Ventilator-associated Conditions Research Articles

Application of ventilator-associated events (VAE) in ventilator-associated pneumonia (VAP) notified in Brazil (IMPACTO MR-PAV): a protocol for a cohort study

IntroductionCertain criteria for ventilator-associated events (VAE) definition might influence the type of an event, its detection rate and consequently the resource expenditure in intensive care unit. The Impact of Infections...

2420. Analysis of Diagnostic Criteria for ECMO-Associated Pneumonia

Abstract Background Ventilator-associated pneumonia (VAP) is a well-established cause of morbidity and mortality in critically ill patients, but diagnostic criteria exclude patients on extracorporeal membrane oxygenation (ECMO). Despite this, VAP has been used to approximate pneumonia in patients on ECMO for study purposes (Figure 1). An adequate definition to recognize and prevent nosocomial pneumonia in this population is needed. Our institution began looking at a set of diagnostic criteria for EAP (ECMO-Associated Pneumonia, Figure 2). We performed a retrospective analysis to test the validity of VAP and our new EAP definition as diagnostic criteria for pneumonia in ECMO patients.Figure 1.Criteria for Probable VAP. Simplified from NHSN criteria. VAC=ventilator-associated condition. iVAC=infection-related ventilator-associated condition. VAP=ventilator-associated pneumonia.Figure 2.Proposed diagnostic criteria for ECMO-associated pneumonia (EAP) Methods Our center maintains a database of clinical parameters for patients on ECMO, which includes outcomes of interest verified in real time. Patient charts coded as having an outcome of pneumonia from 2018 to 2021 were pulled and independently adjudicated to determine if they met our inclusion criteria (Figure 3). 20 patients were identified as having at least one event. We observed their stay on ECMO up to 30 days. We calculated the established VAP criteria (Figure 1) and our proposed EAP criteria (Figure 2) daily. Dates of clinical pneumonia were time of positive culture and subsequent 5 days.Figure 3.Selection process for study population. BAL=bronchoalveolar lavage Results 85% of patients were on VV ECMO and 50% patients with SARS-CoV-2 (Table 1). In 20 patients with clinically diagnosed, culture confirmed pneumonia, only 1% of patients met criteria for Probable VAP (sensitivity 4%, Table 2). Probable EAP Definition 2 was the most sensitive model for predicting clinical pneumonia (sensitivity 91.1%), followed distantly by the Confirmed EAP model (sensitivity 19.6%). The EAP model had a stronger relationship with clinical pneumonia than the VAP model as demonstrated by the ROC curves (Figure 4). Individual components (flow, sweep, FiO2, PEEP) could not predict onset of clinical pneumonia within 48 to 72 hours.Table 1.Characteristics of study population Table 2. Percentage of days with pneumonia as identified by each set of diagnostic criteria, with sensitivity calculated. Figure 4 ROC curves for comparison. Probable EAP Definition 2 had the highest sensitivity for diagnosing EAP. Conclusion Our study reiterates that VAP criteria should not be used to approximate diagnosis of pneumonia in patients on ECMO. As oxygenation and sepsis triggers adjustment of flow and sweep we found this in combination with infectious parameters, and BAL culture that was more sensitive in predicting clinical pneumonia. These measures require validation in a larger cohort. Disclosures James Kirklin, MD, Data Center for STS Intemacs/Pedimacs Registries: Director, partial salary support|Kirklin Solutions, Inc.: Ownership Interest

Prevalence of ventilator-associated events and antibiogram of bacterial isolates of ventilator-associated pneumonia in a tertiary care hospital of Uttarakhand.

