Ventilator-associated Complications Research Articles

Assisted Breathing with a Diaphragm Pacing System: A Systematic Review.

PurposePatients with respiratory failure associated with neurological dysfunction often require mechanical ventilator support, which poses increased economic burden and ventilator-associated complications. A diaphragm pacing system (DPS) is an implanted device that provides respiratory support for such patients. In this systematic review, we reviewed the literature to assess the safety and efficacy of DPS for patients with respiratory failure resulting from amyotrophic lateral sclerosis (ALS) or cervical spinal cord injuries.Materials and MethodsThe following databases were searched from July 10 to July 30, 2018: MEDLINE, EMBASE, Cochran library, KoreaMed, Research Information Sharing Service, Korean studies Information Service System, Korea Institute of Science and Technology Information, and Korean Medical database. The abstracts and full texts of the searched articles were reviewed by two reviewers.ResultsThe search keywords generated 197 articles: two randomized controlled trials, two case-control studies, and one case report involving patients with ALS; one cohort study, one case-control study, and two case reports involving patients with cervical spine injury; and one case report involving patients with both conditions were included. The primary outcome was safety profile (complications and adverse event) and efficacy (overall survival and sleep improvement). Complications and adverse events were more common in patients with ALS and spinal cord injury receiving DPS than in controls. Efficacy outcomes were inconsistent across ALS studies.ConclusionBased on safety and efficacy results, we do not support using DPS to manage respiratory failure in patients with ALS or cervical spine injury.

Assessment of Ventilator-Associated Events and Compliance Rate of Ventilator Care Bundle among Mechanically Ventilated Patients in Neuro Intensive Care Units

Ventilator-associated events (VAEs) consist of ventilator-associated conditions (VAC), infection-related ventilator-associated complications (IVAC), and possible ventilator-associated pneumonia (VAP). A descriptive survey was conducted to assess VAEs, and the compliance rate of ventilator care bundle among mechanically ventilated patients in neuro intensive care units of a tertiary care hospital. The study was done in 2016 with a sample size of 30. A standardised tool, CDC’s VAE algorithm and a validated, structured ventilator care bundle guidelines observational check-list were used for collecting data. Assessments were done twice daily for seven days. Only one patient each (3%) developed VAC, and IVAC and none had developed VAP. The samples were not fully compliant with all elements of ventilator care bundle all the time. However, the head of bed elevation compliance was 100 percent. The rest of the bundle elements compliance were: deep vein thrombosis (DVT) prophylaxis 93 percent, peptic ulcer disease (PUD) prophylaxis (94%), sedation break (74%), hand hygiene (78%) and oral care (61%). Further, large sample studies are needed to identify predictors of VAEs.

Protocol for a multi-centered, stepped wedge, cluster randomized controlled trial of the de-adoption of oral chlorhexidine prophylaxis and implementation of an oral care bundle for mechanically ventilated critically ill patients: the CHORAL study

BackgroundRoutine application of chlorhexidine oral rinse is recommended to reduce risk of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Recent reappraisal of the evidence from two meta-analyses suggests chlorhexidine may cause excess mortality in non-cardiac surgery patients and does not reduce VAP. Mechanisms for possible excess mortality are unclear. The CHORAL study will evaluate the impact of de-adopting chlorhexidine and implementing an oral care bundle (excluding chlorhexidine) on mortality, infection-related ventilator-associated complications (IVACs), and oral health status.MethodsThe CHORAL study is a stepped wedge, cluster randomized controlled trial in six academic intensive care units (ICUs) in Toronto, Canada. Clusters (ICU) will be randomly allocated to six sequential steps over a 14-month period to de-adopt oral chlorhexidine and implement a standardized oral care bundle (oral assessment, tooth brushing, moisturization, and secretion removal). On study commencement, all clusters begin with a control period in which the standard of care is oral chlorhexidine. Clusters then begin crossover from control to intervention every 2 months according to the randomization schedule. Participants include all mechanically ventilated adults eligible to receive the standardized oral care bundle. The primary outcome is ICU mortality; secondary outcomes are IVACs and oral health status. We will determine demographics, antibiotic usage, mortality, and IVAC rates from a validated local ICU clinical registry. With six clusters and 50 ventilated patients on average each month per cluster, we estimate that 4200 patients provide 80% power after accounting for intracluster correlation to detect an absolute reduction in mortality of 5.5%. We will analyze our primary outcome of mortality using a generalized linear mixed model adjusting for time to account for secular trends. We will conduct a process evaluation to determine intervention fidelity and to inform interpretation of the trial results.DiscussionThe CHORAL study will inform understanding of the effectiveness of de-adoption of oral chlorhexidine and implementation of a standardized oral care bundle for decreasing ICU mortality and IVAC rates while improving oral health status. Our process evaluation will inform clinicians and decision makers about intervention delivery to support future de-adoption if justified by trial results.Trial registrationClinicalTrials.gov, NCT03382730. Registered on December 26, 2017.

