Pediatric Ventalitor -Associated Event PedVAE

lecture

1. National CenterforEmerging andZoonoticInfectiousDiseases
PediatricVentilator-associatedEvent(PedVAE)

2. TrainingObjectives
▪Explainthehistoryanddevelopmentof PedVAE
▪ReviewPedVAEkeyterms
▪Explainhowto SelectDailyMinimumValues
▪DescribethePedVAESurveillanceAlgorithm
▪Demonstrateuseof thePedVAECalculator

3. ▪Ventilatedpatientsareathighriskforcomplicationsandpoor outcomes
–Ventilator-associatedpneumonia(VAP),sepsis,AcuteRespiratoryDistress
Syndrome(ARDS),pulmonaryembolism,barotrauma,andpulmonaryedema
▪Suchcomplicationscanleadtolongerdurationofmechanicalventilation,
longerstaysintheICU andhospital,increasedhealthcarecosts,and
increasedriskofdisabilityand death
▪In pretermneonates,prolongedmechanicalventilationforrespiratory
distresssyndromecancontributetothedevelopmentof chroniclung
disease
▪Prolongedmechanicalventilationinextremelylow birthweightinfantsis
alsoassociatedwithneurodevelopmentaldelay
VentilatedPatientsandtheNeedforSurveillance

4. PedVAESurveillance:Development
▪Neonatal&Pediatric VAESurveillanceWorkingGroup
convened in 2012 to explore use of VAE (adult algorithm) in
pediatricand neonatalinpatientlocations
–Insufficientdatatousethe sameapproachasusedfor
adults

5. PedVAESurveillance:Development
▪Publication*in 2016ontheuseofa
pediatricVAE-likedefinition
demonstrateddetectionofevents
defined by changes in FiO
2and Mean
AirwayPressurewereassociatedwith
increasesinlengthofstayand
mortality
*Cocoros NM, Kleinman K, Priebe GP,et al. Ventilator-Associated Events
in Neonates and Children--A New Paradigm. Crit Care Med. 2016
Jan;44:14-22.

6. PedVAESurveillance: Availableas of 2019
▪Neonatal& PediatricVAESurveillance
WorkingGroupconsensusreachedto
begin developmentwith aplan to
implementPedVAEasanavailableeventin
NHSN
▪PedVAEfieldtestingconductedin2017
▪PedVAEavailableasan NHSNevent
beginning January2019

7. PedVAESurveillance–Before youbegin

8. Whois eligibleforPedVAEsurveillance?
▪Ventilatedinpatientsofacutecarehospitals,longtermacutecare
hospitals,inpatientrehabilitationfacilities
▪Patientsinpediatricandneonatallocationsonly
wheredenominatordata(patientdaysand
ventilatordays)canbecollected
–Ventilatedadultsinpediatriclocationsareincluded
inPedVAEsurveillance –regardlessofage

9. Whois NOTeligibleforPedVAEsurveillance?
▪Patientson extracorporeallifesupportorparacorporealmembrane
oxygenationarenoteligibleforVAEsurveillance
–Ineligibilityonly appliestoperiodsoftimewhilereceivingthis
formof support
▪Non-acutecarelocationsinacutecarefacilitiesarenot eligibleto
participateinPedVAEsurveillance.

10. Whataboutotherspecificmodesofmechanical
ventilation?
▪INCLUDEpatientson:
–HighFrequencyOscillatoryor jet ventilation(HFO)
–AirwayPressureReleaseVentilation(APRV)
–VolumetricDiffusiveRespiration(VDR)–FiO
2parameteronly
▪INCLUDEpatientswhoarereceivingaconventionalmodeof mechanical
ventilationwhilereceiving:
–Surfactant
–Corticosteroids
–Pronepositioning
–Nitricoxidetherapy
–Helium-oxygenmixture
–Epoprostenoltherapy

11. PedVAEAlgorithmOverview
Remember:The PedVAEdefinitionalgorithmisforuseinsurveillance;itisnotaclinical
definition algorithmandisnotintendedforusein theclinicalmanagementofpatients.

