VAP BUNDLE, VENTILATOR ASSOCIATED PNEUMONIA BUNDLE

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"isagroupofevidence-
basedcarecomponentsforagiven
diseasethat,whenexecuted
together,mayresultinbetter
outcomesthanifimplemented
individually.

3. Bundles
In a bundle, the individual elements are built
around best evidence-based practices.
Thesciencesupportingtheindividual
treatmentstrategiesinabundleissufficiently
maturesuchthatimplementationofthe
approachshouldbeconsideredeitherbest
practiceorareasonableandgenerally
acceptedpractice.

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 48h 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 >10×10
9
/L orleucopeniaWBC
<3×10
9
/L.
(5)Tenleucocytesper 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
•Theuseoftheoralantisepticchlorhexidine
gluconatehasbeendefinitivelydemonstrated
tobeaneffectiveVAPpreventionstrategy,
anditsusehasbeenadvocatedinthemost
recentevidence-basedVAPpreventionclinical
practiceguidelines.Furthermore,safety,
feasibility,andcostconsiderationsforthis
interventionareallveryfavorable.

10. •Provideendotrachealtubeswithsubglottic
secretiondrainageportsforpatientslikelyto
requiregreaterthan48or72hoursof
intubationhelpsinpreventionofVAP.
•Extubatingpatientstoplaceasubglottic
secretiondrainageendotrachealtubeisnot
recommended.

11. Subglottic suction

12. GASTROINTESTINAL PROPHYLAXIS
ThisisnotaspecificstrategyforVAPprevention.It
wasincludedintheVentilatorBundleasastrategyto
preventstressrelatedmucosaldisease,as
mechanicalventilationisasignificantriskfactor.
Aprospectivemulticentercohortstudyevaluated
potentialriskfactorsforstressulcerationinICU
patientsanddocumentedtheoccurrenceofclinically
importantgastrointestinalbleeding

13. DVT PROPHYLAXIS
•Includedeepvenousprophylaxisaspartofyour
ICUorderadmissionsetandventilatororderset.
•Similartostressulcerprophylaxis,DVT
prophylaxishasnotbeendemonstratedto
reducetheriskofVAP.Itremainspartofthe
VentilatorBundleinordertopreventother
seriouscomplicationsthatcouldincreasethe
morbidityandmortalityofthesepatientsand
shouldberetained

15. HEAD OF BED ELEVATION
•Thesemirecumbentposition,achievedby
elevationoftheheadofthebed,isanintegral
portionoftheVAPbundle.Ithasbeen
speculatedthatthesemirecumbentposition
maydecreaseVAPbyreductionin
gastroesophagealrefluxandsubsequent
aspirationofgastrointestinal,oropharyngeal,
andnasopharyngealsecretions.

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
•Implementaprotocoltolightensedationdailyat
anappropriatetimetoassessforneurological
readinesstoextubate.
–Includeprecautionstopreventself-extubationsuch
asincreasedmonitoringandvigilanceduringthetrial.
•Includeasedationvacationstrategyinoverall
plantoweanthepatientfromtheventilator.
‘Sedationvacations’areanintegralcomponentof
theVAPbundleandcanhavemajorimplications
inthatpatientswhoareextubatedearlyareat
decreasedriskofVAP.

18. •Mostrecently,aprotocolthatpairs
spontaneousawakeningtrials(SATs),thatis,
dailyinterruptionofsedatives,withSBTshas
beenconfirmedtobeeffective.

19. Thanks for listening….