547. Multidrug-Resistant Pseudomonas aeruginosa in an Academic Regional Burn Intensive Care Unit

Background Pseudomonas aeruginosa infection can lead to morbidity, mortality and increased hospital length of stay especially in Burn Intensive Care Units (BICU) patients. Reports of multi-drug-resistant Pseudomonas aeruginosa outbreaks in the BICU are increasing. We investigated the epidemiology of Carbapenem-Resistant Pseudomonas aeruginosa (CRPA) in our BICU.MethodsClinical and laboratory characteristics of all CRPA isolates identified between 5/8/16 and 3/14/19, in an 11-bed BICU in an academic 870-bed public safety-net hospital were reviewed and defined as Meropenem MIC 4 or greater. Retained isolates were sent for pulse-field gel electrophoresis (PFGE). Infection prevention (IP) observations and interventions were intensified and environmental cultures were collected. Patient charts were reviewed.Results27 patients between ages 5–61 years old were found to have CRPA (only 2 patients < 18 years). 21/27 (77.7%) were male. 21/27 (77.7%) had >40% total body surface area (TBSA) burns, 3/27 (11.1%) had 20–39% TBSA burn and 1/27 (3.7%) had < 20% TBSA burn. 19/27 (70.3%) patients had bacteremia, 6 had respiratory infections with 3 (11.1%) Infection-related Ventilator-Associated Complications (IVAC), 3 had urinary tract infection, and 1 had CRPA from a central venous catheter tip. There were very few co-morbidities. Twenty isolates from 11 different patients were typed and revealed 2 different clonal strains. 5/11 (45%) patients had strain A, and 2/11 (18%) patients had strain B. 3/11 (27.2%) patients had unique strains. CRPA was isolated from 5 different rooms. Water cultures did not reveal CRPA. Failure of hand hygiene, non-adherence to isolation/PPE protocols and clutter were found. Each failure was corrected. No new CRPA patient isolates have been identified.ConclusionTransmission was halted by reinforcement of IP measures. Importantly water was not a source of CRPA in this setting and the data suggest transmission due to environmental contamination.DisclosuresTrish M. Perl, MD; MSc, 7–11: Advisory Board; medimmune: Research Grant

Nested case-control study on paediatric early warning score and ventilator-associated complications in children with acute respiratory distress syndrome

To explore the relationship between paediatric early warning score (PEWS) and the occurrence of mechanical ventilation complications in children with acute respiratory distress syndrome (ARDS). Methods: A total of 110 children with ARDS diagnosed in First Affiliated Hospital of Hebei North University, who underwent mechanical ventilation, were selected. The baseline data, blood gas analysis index, laboratory test index, ventilator parameters, pediatric critical illness score (PCIS) and PEWS in the children were recorded. With reference to ventilatory treatment results, the children with ventilator-associated complications were included in the trial group (n=20), while the patients with good cohort status were included in the control group (n=40) according to the nested case-control study. Independent sample t-test and multivariate logistic regression analysis were used to analyze the factors affecting the occurrence of complications after ventilatory treatment. Results: There were statistically significant differences in multiple organ dysfunction syndrome (MODS), partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2), partial pressure of carbon dioxide (PaCO2), serum creatinine (SCr), albumin (ALB), blood urea nitrogen (BUN), mechanical ventilation time, mean article pressure (MAP), tidal volume (VT), positive end-expiratory pressure (PEEP), PCIS, PEWS between the control group and the experimental group (all P<0.05). Multivariate logistic regression analysis showed that MODS, PaO2/FiO2, PaCO2, VT, PEEP and PEWS had influence on complications after mechanical ventilation in children with ARDS (all P<0.05). Conclusion: The MODS, PaO2/FiO2, PaCO2, VT, PEEP, and PEWS exert effects on complications after mechanical ventilation in children with ARDS. PEWS combined with other indicators can assess the risk of complications in children with ARDS after mechanical ventilation.