12. PedVAEDefinitionAlgorithmSummary

13. PedVAEsaredeterminedbyidentificationofdeterioration
inrespiratorystatusafteraperiodofstabilityor
improvementontheventilator
▪Usingeitheroftwokeyparametersthatdemonstrateeffective
oxygenationin ventilatedpatients
–FiO
2
–MeanAirway Pressure(MAP)

14. FiO
2
▪FractionofOxygenininspiredgas
–FiO
2ofroomairis0.21
–Oxygenconcentrationof roomairis21%
▪FiO
2is a setting on the ventilator and is one of the key
parameters that can be adjusted depending on the patient’s
oxygenationrequirement

15. MAP
▪MeanAirwayPressure–Mean(average)pressureexertedonthe airway
and lungs from the beginning of inspiration until the beginning of the
next inspiration(inspiratorycycle)
▪MAP is a measured/calculated value (not a ventilator setting) that is
determinedby
–PEEP-PeakEnd-Expiratory Pressure
–PIP-PeakInspiratory Pressure
–Inspiratorytime
–Otherparameterslikeflowor frequency
▪MAP forpurposesofPedVAEsurveillanceisNOTMeanArterial
Pressure

16. FiO
2andMAP
▪FiO
2ventilatorsettingsandMAPvaluesdocumentedacrossthecalendar
dayareusedtoidentifythedailyminimumFiO
2anddailyminimumMAP
values
▪ThedailyminimumFiO
2and dailyminimumMAPvaluesareusedto
determineboththeperiodofstabilityorimprovementandtheperiodthat
indicatesworseningoxygenation.
▪Stability,improvementor worseningisnotdeterminedby comparingFiO
2
settingsand MAPvaluesthatoccurduringacalendardaybutby
comparingthedailyminimumvaluesfromcalendardayto calendarday
▪Useacalendardaynot anyother“24-hour captureperiod”

17. Daily MinimumFiO
2and MAP

18. DailyMinimumFiO
2andMAP
▪FiO
2settingsand MAPreadingsaretypicallyrecordedinthepaperor
electronicmedicalrecord,onrespiratorytherapyand/ornursingflow
sheets,inthesectionoftheflow sheetthatpertainstorespiratory
status/mechanicalventilation
▪When choosing thedailyminimumFiO
2andMAP,useall
documentedfindingsthatarerecordedthroughoutthecalendarday
duringtimeswhenthepatientisreceivingsupportfromaneligiblemode
ofmechanicalventilation
–Include FiO
2and MAP values documented during weaning/mechanical ventilation
liberationtrialsas longas thepatientis receiving ventilatorsupportduringthosetrials
–Excludes FiO
2and MAP values documented during periods of time when the patient is
on extracorporealorparacorporealmembraneoxygenation

19. DailyMinimumFiO
2
▪ThedailyminimumFiO
2isdefinedasthelowestdocumentedFiO
2 setting
that wasmaintainedfor>1 hourduringacalendarday
▪Protocolprovidesexamplesof how>1 houristobedeterminedtoensure
standardizationacrossallfacilities
–Iftrackingevery15minutes,5consecutiverecordingsofacertainlevelwould
beneeded(e.g.,at09:00,09:15,09:30,09:45and10:00)
–Iftrackingevery30minutes,3consecutiverecordingsatacertainlevelwould
beneeded(e.g.,at09:00,09:30,and10:00)
–IftrackingPEEP everyhour,2consecutiverecordingsata certainlevel(e.g.,at
09:00and10:00)
▪If thereisno settingthathasbeenmaintainedfor>1hour thenselectthe
lowestsettingregardlessoftheperiodoftimeinwhichthesettingwas
maintained