Despite progress in diagnosing and managing ventilator-associated pneumonia (VAP), ongoing monitoring of ventilator-associated events (VAE) is crucial due to VAP's persistent prominence as the primary cause of Hospital-Acquired Infection (HAI) among Intensive Care unit patients. This study was done to illuminate the prevalence of VAE and antibiogram of bacterial isolates of VAP in a tertiary care hospital of Uttarakhand. This cross-sectional study focused on ICU patients. Adult patients ventilated for > 2 days were monitored daily, with VAE data analyzed using Center of Disease Control & Prevention (CDC) criteria. Specimens were sent to the Microbiology Department and cultured on Blood agar and MacConkey agar. Identification and antimicrobial profiles of isolates were determined using Vitek-2 Compact. 1220 ventilated individuals were assessed in total. VAE was diagnosed in 6.4% (78/1220) of the patients, the same later developed ventilator associated condition (VAC), 74 developed the infection-related VAC (IVAC), and 60 developed the possible/probable VAP (PVAP) among the 78 VAE cases. Klebsiella pneumoniae (35%), Acinetobacter baumannii (33%), and Pseudomonas aeruginosa (16%) were the most common isolated organisms. Colistin (57%) was the most effective against Klebsiella pneumoniae, followed by amikacin (28.5%) and trimethoprim+sulfamethoxazole (24%). Pseudomonas aeruginosa was most susceptible to imipenem (70%), meropenem, cefoperazone+sulbactam, and colistin (60%). Acinetobacter baumannii was most susceptible to colistin (85%), tigecycline (65%), and trimethoprim+sulfamethoxazole (25%). The most common cause of HAI is VAP. The purpose of this study is to determine the importance of starting suitable antibiotics early for prognosis and the difficulty of diagnosing VAP.

Assessment of changes in the national surveillance data for adult and pediatric VAE during the COVID-19 pandemic in hospitals

Background: Among US acute-care hospitals (ACHs) reporting to the NHSN, significant increases in the incidence of Ventilator-Associated Events (VAEs) were observed during the COVID-19 pandemic years in comparison with 2019. We assessed changes in the national event-level VAE data, including the incidence of specific event-types: Ventilator-Associated Condition (VAC), Infection-related Ventilator-Associated Complication (IVAC) and Possible Ventilator-Associated Pneumonia (PVAP). We also examined changes in associated pathogens, and we evaluated incidence density rates (IDRs) of pediatric VAE (PedVAE) before and during the pandemic years. Methods: We analyzed data on VAE and PedVAE reported to NHSN between 2019 through the second quarter of 2022 (2022Q2) in ACHs. Annual proportions of VAC, IVAC, or PVAP were calculated; changes versus 2019 were assessed. The 10 most common PVAP pathogens reported annually were examined, and the percentages and ranks for each were calculated. Among pediatric and neonatal locations, PedVAE IDR were calculated as the number of events per 1,000 ventilator days and were compared between the pre-pandemic and pandemic years. All comparisons were conducted using a mid-P exact test, and P<0.05 was considered statistically significant. Results: Between 1,266 - 1,357 ACHs reported VAE data each year. A total of 24,836 (2019), 37,592 (2020), and 50,362 (2021) VAEs were reported. The proportion of VAC events in 2020 (64.1%) was significantly higher than in 2019 (62.9%), while the 2020 and 2021 PVAP proportions (8.7% and 9.2%, respectively) were significantly lower than in 2019 (10.0%). The majority of VAEs were reported from the same location types annually. The top 3 PVAP pathogens reported for each year remained unchanged: Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella. However, the proportion identified as Haemophilus influenzae decreased significantly each year from 2019-2021, with the rank dropping from #5 in 2019 (6.6%) to #10 in 2021 (2.3%). Between 199 – 257 ACHs conducted PedVAE surveillance. PedVAE IDR were significantly lower in 2020 (0.8), 2021 (1.1), and the first half of 2022 (0.8) when compared to 2019 (1.3). Conclusions: This study provides a national view of specific VAEs before and during the COVID-19 pandemic. Some changes in the associated pathogens, and the proportions of VAC and PVAP, were observed. This study is the first to produce national benchmarks for PedVAE IDR. Additional ACHs conducting PedVAE surveillance in NHSN would improve the representativeness of our results.Disclosures: None

Ventilator associated events:incidence, microbiological profile and outcome in the intensive care unit in a tertiary hospital of eastern Nepal