Comparison of ventilatory modes to facilitate liberation from mechanical ventilation: protocol for a systematic review and network meta-analysis

IntroductionTimely liberation from invasive mechanical ventilation is important to reduce the risk of ventilator-associated complications. Once a patient is deemed ready to tolerate a mode of partial ventilator assist, clinicians...

Factors associated with ventilator-associated events: an international multicenter prospective cohort study.

A secondary analysis of a prospective multicenter cohort was performed in six intensive care units (ICU) in four European countries (France, Greece, Spain and Turkey). The main objective was to identify factors associated with ventilator-associated events (VAEs) in adults who underwent mechanical ventilation (MV) ≥ 48h. Secondary objectives were to identify: variables influencing VAE in the subpopulation with endotracheal intubation and in those subjects who were ventilated > 7days. Subjects who had undergone MV ≥ 48h were included. In subjects with multiple episodes of MV, only the first one was eligible. The adult definitions for VAEs were adjusted to the 2015 update of the CDC's 2013 National Healthcare Safety Network Association. Factors associated with VAE were estimated through multivariate Cox proportional hazards analysis. Among 163 adults (42 tracheostomies), 76 VAEs (34.9VAEs/1,000ventilator-days) were documented: 9 were Ventilator-Associated Conditions (VAC) and 67 Infection-related Ventilator-Associated Complications (IVAC)-plus (9 only IVAC and 58 Possible Ventilator-Associated Pneumonia). VAEs developed after a median of 6days (interquartile range: 4-9). VAEs were independently associated with long-acting sedative/analgesic drugs (Hazard Ratio [HR]: 4.30), selective digestive decontamination (SDD) (HR: 0.38), and surgical/trauma admission (HR: 2.30). Among 116 subjects with endotracheal tube, SDD (HR: 0.21) and surgical/trauma admission (HR: 3.11) remained associated with VAE. Among 102 subjects ventilated >7days, only long-acting sedative/analgesic agents (HR: 8.69) remained independently associated with VAE. In summary, SDD implementation and long-acting analgesic/sedative agents restriction prescription may prevent early and late VAEs, respectively. Bundles developed to prevent VAEs should include these two interventions.

Fluid Overload and Kidney Injury Score as a Predictor for Ventilator-Associated Events.

Objective: The Pediatric and Neonatal Working group developed new ventilator associated events (VAE) definitions for children and neonates. VAE includes ventilator-associated condition (VAC), infection-related ventilator-associated complication (IVAC), and ventilator-associated pneumonia (VAP). Acute kidney injury (AKI) and fluid overload (FO) have been associated with worse clinical outcomes of ventilated children. Fluid Overload and Kidney Injury Score (FOKIS) is an automatically calculated score that combines AKI and FO in one numeric quantifiable metric. This study analyzed the association between FOKIS and VAE.Design: Retrospective matched case control study.Setting: A freestanding children's hospital.Patients: A total of 168 who were ventilated > 2 days.Interventions: None.Measurements and Main Results: We identified 42 VAC cases (18 IVAC and 24 non-infection-related VAC cases). Controls were matched to cases for age, immunocompromised status and ventilator days prior to VAC. VAC cases had longer ICU days, median (IQR), 28.5 (15, 47) vs. controls 11 (6, 16), p < 0.001; longer ventilation days, 19.5 (13, 32) vs. 9 (4,13), p < 0.001; and higher hospital mortality, 45.2 vs. 18%, p < 0.001. VACs had a higher incidence of AKI, 85.7 vs. 47.3%, p < 0.001; higher peak daily FO% within 3 days preceding VAC, mean (SD), 8.1(7.8) vs. 4.1 (3.4), p < 0.005; and higher peak FOKIS, 6.4(3.8) vs. 3.7(2.8), (p < 0.001). Multivariate regression model adjusted for severity of illness identified peak FOKIS (odds ratio [OR] 1.29, 95%CI: 1.14–1.48, p < 0.001) and peak inspiratory pressure (OR 1.08, 95%CI: 1.02–1.15, p = 0.007) as risk factors for VAC.Conclusions: The FOKIS and its clinical variables were associated risk factors for ventilator-associated events. Further studies will determine the utility of FOKIS as a predictor for VAEs.