20. IdentifytheDailyMinimumFiO
2forMonday
Selectthelowestvaluerecordedforthecalendardaythatis
maintainedfor>1 hour
--
Monday
12am
3am4am6am9am12pm3pm9pm11pm
FiO
2 0.800.700.900.800.800.750.750.750.75

21. --
Monday
12am
3am4am6am
--
9am12pm3pm9pm11pm
FiO
2 0.800.700.900.800.800.750.750.750.75
IdentifytheDailyMinimumFiO
2
Selectthelowestvaluerecordedforthecalendardaythatis
maintainedfor>1 hour
▪ForMonday:0.75isthe DailyMinimumFiO
2.Thelowestvalueof
0.70wasnotmaintained for > 1hour

22. IdentifytheDailyMinimum FiO
2forMondayand
Tuesday
Ventilation isinitiatedlateinthecalendarday
-- Monday
23002330
Tuesday
003001000300060009001200
FiO
2 0.700.800.80O.800.800.750.750.80

23. --
ss
Monday
23002330
Tuesday
003001000300060009001200
FiO
2 0.700.800.80O.800.800.750.750.80
IdentifytheDailyMinimumFiO
2 forMondayandTuesday
Ventilationis initiatedlate in the calendarday
▪Monday:0.70istheDaily MinimumFiO
2 , therewasnovaluemaintainedfor> 1hour
▪Donotlooktothenextcalendardaytodetermineif a settingwasmaintained>1hour
▪Tuesday:0.75 istheDaily MinimumFiO
2,thelowestvaluemaintainedfor>1hour

24. DailyMinimumMAP
▪The dailyminimumMAPisthelowestvalue documentedduring a
calendar dayregardlessofhow long thevalue ismaintained
▪WhendeterminingthedailyminimumMAP,ifMAP values includea
decimal place, then round the MAP value to the nearest whole
number.For example:
–AMAPof10.00 –10.49isroundedto10
–AMAPof10.50 –10.99isroundedto11

25. DailyMinimumMAP
▪Forpatients<30daysMAP values of0-8 cmH
2O areconsidered
equalto8cmH
2O
–Anydaywheredaily minimum MAPis0-8cmH
20willbeassignedadaily
minimumMAPvalueof8cmH
20.
▪Forpatients≥30 daysMAP values 0-10 cmH
2O areconsidered
equalto10cmH
2O
–Anydaywheredaily minimum MAPis0-10cmH
20willbeassignedadaily
minimumMAPvalueof10cmH
20.

26. IdentifytheDaily MinimumMAPforaPatient<30Days
--Monday
12am
3am6am9am12pm3pm6pm9pm
MAP 8 6 8 5 5 81010

27. IdentifytheDaily MinimumMAPforaPatient<30Days
Selectthelowestvaluerecordedforeachcalendarday
Explanation: Thelowestvalueis5 cmH
2OonMonday,butremember
thatforpatients<30 days,values0-8=8.
Monday:DailyMinimumMAPis8cmH
2O

28. IdentifytheDaily MinimumMAPforaPatient≥30Days
--
Monday
12am3am6am9am12pm3pm6pm9pm
MAP 8 6 8 5 5 81010

29. --
Monday
12am3am6am9am12pm3pm6pm9pm
MAP 8 6 85(10)5 81010
IdentifytheDaily MinimumMAPforaPatient≥30Days
Select the lowest value recorded for each calendar day
regardless ofhowlongitwasmaintained
Explanation:The lowest value is 5 cmH
2O onMonday,butremember
thatforpatients ≥ 30days,values 0-10=10.
Monday:DailyMinimumMAPis10cmH
2O

30. PedVAESurveillance

32. MeetingPedVAE
▪Patientmustbe ventilated>2daystobe eligibleforPedVAE
surveillance
–However,thefirsttwodaysof mechanicalventilationcanestablisha
baselineperiod
▪Patients mustbemechanicallyventilatedforatleast4calendar
daystofulfillPedVAEcriteria(wherethedayofintubationor
initiationofmechanicalventilationis day 1)
–2daysofstabilityor improvement
–2daysofevidenceofworseningoxygenation

