ABSTRACT
PURPOSE: The purpose of this study was to confirm the compliance of the application of a ventilator-associated pneumonia bundle and understand its effects on the decrease in the incidence of ventilator-associated pneumonia. METHODS: This was a retrospective observational study with history control group design. Subjects were selected from January to June 2014, prior to the intervention using the ventilator-associated pneumonia bundle. Subjects were also selected from October 2014 to March 2015, 3 months after the intervention. The number of subjects was 112 before the intervention, and 107 after the intervention. RESULTS: The number of nurses who followed the bundles increased from 8 out of 29 (27.6%) before the intervention to 19 out of 29 (65.5%) after the intervention (odd ratio=4.99, confidence interval=1.63–15.25, p=.004). There were 3 cases of ventilator-associated pneumonia before the intervention and 1 case after the intervention. The ventilator days were 2,143 days before the intervention and 2,232 days after the intervention. The ventilator-associated pneumonia rate of the 1,000 ventilator days was 1.40 before the intervention and decreased to 0.45 after the intervention. CONCLUSION: This study is meaningful, as there has been little research conducted regarding the application of the ventilator-associated pneumonia bundle in South Korea.
Subject(s)
Compliance , Critical Care , Incidence , Infection Control , Intensive Care Units , Korea , Observational Study , Pneumonia, Ventilator-Associated , Retrospective Studies , Ventilators, MechanicalABSTRACT
Objective To observe the impact of improving the compliance of ventilator bundle on morbidity of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients undergoing mechanical ventilation (MV) guided by context of Joint Commission International (JCI) settings, and to study the oral care efficacy of suction tube sponge brush. Methods A prospective study was conducted. The patients who needed MV admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Xiamen University from January 2013 to December 2016 were enrolled. In the context of JCI settings, necessary measurements were taken to enhance the compliance of ventilator bundle each year. In 2013, the preventive measures were set up and the education was strengthened. In 2014,the compliance of hand hygiene and bedside elevation was strengthened. In 2015, a control study was conducted to evaluate the effect between the traditional cotton dipped in chlorhexidine and the suction tube sponge brush rinsed with chlorhexidine on oral health impact parameters. The suction tube sponge brush rinsed with chlorhexidine oral care was introduced to improve compliance. In 2016, electronic bundle checklist for daily self-audits was conducted. The annually morbidity of VAP through the software of hospital and ICU was collected and calculated. The annual incidence of VAP was indicated by the VAP cases per 1000 MV days. Based on the VAP incidence rate in 2013 as 1, the VAP incidence-rate ratio (IRR) of each year was calculated. Results During the study period, a total of 2733 patients admitted to the ICU, including 1403 patients undergoing MV. Ninety-four of the 1403 patients with community-acquired pneumonia (CAP), aspiration pneumonia, back elevation ban, incomplete information, and withdrew from the study were excluded. 1399 patients undergoing MV were enrolled in the final analysis, with total MV days of 11012 days, and 94 patients occurred VAP. The annual incidence of VAP was progressively declined from 2013 to 2016, and the VAP cases per 1000 MV days were 17.0, 10.0, 5.9, 3.5 cases, respectively. Based on the VAP incidence rate in 2013, the IRR of VAP from 2014 to 2016 was also progressively declined, which was 0.59 [95% confidence interval (95%CI) = 0.35-0.98], 0.35 (95%CI = 0.18-0.64), and 0.21 (95%CI = 0.09-0.41), with statistical significance (all P 0.05). Conclusion Ventilator bundle can effectively reduce the morbidity of VAP in the context of JCI settings, and the oral care by using suction tube sponge brush and chlorhexidine can effectively improve oral hygiene.
ABSTRACT
ObjectiveTo compare the sedative effect and safety of dexmedetomidine and midazolam in the intensive care unit (ICU) patients undergoing ventilator bundle treatment.MethodsA prospective single-blind randomized controlled trial (RCT) was conducted. Ninety patients receiving ICU ventilator-assisted therapy and ventilator bundle treatments for more than 3 days in the First Department of Critical Care Medicine of the Second Hospital of Lanzhou University from January 2013 to December 2014 were enrolled. The patients were randomly divided into two groups for sedative treatment. The patients in dexmedetomidine group (n = 42) were given dexmedetomidine 0.2-0.7μg·kg-1·h-1 to achieve a goal of satisfactory sedation [Richmond agitation-sedation scale (RASS) score 0 to - 2 during the day, and -1 to -3 at night). The patients in midazolam group (n = 48) were given midazolam 2-3 mg intravenously first, and then 0.05 mg·kg-1·h-1 for maintenance. The drug dose was adjusted according to RASS every 4 hours to maintain the appropriate sedation depth. The patients in both groups received continuous intravenous infusion of fentanyl for analgesia. Ventilator bundle treatments included the head of a bed up 30°to 45°, awaken and extubation appraisal, daily use of proton pump inhibitors for peptic ulcer prevention, prevention of deep vein thrombosis (DVT), chlorhexidine mouth nursing, and removal of sputum by suction from subglottic area. When the patients in both groups obtained satisfactory target sedation, daily awakening was conducted, and spontaneous breathing test (SBT) was carried out to determine optional weaning time. When the condition was optimal, weaning was conducted, otherwise ventilator bundle treatments were continued. The systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), respiratory frequency (RR) were monitored before and 15, 30, 60, 120, 180 minutes after the treatment, and at the moment of extubation and 30 minutes after extubation. The duration of mechanical ventilation, extubation time, length of ICU stay, and the incidence of adverse events were also recorded. Results Both dexmedetomidine and midazolam could give rise to sedation with same score of analgesia in patients in both groups, and similar effect of sedation and analgesia could be achieved. Compared with midazolam, dexmedetomidine could significantly reduce the duration of mechanical ventilation (hours: 108.33±21.96 vs. 119.85±20.29,t = -2.586, P = 0.011), earlier extubation time (hours: 112.95±22.20 vs. 128.58±26.18,t = -3.031,P = 0.003), length of ICU stay (hours: 149.21±20.47 vs. 163.88±33.59,t = -2.457,P = 0.016), the incidence of delirium [9.5% (4/42) vs. 31.2% (15/48),χ2 = 6.349,P = 0.012], but it would elevate the incidence of severe hypotension [28.6% (12/42) vs. 8.3% (4/48),χ2 = 6.277,P = 0.012] and severe bradycardia [19.0% (8/42) vs. 8.3% (4/48),χ2 = 2.225,P = 0.136]. Both drugs could lower SBP, DBP, MAP, and HR, and the effect in dexmedetomidine group was more significant from 60 minutes after treatment [SBP (mmHg, 1 mmHg = 0.133 kPa): 113.12±14.42 vs. 124.40±15.79, DBP (mmHg): 69.02±9.62 vs. 76.94±10.41, MAP (mmHg): 83.76±10.50 vs. 92.77±11.87, HR (bpm): 79.19±12.28 vs. 87.42±17.77,P< 0.05 orP< 0.01]. Both sedatives could significantly lower the rate of spontaneous breathing, and the effect of midazolam group was more significant from 60 minutes after treatment compared with dexmedetomidine group (times/min: 18.27±4.29 vs. 20.07±4.11,P< 0.05).Conclusions The sedative effects of dexmedetomidine in the ICU patients treated with ventilator bundle treatment are satisfactory, and it can shorten the duration of mechanical ventilation, extubation time and length of ICU stay, reduce the incidence of delirium. However, monitoring should be strengthened in order to prevent and control the adverse effects such as severe hypotension and severe bradycardia.