Immediate extubation after heart transplantation in a child by remifentanil-based ultra-fast anesthesia

Rationale:Ventilator-associated complications comprise important fatal aetiologies during heart transplantation. Ultra-fast anesthesia might provide the most effective measure to prevent this type of complication. Immediate extubation after heart transplantation (IEAHT) has recently been reported in adult patients. However, IEAHT in children is much more challenging due to limitations in anesthesia protocols. Recently, we managed to perform an ultra-fast anesthesia protocol combined with IEAHT during a heart transplant operation in a child, who had an excellent postoperative outcome.Patient concerns:A 13-year-old girl had been diagnosed with dilated cardiomyopathy 5 years before this case, due to intractable dyspnoea and cough. She received multiple medical treatments after diagnosis, with minimal effects. Physical examination findings included a bulge in her left chest and pitting edema over both legs. Moist rales could be heard in the lung. Echocardiography revealed very large heart chambers, with an ejection fraction of 17%.Diagnosis:The patient was diagnosed with dilated cardiomyopathy and scheduled to undergo an emergent operation for heart transplantation.Interventions:The patient underwent an ultra-fast anesthesia protocol and ultra-fast reversal during heart transplantation. General anesthesia was induced with etomidate, fentanyl, and vecuronium; it was then maintained with remifentanil-based total intravenous anesthesia.Outcomes:Immediately after the end of the operation, the patient was brought to consciousness with stable breathing and haemodynamics. The patient was successfully extubated on the operating table and transferred to the intensive care unit with spontaneous breathing, without postoperative mechanical ventilation. The recovery period was uneventful and the patient was discharged 1 month later without complications.Lessons:Our experience, in this case, revealed that IEAHT in children is achievable if the ultra-fast protocol is performed properly and carefully, in order to prevent ventilator-associated complications.

Pediatric Ventilator-Associated Events: Analysis of the Pediatric Ventilator-Associated Infection Data.

To compare the prevalence of infection applying the proposed pediatric ventilator-associated events criteria versus clinician-diagnosed ventilator-associated infection to subjects in the pediatric ventilator-associated infection study. Analysis of prospectively collected data from the pediatric ventilator-associated infection study. PICUs of 47 hospitals in the United States, Canada, and Australia. Two-hundred twenty-nine children ventilated for greater than 48 hours who had respiratory secretion cultures performed to evaluate for suspected ventilator-associated infection. None. Applying the proposed pediatric ventilator-associated event criteria, 15 of 229 subjects in the ventilator-associated infection study qualified as "ventilator-associated condition" and five of 229 (2%) met criteria for "infection-related ventilator-associated complication." This was compared with 89 of 229 (39%) diagnosed as clinical ventilator-associated infection (Kappa = 0.068). Ten of 15 subjects identified as ventilator-associated condition did not meet criteria for infection-related ventilator-associated complication primarily because they did not receive 4 days of antibiotics. Ventilator-associated condition subjects were similar demographically to nonventilator-associated condition subjects and had similar mortality (13% vs 10%), PICU-free days (6.9 ± 7.7; interquartile range, 0-14 vs 9.8 ± 9.6; interquartile range, 0-19; p = 0.25), but fewer ventilator-free days (6.6 ± 9.3; interquartile range, 1-15 vs 12.4 ± 10.7; interquartile range, 0-22; p = 0.04). The clinical ventilator-associated infection diagnosis in the ventilator-associated infection study was associated with fewer PICU-free days but no difference in mortality or ventilator-free days. The ventilator-associated event criteria appear to be insensitive to the clinical diagnosis of ventilator-associated infection. Differentiation between ventilator-associated condition and infection-related ventilator-associated complication was primarily determined by the clinician decision to treat with antibiotics rather than clinical signs and symptoms. The utility of the proposed pediatric ventilator-associated event criteria as a surrogate for ventilator-associated infection criteria is unclear.

