior to Extubation
Continuous subglottic suctioning
ETT with dedicated lumen to
continuously or intermittently suction above
suction above the cuff may
reduce the risk of VAP.
Am J Respire cri car Med Oct.. 2010
48. Ventilator Circuit-Management
Vent circuit should not be routinely opened
once ventilation is initiated
Disconnection of ventilation tubing can lead to
loss of PEEP and alveolar de-recruitment
If circuit must be disconnected, clamp ETT
with padded Kelly forceps to avoid PEEP loss
Expiratory condensation should be removed via
the trap in the tubing
Inspiratory condensation – if clean, may be
drained back into the water reservoir
Ventilator circuit can be changed weekly, unless
it is soiled with blood or vomitus
49. Ventilator Circuits Humidification Systems
Appropriate Humidification of inspired air
Active Humidification or Passive Humidification
Heat and Humidity Exchangers (HMEs) should not be
routinely changed unless:
Visibly soiled
> 5 cm H2O auto-PEEP
Convert to Heated Humidification (HH) if:
Ventilated longer than 96 hours
Thick/bloody secretions
Resp. Acidosis
Air leak from chest tube or around airway
VT < 300 cc or > 750 cc
50.
51. Enteral Feedings
Early enternal feeding decrease bacterial
colonization and rate of VAP
Bolus feeding should be avoided to minimize
the risk of aspiration
Elevate HOB 30 - 45 degrees
Routinely verify tube placement
No CDC recommendations for:
Preferential use of small bore tubes
Continuous versus intermittent feeding
Post pyloric placement CDC (2003)
52. PATIENT TURNING-
Routine turning of patient for every 2 hrs
increase pulmonary drainage and decrease the
risk of VAP.
Use of beds with continues lateral rotation can
decrease the incidence of pneumonia but do not
decreases mortality or duration of MV
(critical care 2002;30(9):1983-1986)
53. No Data
to Support These Strategies
• Use of small bore versus large bore gastric
tubes
• Continuous versus bolus feeding
• Gastric versus small intestine tubes.
• Closed versus open suctioning methods.
• Kinetic beds.
54. NEW DEVELOPMENT
• National healthcare safety(NHSN) and CDC proposed-
VAP terminology changed to VAC (ventilated associated
conditions and complications) not necessarily limited VAP.
• VAP Surveillance definination algorithm.
Chest x ray is not included ,
And diagnosis is mainly depend on worsening of gas exchange,
clinical features, isolation of microorganism in resp.secreation .
• ETT-- with continuous subglottic suction, ployurethrene cuff,Sponge
cuff , Silver nitrate and antibiotic coated ETTs.
• VAP industrial complex- kinetic beds, inlines suction catheters
• VAP bunddle with 7 components – 5+ Replacing NGT to
Orogastric tube and Hand washing by health care personnel.
IMPLEMENTATION and ENFORCEMENT of VAP bundle
55.
56. SUMMARY
Nosocomial pneumonia and especially VAP are the
most frequent infectious complications in the ICU, and
they significantly contribute to morbidity and mortality.
VAP is an important determinant of ICU and hospital
lengths of stay and healthcare costs.
No standard to diagnose.
Several simple preventive measures(VAP bundle) and
timely initiation of appropriate antibiotics ensure better
outcomes in patients with VAP.
Editor's Notes
Risk is greatest in patients with trauma or surgery of the head, neck, thorax, or abdomen.
Mechanically ventilated (ETT or trache) for > 48 hours