Updates in preventative strategies in the ICU

Preventing Ventilator Associated Pneumonia (VAP)

• Traditionally ICUs use techniques such as head of bed elevation> 30 degrees, chlorhexidine mouth rinses, reduced sedation, and controlling cuff pressure between 20-30 cm H2O to reduce VAP
• A new trial confirms that subglottic suctioning also reduces VAP
• Endotracheal tubes are made with a suction line along the edge with fenestrations below the vocal cords and above the cuff
• This is hooked to wall suction removing secretions before they are aspirated
• VAP rates are very low in the US (most likely due to under-reporting)
• It is reported at around 15 VAPs/ 1000 ventilator days in Europe

The trial

• 5 ICUs in Belgium; 352 total patients with suctioning vs control were randomized
• Reduced incidence of confirmed VAP 9% vs 18%, decrease ventilator days 10 vs 20 and antibiotic use 7% absolute reduction

Bottom Line

• More expensive around $20 or more vs $1 for a regular ETT
• NNT around 11 to prevent one VAP: it is cost efficient
• Use them in patients who will remain intubated for > 48hrs (not elective surgical patients)

Daily bathing with chlorhexidine does not reduce health care associated infections

• It is believed that daily bathing with chlorhexidine antibiotic washes decrease rates of infection in the ICU; this is debatable

The trial

• One center, 5 ICUs, 9340 patients
• 10 week cleaning period followed by a two week washout then crossover to the alternate treatment (non-antibiotic washes)
• Looking for CLABSIs, CAUTIs, VAP and C. diff infections
• 55 infections occurred in the chlorhexidine group; 60 in the control goup.
• 2.86 per 1000 patient days (chlorhexidine group) vs 2.9 per 1000 patient days (control)

Bottom Line

• Does not appear to be helpful (perhaps specific patient groups such as bone marrow units may benefit)
• More expensive to use these washes and can lead to resistance
• Very well designed study with a variety of ICUs used (although one center)

References

Chlorhexidine Bathing and Health Care Associated InfectionsA Randomized Clinical Trial

Prevention of ventilator-associated pneumonia and ventilator-associated conditions: a randomized controlled trial with subglottic secretion suctioning*.