2105. Electronic Records of Daily Subglottic Suctioning Predict Infectious and Non-infectious Adverse Ventilator-Associated Events During Critical Care

BackgroundMechanical ventilation is a life-sustaining therapy for critically ill patients, but is associated with increased hospital costs and risk for significant complications with poor outcomes. Adverse ventilator-associated events (VAEs) can be broadly divided into infectious (infectious ventilator-associated complication (IVAC) or ventilator-associated pneumonia (VAP)) and non-infectious (ventilator-associated complication (VAC)) types. We sought to identify factors that predict both types, and factors that discriminate risk for infectious vs. noninfectious VAE, using electronic medical record (EMR) data available prior to index event.MethodsWe evaluated 90 consecutive adverse VAEs in the medical intensive care unit of an academic medical center (January 1, 2013–June 30, 2016) to determine prior patient and care factors that discriminate risk for incident VAE. VAE were defined by surveillance criteria from the CDC. Patient and care data were extracted via the EMR.ResultsA generalized linear mixed effects model found an increase of 1.1 (95% CI 0.53–1.7) subglottic suction events per day (SS/day) on the day before VAE diagnosis, relative to the 4 prior days. Of the 90 VAE included in the study, 41 were infectious (IVAC or VAP), and 49 were labeled ventilator-associated condition (VAC). In the IVAC/VAP group, mean SS/day was 8.0 on the day of VAE diagnosis, 7.5 one day prior, and 6.2 two days prior, compared with 6.6, 6.4, and 5.5 SS/day in the VAC group. Change in antibiotic prescription (87.8% (36) of patients in the IVAC/VAP group vs. 46.9% (23) in the VAC group) (P = 0.023) and acute liver injury (mean AST and ALT 52.9 and 43.6 3 days before IVAC/VAP vs. 1,035.4 and 523.9 before VAC) also differed between the groups (P = 0.0095 and 0.0025).ConclusionIncreased daily subglottic suctioning predicts both non-infectious and infectious VAE, but the observed increase is greater prior to IVAC/VAP. Change in antibiotic prescription and acute liver injury also discriminated IVAC/VAP from non-infectious VAE in this small cohort.Disclosures All authors: No reported disclosures.

Using Objective Fluid Balance Data to Identify Pulmonary Edema in Subjects With Ventilator-Associated Events

A ventilator-associated events (VAEs) algorithm was developed to detect events in mechanically ventilated subjects using objective parameters, and we aimed to use objective data of fluid balance to identify pulmonary edema-associated VAEs. This single-center retrospective cohort study was conducted in a medical ICU and enrolled all mechanically ventilated patients between July 2016 and June 2017. Electronic medical records were reviewed to obtain data regarding ventilator-associated conditions (VACs), infection-related ventilator-associated complications (IVACs), possible ventilator-associated pneumonia (VAP), and traditionally defined VAP. Of the 1,158 mechanically ventilated subjects, 85 (7.3%) subjects developed VAEs with a corresponding incidence rate of 7.7 events per 1,000 ventilator days. Among the 85 subjects with VAEs, 52 (61.2%) were classified as IVACs, while 23 (27.1%) had possible VAP. Notably, pulmonary edema was the main etiology (29.0%) for VAEs in the 62 subjects with non-possible VAP VAEs. Compared with those without pulmonary edema, subjects with pulmonary edema had a higher positive fluid balance 2 d before (+1,228 vs +173.5 mL, P = .005) and 1 d before (+1,622 vs +313 mL, P = .002) the diagnosis of VAE. In the multivariate logistic regression analysis (adjusted odds ratio [OR]) adjusted for potential confounders, an older age (adjusted OR 1.072, 95% CI 1.001-1.147), receiving renal replacement therapy (adjusted OR 8.906, 95% CI 1.454-54.558), and a positive cumulative difference between fluid balance 2 d and 1 d before VAE indexing (adjusted OR 1.527 per L positive, 95% CI 1.153-2.023) were independently associated with pulmonary edema in subjects with VAEs. These findings provide epidemiological evidence of VAEs in a medical ICU and showed that fluid balance may be used to identify pulmonary edema-associated VAEs. Further studies are warranted to validate and translate these findings into an automated surveillance system for VAEs.

Correction to: Infection-related ventilator-associated complications in ICU patients colonised with extended-spectrum β-lactamase-producing Enterobacteriaceae.

The members of the OUTCOMEREA Study Group were provided in such a way that they could not be indexed as collaborators on PubMed. The publisher apologizes for this error and is pleased to list the members of the group here.

Ventilator Bundle Compliance and Risk of Ventilator-Associated Events.