Ventilator associated events (VAE) refer to new surveillance definition developed by Centre for Disease Control and prevention (CDC)/ National Healthcare Safety Network (NHSN) is in use since the year 2013, switching the focus of surveillance from ventilator associated pneumonia (VAP) to ventilator associated events (VAE). A number of studies have been conducted in the United States and other Western countries to evaluate its practicality. However, information on VAE in Asian countries is scarce. The purpose of this preliminary study was to illuminate the incidence and microbiological profile of VAEs in tertiary hospital in Nepal, as a first step in the effort to determine its practicality.The objective of the study was to determine the incidence, etiological agent and mortality of VAE in patients on mechanical ventilation in medical Intensive care unit (ICU) of a tertiary hospital. Patients admitted in ICU on Mechanical Ventilation were evaluated daily using the VAE surveillance criteria. At least 2 days of stable or decreasing ventilator settings followed by at least 2 days of increased ventilator settings was used as definition of VAE. Three tiered approach of VAE, namely Ventilator-Associated Condition (VAC), Infection-related Ventilator-Associated Complication (IVAC) and Possible VAP (PVAP) was used for the final classification of cases. Of the 313 patients admitted to the ICU over the period of one year, 52 patients received MV for ≥2 days and met baseline criteria for VAEs Surveillance. Out of 52 patients, 14(27%) developed VAC only, 13(25%) developed IVAC only and 25(48%) patients developed PVAP. Endotracheal aspirate culture was positive in 25 patients (48%). The organisms isolated 14(53.84%), 7(26.92%), 4(15.38%), and 1(3.84%). Polymicrobial growth was observed in one Almost all the isolates 25 (96%) being multidrug resistant. Overall mortality rate in patients with VAE was 36.5% with highest mortality rate in PVAP (44%). Early onset PVAP was observed in 9 (36%) where as 16 (64%) had late‑ onset VAP.VAE mostly being health care associated event and prevalence of multidrug resistance in as observed in this study warrant clinician to practices infection control measures and rationale use of antimicrobials as effective measures for infection control.

Evaluation of a Closed Suction System With Integrated Tube-Scraping Technology.

Endotracheal tube (ETT) scraping or sweeping refers to mucus removal from an ETT that can increase airway resistance. The study objective was to evaluate the effect of ETT scraping on the duration of mechanical ventilation, time to first successful spontaneous breathing trial (SBT), duration of hospital stay, and occurrence of ventilator-associated events (VAEs). This was a single-center, randomized clinical trial of adult subjects intubated between October 2019-October 2021. Subjects were randomly assigned to either ETT suctioning via a standard in-line suction catheter (control group) or ETT suctioning and scraping via a suction catheter with balloon-sweeping technology (experimental group). Airway suctioning was performed as clinically indicated, and the ETT was scraped every time a respiratory therapist suctioned the subject. The study outcome was duration of mechanical ventilation, time to first successful SBT, hospital length of stay, and VAE rate. Intent-to-treat statistical analysis was performed. Of 272 randomized subjects, the median age was 63 (interquartile range [IQR] 52-73) y; 143 (53%) were males, and 154 (57%) had a primary diagnosis of acute respiratory failure. There were no significant differences between the groups in median duration (h) of mechanical ventilation (72 [37-187] vs 70.6 [37-148], P = .58). There was no significant difference between the study groups in median time (h) to the first successful SBT (46.7 [IQR 30-87] vs 45.7 [IQR 27-95], P = .81), length of hospital stay (P = .76), the incidences of ventilator-associated conditions (P = .13), or infection-related ventilator-associated complications (P = .47). ETT suctioning plus scraping, compared to ETT suctioning alone, did not significantly improve the duration of mechanical ventilation, time to first successful SBT, length of hospital stay, and VAEs. These study findings do not support the routine use of ETT scraping for mechanically ventilated patients.

Association between cuffed tracheal tube use and reduced ventilator-associated pneumonia and conditions after elective cardiac surgery in infants and young children.

Ventilator-associated pneumonia (VAP) is a serious complication in children after cardiac surgery that may result from micro-aspiration. However, the current recommendation to use cuffed tracheal tubes (TTs) versus uncuffed TTs in children is still uncertain. Our main aim was to evaluate the incidence of VAP, ventilator-associated tracheobronchitis (VAT) and ventilator-associated conditions (VAC) in children up to five years old who underwent elective cardiac surgery. Single-center, prospective before-and-after study at a tertiary pediatric intensive care unit (PICU) in Italy. 242 patients (121 in each group) through the following periods: phase I (from Jan 2017 to 20th Feb 2018), during which children were intubated with uncuffed TTs; phase II (from 21th Feb 2018 to Feb 2019), during which children were intubated with cuffed TTs. Data were collected using an electronic dedicated database. Median age was five months. The use of cuffed tubes reduced the risk of VAC and VAP respectively 15.8 times (95% CI 3.4-73.1, P=0.0008) and 14.8 times (95% CI 3.1-71.5, P=0.002). No major related airway complications were observed in the cuffed TTs group. Average treatment effect, calculated after propensity score matching, confirmed the significant effect of cuffed TTs on VAC and VAP. Our study suggests a marked reduction of VAP and VAC associated with use of a cuffed versus uncuffed TT in infants and children ≤5 years of age after elective cardiac surgery. A randomized clinical trial is needed to confirm these results and define the impact of use of a cuffed versus uncuffed TT across other relevant ICU outcomes and non-cardiac PICU patients.