33. What do we mean when we use "Baseline" and "Worsening" in
thePedVAEdefinition?
▪Baseline:≥ 2calendar daysofstableordecreasingdailyminimumFiO2or
MAP values and immediately precedes the first day of increased daily
minimumMAPorFiO2.
▪Worsening:After a periodof stabilityorimprovement on theventilator,the
patienthas atleastoneof thefollowing indicatorsof worseningoxygenation:
•Increasein dailyminimumFiO2of≥0.25(25points)overthedaily
minimumFiO2of thefirstdayinthebaselineperiod,sustainedfor≥2
calendardays.
OR
•Increaseindaily minimumMAPvalues of ≥4 cmH2Ooverthedaily
minimumMAPofthefirst dayinthebaseline period,sustainedfor≥ 2
calendardays.

34. Determiningif aPedVAEis identifiedusingthe Daily
MinimumFiO2andMAPValues
FiO2: abaselineperiodofstabilityorimprovementimmediatelyfollowed
by anincreaseindailyminimumFiO
2of≥0.25 (25 points)overthedaily
minimumFiO
2of thefirstdayinthebaselineperiod,sustainedfor≥2
calendardays
MAP: abaselineperiodofstabilityorimprovementimmediatelyfollowed
by anincreaseindailyminimumMAPvaluesof≥4cmH
2Ooverthedaily
minimumMAPof thefirstdayinthebaselineperiod,sustainedfor≥ 2
calendardays

35. VentDay
DailyMinimum
MAP
DailyMinimum
FiO
2
1 13 60
2 8(7) 40
3 8(7) 40
4 12 65
5 12 50
6 10 40
7 8 40
8 8 40
OperationalizingPedVAE
(patientis <30 days-MAPvalues0-8=8)
First, determine if a
baselineperiodof
stability or improvement
isestablishedineither
the Daily Minimum MAP
or Daily minimum FiO
2
parameter.

36. VentDay
DailyMinimum
MAP
DailyMinimum
FiO
2
1 13 60
2 8(7) 40
3 8(7) 40
4 12 65
5 12 50
6 10 40
7 8 40
8 8 40
≥-2 dayperiodof
stability (MAPor
FiO
2)
OperationalizingPedVAE
(patientis<30days)

37. 6
7
8
VentDay
DailyMinimum
MAP
DailyMinimum
FiO
2
1 13 60
2 8(7) 40
3 8(7) 40
≥2-dayperiodof
stability
(MAPorFiO
2)
4 12 65
5 12 50
≥ 2-day perio
theMAPpar
increaseof≥4
firstdayofthe
dofworseningin
ameterwithan
10 40
cmH
2Ooverthe
8 40
baselineperiod 8 40
OperationalizingPedVAE
(patientis<30days)

38. 6
7
8
VentDay
DailyMinimum
MAP
DailyMinimum
FiO
2
1 13 60
2 8(7) 40
3 8(7) 40
≥2-dayperiodof
stability
(MAPorFiO
2)
4 12 65
5 12 50
≥ 2-day perio
theMAPpar
increaseof≥4
firstdayofthe
dofworseningin
ameterwithan
10 40
cmH
2Ooverthe
8 40
baselineperiod 8 40
APedVAEisidentifiedintheMAPparameter

39. VentDay
DailyMinimum
MAP
DailyMinimum
FiO
2
1 13 60
2 10(7) 40
3 10(7) 40
4 12 65
5 12 50
6 10 40
7 8 40
8 8 40
Whatif wetakethesameexampleinapatient≥30 days?