OBJECTIVEVentilator bundles encompass practices that reduce the risk of ventilator complications, including ventilator-associated pneumonia. The impact of ventilator bundles on the risk of developing ventilator-associated events (VAEs) is unknown. We sought to determine whether decreased compliance to the ventilator bundle increases the risk for VAE development.DESIGNNested case-control study.SETTINGThis study was conducted at 6 adult intensive care units at an academic tertiary-care center in Tennessee.PATIENTSIn total, 273 patients with VAEs were randomly matched in a 1:4 ratio to controls by mechanical ventilation duration and ICU type.METHODSControls were selected from the primary study population at risk for a VAE after being mechanically ventilated for the same number of days as a specified case. Using conditional logistic regression analysis, overall cumulative compliance, and compliance with individual components of the bundle in the 3 and 7 days prior to VAE development (or the control match day) were examined.RESULTSOverall bundle compliance at 3 days (odds ratio [OR], 1.15; P=.34) and 7 days prior to VAE diagnosis (OR, 0.96; P=.83) were not associated with VAE development. This finding did not change when limiting the outcome to infection-related ventilator-associated complications (IVACs) and after adjusting for age and gender. In the examination of compliance with specific bundle components increased compliance with chlorhexidine oral care was associated with increased risk of VAE development in all analyses.CONCLUSIONSVentilator bundle compliance was not associated with a reduced risk for VAEs. Higher compliance with chlorhexidine oral care was associated with a greater risk for VAE development.Infect Control Hosp Epidemiol 2018;39:637-643.

Infection-related ventilator-associated complications in ICU patients colonised with extended-spectrum β-lactamase-producing Enterobacteriaceae.

To investigate the clinical significance of infection-related ventilator-associated complications (IVAC) and their impact on carbapenem consumption in mechanically ventilated (MV) patients colonised with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE). Inception cohort study from the French prospective multicenter OUTCOMEREA database (17 ICUs, 1997-2015) including all ESBLE carriers (systematic rectal swabbing at admission then weekly and/or urinary or superficial surgical site colonisation) with MV duration > 48h and ≥ 1 episode of IVAC after carriage documentation. All ICU-acquired infections were microbiologically documented. The 318 enrolled ESBLE carriers (median age 68years; males 67%; medical admission 68%; imported carriage 53%) experienced a total of 576 IVAC comprising 361 episodes (63%) without documented infection, 124 (21%) related to infections other than ventilator-associated pneumonia (VAP), 73 (13%) related to non-ESBLE VAP and 18 (3%) related to ESBLE VAP. Overall, ESBLE infections accounted for only 43 episodes (7%). Carbapenem exposure within the preceding 3days was the sole independent predictor of ESBLE infection as the causative event of IVAC, with a protective effect (adjusted odds ratio 0.2, 95% confidence interval 0.05-0.6; P < 0.01). Carbapenems were initiated in 9% of IVAC without infection, 15% of IVAC related to non-VAP infections, 42% of IVAC related to non-ESBLE VAP, and 56% of IVAC related to ESBLE VAP (ESBLE VAP versus non-ESBLE VAP: P = 0.43). IVAC in ESBLE carriers mostly reflect noninfectious events but act as a strong driver of empirical carbapenem consumption. ESBLE infections are scarce yet hard to predict, strengthening the need for novel diagnostic approaches and carbapenem-sparing alternatives.

Noninvasive ventilation in acute respiratory insufficiency

The use of noninvasive ventilation reduces ventilator-associated complications. Thus, the outcome of patients suffering from acute hypercapnic respiratory insufficiency as well as cardiogenic lung edema can be improved. For the use of noninvasive ventilation to be successful and safe, its correct application is pivotal.

Risk Factors for Ventilator-Associated Events in a PICU.

The term ventilator-associated events includes ventilator-associated condition, infection-related ventilator-associated complication, and ventilator-associated pneumonia. We sought to identify potential new risk factors for ventilator-associated condition and infection-related ventilator-associated complication in the PICU population. Matched case control study. Children's hospital at a tertiary care academic medical center. During the study period, 606 patients were admitted to PICU and ventilated more than 48 hours; 70 children met ventilator-associated condition criteria. None. We applied the definition for ventilator-associated condition (i.e., a sustained increase in ventilator settings after a period of stable or decreasing support) to our database. Within ventilator-associated condition cases, 40 cases were infection-related ventilator-associated complication and 30 cases were noninfectious-related ventilator-associated condition. We identified 140 controls and matched to ventilator-associated condition cases with regard to age, immunocompromised status, and ventilator days to event. Patients with ventilator-associated condition had longer ICU stay versus controls; 24 days median (12-43 interquartile range) versus 7 days (4-14); (p < 0.01), respectively, and longer duration of ventilatory support 17 days (10-32) versus 6 days (3-10); p < 0.01, respectively. Mortality was 22.8% in the ventilator-associated condition versus 9% in the control group (p < 0.01). A multivariate regression analysis adjusted for Pediatric Index of Mortality 2 identified mean peak inspiratory pressure and acute kidney injury to be associated with ventilator-associated condition (odds ratio, 1.12 [95% CI, 1.02-1.22] and odds ratio, 2.85 [1.43-5.66], respectively). Acute kidney injury and neuromuscular blockade in a multivariate regression analysis adjusted for Pediatric Index of Mortality 2 were associated with infection-related ventilator-associated complication (odds ratio, 2.36 [1.03-5.40] and 3.19 [1.17-8.68], respectively). There is an association between ventilator-associated condition and infection-related ventilator-associated complication in critically ill children with acute kidney injury, ventilatory support, and neuromuscular blockade. Attention should be given by clinical practitioners to recognize these modifiable risk factors and to implement strategies to decrease the prevalence of ventilator-associated events.