Ventilator-associated Events Surveillance in a Trauma Intensive Care Unit: A Prospective Study of Incidence, Predictive Values, Sensitivity, Specificity, Accuracy, and Concordance with Ventilator-associated Pneumonia.

IntroductionThe Centres for Disease Control and Prevention (CDC) introduced a new definition of ventilator-associated events (VAEs) in 2013 in place of longstanding ventilator-associated pneumonia (VAP) definition. Three entities under VAE, ventilator-associated condition (VAC), infection-related ventilator-associated complication (IVAC), and possible ventilator-associated pneumonia (PVAP), were introduced.ObjectivesTo assess the incidence of all VAEs in a tertiary care trauma ICU and to find the predictive value of VAE and sensitivity of VAE definitions for VAP.DesignCohort prospective study at trauma intensive care unit (ICU) of PGIMER, Chandigarh, from July 2018 till June 2019.Materials and methodsPatients admitted in trauma ICU were checked for VAP and VAE criteria defined by CDC.ResultsFour hundred and sixty five patients were observed. Around 378 patients were included in the study with 4046 patient days and 3031 mechanical ventilation (MV) days. Incidence rate of PVAP, IVAC, VAC, and VAP was 2.97, 6.60, 10.23, and 9.24 per 1000 ventilator days, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of diagnosing VAP were 0.61, 0.97, 0.68, and 0.97 for VAC; 0.80, 0.97, 0.57, and 0.99 for IVAC; and 0.78, 0.94, 0.25, and 0.9 for PVAP, respectively. Kendall's W test showed that there was very poor concordance between VAP and VAE.How to cite this articleKaur K, Jain K, Biswal M, Dayal SK. Ventilator-associated Events Surveillance in a Trauma Intensive Care Unit: A Prospective Study of Incidence, Predictive Values, Sensitivity, Specificity, Accuracy, and Concordance with Ventilator-associated Pneumonia. Indian J Crit Care Med 2022;26(5):584–590.

Efficacy and safety of proton pump inhibitors versus histamine-2 receptor blockers in the cardiac surgical population: insights from the PEPTIC trial.

The comparative effectiveness and safety of proton pump inhibitors (PPIs) versus histamine-2 receptor blockers for stress ulcer prophylaxis in the cardiac surgical intensive care unit population is uncertain. Although the Proton Pump Inhibitors versus Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) trial reported a higher risk of mortality in the PPI arm with no difference in gastrointestinal bleeding, detailed information on surgical variables and clinically relevant surgical subgroups was not available. The analysis included all Canadian cardiac surgery patients enrolled in the PEPTIC trial. Data were electronically linked using unique patient identifiers to a clinical information system. Outcomes of interest included in-hospital mortality, gastrointestinal bleeding, Clostridium difficile infections, ventilator-associated conditions and length of stay. We studied 823 (50.6%) randomized to PPIs and 805 (49.4%) to histamine-2-receptor blockers. In the intention-to-treat analysis, there were no differences in hospital mortality [PPI: 4.3% vs histamine-2 receptor blockers: 4.8%, adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.55-1.70], gastrointestinal bleeding (3.9% vs 4.8%, aOR 1.09, 95% CI 0.66-1.81), C. difficile infections (0.9% vs 0.1%, aOR 0.18, 95% CI 0.02-1.59), ventilator-associated conditions (1.6% vs 1.7%, aOR 0.92, 95% CI 0.85-1.00) or median length of stay (9.2 vs 9.8 days, adjusted risk ratio 1.06, 85% CI 0.99-1.13). No significant treatment differences were observed among subgroups of interest or per-protocol populations. In a secondary analysis of cardiac surgery patients enrolled in the PEPTIC trial in Canada, no differences in effectiveness or safety were observed between use of PPIs and histamine-2 receptor blockers for stress ulcer prophylaxis. anzctr.org.au identifier: ACTRN12616000481471.