40. 65
VentDay
DailyMinimum
MAP
DailyMinimum
FiO
2
≥2-dayperiodof
worsening in the MAP
parameter with an
increase of ≥ 4 cm H
2O
ver the baseline period is
not identified
1 13 60
2 10(7) 40
3 10(7) 40 o
4 12
5 12 50
6 10 40
7 8 40
8 8 40
APedVAEis NOTidentified
Remember–forpatients≥30days,aMAPof1-10 areequalto10

41. 65
VentDay
DailyMinimum
MAP
DailyMinimum
FiO
2
≥2-dayperiodof
worsening in the MAP
parameter with an
increase of ≥ 4 cm H
2O
overthefirstdayinthe
aselineperiod–10to 14
1 13 60
2 10(7) 40
3 10(7) 40
4 14
b
5 14 50
6 10 40
7 8 40
8 8 40
APedVAEisidentified
Patients≥30days–MAPvaluesof1-10areequalto10

42. DateofEvent
▪Thedateof onsetofworseningoxygenation (day 1of the
required≥ 2-day periodof worseningoxygenation followinga
≥2-dayperiodofstability orimprovementonthe ventilator)
–EarliestdateofeventforVAEismechanicalventilationday3 (firstday
ofworseningoxygenation)
–FirstpossibledaythatPedVAEcriteriacanbefulfilledismechanical
ventilationday4

43. DateofEventcontinued
▪Setsthe14-day PedVAEEventPeriod
–EachPedVAEis14 daysinduration(arbitrary—tostandardize).
–TheDateofEventisday1 of thePedVAEEventPeriod.So,forexample,
ifJune1isthedateof onsetof worseningoxygenationandaPedVAEis
reported,asecondPedVAEcannotbedetectedandreporteduntil
June15.
▪Definesthe periodduringwhichtheantimicrobialand
pathogen optional questionsapply

44. ReportingException relatedtoDateof Event
▪Ifthedateof event(dateofonsetofworsening oxygenation)ison
orafterthedateofdocumentationofevidenceofconsentANDthe
patient is being supported for organ donation purposes, the event
shouldnotbereportedasaPedVAE.

45. 65
50
40
VentDay MAPmin FiO
2min
1 13 60
2 8(7) 40
3 8(7) 40
4 12
EventDate =VentDa
y4(firstday
of genation)
isVent Day 4–
17
5 12 worseningoxy
6 10
14Dayeventperiod
VentDay
7 8 40
8 8 40
OperationalizingPedVAE–DateofEvent
(patientis<30days)

46. PedVAEDataCollectionandReporting

47. DenominatorData
≤750g 751-1000g1001-1500g1501-2500g >2500g
Extremelypreterm
(<28weeks)
Very preterm
(28to<32weeks)
Moderatetolate
preterm
(32to<37weeks)
Term
(≥37weeks)
▪PatientDays(required)
▪VentilatorDays(required)
▪NICUdenominatordata(patientdaysand ventilatordays)
–NICUBirthweight(required)
–NICUGestationalAge (optional)
▪EpisodesofMechanicalVentilation(optional)

48. https://www.cdc.gov/nhsn/pedvae-calculator/index.html

52. Enterthe dateof mechanicalventilation initiation
andrespondtothedayof lifequestion.
ThisallowsthecalculatortodeterminewhichDaily
MinimumMAPvalueinterpretationtouseonthe
nextscreen.
ClickNEXT.

53. PedVAECalculator
▪Notethepatientis<30
daysonMechanical
VentilationStartDate
–the agecategory and
dayoflifearenotable
tobeeditedonthis
screen
▪Enter the Daily Minimum
Values and click on
Calculate PedVAE.

54. ▪The Calculator interprets MAP
values of 0-8 cmH
2O as equal
to8 cmH
2Osincethepatient<
30 days
▪APedVAEisidentified

55. ▪TheCalculatorinterpretsMAPvalues
of0-10cmH
2Oasequalto10cmH
2O
sincethepatient≥30days
▪NoPedVAEisdetectedbecausethe
increaseoverthebaseline(10)isnot
≥4cmH
20
▪SelectExplainbutton forfurther
explanation