Update on ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is the most frequent life-threatening nosocomial infection in intensive care units. The diagnostic is difficult because radiological and clinical signs are inaccurate and could be associated with various respiratory diseases. The concept of infection-related ventilator-associated complication has been proposed as a surrogate of VAP to be used as a benchmark indicator of quality of care. Indeed, bundles of prevention measures are effective in decreasing the VAP rate. In case of VAP suspicion, respiratory secretions must be collected for bacteriological secretions before any new antimicrobials. Quantitative distal bacteriological exams may be preferable for a more reliable diagnosis and therefore a more appropriate use antimicrobials. To improve the prognosis, the treatment should be adequate as soon as possible but should avoid unnecessary broad-spectrum antimicrobials to limit antibiotic selection pressure. For empiric treatments, the selection of antimicrobials should consider the local prevalence of microorganisms along with their associated susceptibility profiles. Critically ill patients require high dosages of antimicrobials and more specifically continuous or prolonged infusions for beta-lactams. After patient stabilization, antimicrobials should be maintained for 7–8 days. The evaluation of VAP treatment based on 28-day mortality is being challenged by regulatory agencies, which are working on alternative surrogate endpoints and on trial design optimization.

Recent advances in surgical management of early lung cancer.

The broad application of low-dose computed tomography screening has resulted in the detection of many more cases of early lung cancer than ever before in modern history. Recent advances in the management of early-stage non-small cell lung cancer have focused on making therapy less traumatic, enhancing recovery, and preserving lung function. In this review, we discuss several new modalities associated with minimally invasive surgery for lung cancer. Firstly, less lung parenchyma resection via sublobar resection has become an acceptable alternative to lobectomy in patients with tumors less than 2cm in size or with poor cardiopulmonary reserve. Secondly, thoracoscopic surgery using a single-portal or needlescopic approach to decrease chest wall trauma is becoming common practice. Thirdly, less invasive anesthesia, using nonintubated techniques, is feasible and safe and is associated with fewer intubation- and ventilator-associated complications. Fourthly, preoperative or intraoperative image-guided localization is an effective modality for identifying small and deep nodules during thoracoscopic surgery.

Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events.

Ventilator-associated events are associated with increased mortality, prolonged mechanical ventilation, and longer ICU stay. Given strong national interest in improving ventilated patient care, the National Institute of Health and Agency for Healthcare Research and Quality funded a two-state collaborative to reduce ventilator-associated events. We describe the collaborative's impact on ventilator-associated event rates in 56 ICUs. Longitudinal quasi-experimental study. Fifty-six ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015. We organized a multifaceted intervention to improve adherence with evidence-based practices, unit teamwork, and safety culture. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. Each unit established a multidisciplinary quality improvement team. We coached teams to establish comprehensive unit-based safety programs through monthly teleconferences. Data were collected on rounds using a common tool and entered into a Web-based portal. ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of ventilator-associated event data. Compliance with all evidence-based interventions improved over the course of the collaborative. The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p = 0.007). During the same time period, infection-related ventilator-associated complication and possible and probable ventilator-associated pneumonia rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p = 0.018, p = 0.012), respectively. A multifaceted intervention was associated with improved compliance with evidence-based interventions and decreases in ventilator-associated event, infection-related ventilator-associated complication, and probable ventilator-associated pneumonia. Our study is the largest to date affirming that best practices can prevent ventilator-associated events.