Complications associated with long-term positive-pressure ventilation in dogs and cats: 67 cases.

To determine the complications associated with positive-pressure ventilation (PPV) in dogs and cats. Retrospective study from October 2009 to September 2013. University Teaching Hospital. Fifty-eight dogs and 9 cats. Medical records were retrospectively reviewed; signalment, complications associated with PPV, duration of PPV, and outcome were recorded. Complications most commonly recorded during PPV included hypothermia 41/67 (61%), hypotension 39/67 (58%), cardiac arrhythmias 33/67 (49%), a positive fluid balance 31/67 (46%), oral lesions 25/67 (37%), and corneal ulcerations 24/67 (36%). A definition of ventilator-associated events (VAE) extrapolated from the Center of Disease Control's criteria was applied to 21 cases that received PPV for at least 4 days in this study. Ventilator-associated conditions occurred in 5 of 21 (24%) of cases with infection-related ventilator-associated conditions and ventilator-associated pneumonia identified in 3 of 21 (14%) cases. Complications are common and diverse in dogs and cats receiving long-term PPV and emphasizes the importance of intensive, continuous patient monitoring and appropriate nursing care protocols. Many of the complications identified could be serious without intervention and suggests that appropriate equipment alarms could improve patient safety. Development of veterinary specific surveillance tools such as the VAE criteria would aid future investigations and allow for effective multicenter studies.

Evaluation of characteristics, clinical relevance and outcome of ventilator associated pneumonia and ventilator associated events algorithm

Background: Surveillance for ventilator-associated pneumonia (VAP) has long been a challenge because of the lack of objective, reliable definitions. Hence, National Healthcare Safety Network (NHSN) has introduced ventilator-associated events (VAEs) as a surveillance definition. While VAE identifies all the possible complications in a mechanically ventilated patient, VAP recognises only the infective complications. There are several retrospective studies reporting no concordance between the occurrence of VAE and VAP. A prospective, observational study in medical intensive care unit (ICU) was conducted over 1 year with the objective of comparing all three tiers of VAE, which are ventilator-associated condition (VAC), infection-related ventilator-associated complication (iVAC) and possible VAP (PVAP), along with VAP in terms of predictive value, characteristics and clinical relevance.Materials and Methods: A prospective cohort study was conducted from July 2018 to June 2019 at PGIMER, Chandigarh, in a 12-bedded medical ICU. All patients with more than 48 h of mechanical ventilation (MV) were included. The demographic data, Acute Physiology and Chronic Health Evaluation-II at 24 h of admission, days of MV, length of ICU stay and outcome of patients were recorded. The patients were screened for both VAP and VAE.Results: Out of a total of 405 patients, 274 patients were included with 3945 patient days and 3330 MV days. The incidence of VAP, VAC, iVAC and PVAP was 6.91, 8.41, 5.41 and 1.50/1000 ventilator days, respectively. Kendall's W-test showed that there was no concordance between VAP and VAE.Conclusion: The study concluded no concordance between cases identified as VAE and VAP.

Esophageal atresia and tracheoesophageal fistula: A retrospective review from a tertiary care institute

A survey of neonates with esophageal atresia and tracheoesophageal fistula (EA ± TEF) to determine additional factors responsible for poor surgical outcomes in our institution where employing an improved standard of care can ameliorate the outcome. We carried out a retrospective review of 54 neonates, who underwent surgical repair of EA± TEF over a 5-year period. We collected data regarding the patients' demographics, perioperative findings, records of neonatal intensive care, and ascertained the effects of gender, gestational age, birth weight, age at operation, type of anomaly, coexisting major anomalies, preoperative inotrope therapy, and duration of postoperative ventilation on the surgical outcome. The mortality rate was 51.9%, out of which, 42.8% of neonates succumbed to ventilator-associated conditions. Age at the time of surgery, gestational age, preoperative inotrope support, presence of coexisting anomalies, and duration of postoperative ventilation were determined as the significant variables predicting mortality(P < 0.05). The area under the Receiver Operating Curve showed the duration of postoperative ventilation as the best indicator of mortality. The Logistic regression model (χ2 = 11.204, P = 0.019) with the above-mentioned variables showed that neonates who were operated before 2.5 days and who required <74.5 hours of postoperative ventilation were 3.91 and 48.30 times more likely to survive respectively, than their counterparts. A delay in surgery due to delayed diagnosis and or delayed transportation to tertiary centres and prolonged ventilatory support have an additional detrimental effect on the surgical outcomes of EA ± TEF.

DETECTION OF VENTILATOR-ASSOCIATED EVENTS AMONG ADULTS USING NAIVE BAYES CLASSIFER

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: Patients on mechanical ventilation are at risk for ventilator-associated pneumonia (VAP). As a potential patient safety measure, the CDC established surveillance definitions known as ventilator-associated events (VAEs). Under the VAE continuum, mechanically ventilated patients can progress from a ventilator-associated condition (VAC), to an infection-related ventilator-associated complication (IVAC), and finally to possible ventilator-associated pneumonia (PVAP). The aim of this study was to develop a screening tool to detect mechanically-ventilated patients at risk for VAEs. METHODS: Using standard procedures to construct a classifier, the dataset was split 7:3 to create samples for training and testing. Considering there are nested classifications in the VAE continuum, we assured VACs, IVACs, and PVAPs, were properly represented as evenly as possible in each sample. From the training set, the classifier calculates the conditional probabilities for each factor in the model. After the proposed model is trained, it is validated against the testing data sample. To appraise the model’s performance, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), area under the curve (AUC), and Matthew’s Correlation coefficient were calculated. All analyses were performed using R 3.6.1 (R Foundation for Statistical Computing, Vienna, Austria) and an alpha level of 0.05 was considered statistically significant. RESULTS: We reported 186 VAE cases (99 VACs, 47 IVACs, and 40 PVAPs) and matched 1:1 with non-VAE cases. After splitting the dataset, there were 260 patients in the training sample and 112 patients in the testing sample. The naïve Bayes classifier demonstrated an overall accuracy result of 83.0% (95% CI; 74.8% – 89.5%) The model was able to correctly classify 80.4% of VAEs (sensitivity) and 85.7% of non-VAEs (specificity). The positive predictive value and the negative predictive value was 81.4% and 84.9%, respectively. The AUC was 0.831 (95% CI; 0.751 – 0.911) and the Matthew’s Correlation coefficient was 0.662. CONCLUSIONS: We present a classification model that potentially could be used to screen our patients at the time of intubation. As this was a single-center retrospective study, the results may be difficult to generalize to other hospitals. We would anticipate that variables that have been implicated in previous studies, such as CHF, to be a ubiquitous factor. Additionally, there may be different factors that contribute to the classification of mechanically ventilated patients at risk for VAEs that are institution-unique. For instance, we chose to include a specific time-dependent variable, as our median time-to-event is 5 ± 3 ventilator days. Likewise, we found chronic kidney disease covaried with CHF, while positive smoking history covaried with COPD. While the addition of both predictors did not enhance the quality of the model, both were subsequently removed. CLINICAL IMPLICATIONS: The model can provide insight on how to anticipate VAP and VAE. This model can ultimately prevent adverse outcomes related to infections and ventilated associated complications. The model needs to be verified and implemented in a prospective setting to see effects on patient outcomes. DISCLOSURES: No relevant relationships by Ragheb Assaly, source=Web Response No relevant relationships by William Barnett, source=Web Response No relevant relationships by Nithin Kesireddy, source=Web Response No relevant relationships by Waleed Khokher, source=Web Response No relevant relationships by Fadi Safi, source=Web Response

Does a Starting Positive End-Expiratory Pressure of 8 cm H2O Decrease the Probability of a Ventilator-Associated Event?

Background: Mechanical ventilation is commonly seen in critical ill patients. The vulnerability of these patients is high, and a wide range of associated conditions can stem from this intervention. To objectively identify nosocomial respiratory conditions and provide conformed surveillance definitions of these events, the Centers for Disease Control and Prevention (CDC) established the ventilator-associated event (VAE) criteria. They denote 3 categories of increasing progression in mechanically ventilated patients from a ventilator-associated condition (VAC) to an infection-related ventilator-associated complication (IVAC) and finally to a possible ventilator-associated pneumonia (PVAP). Manipulation of ventilator settings, such as starting on higher values to not trigger VAC criteria, has been criticized by some experts as not only ‘gaming the system,’ but potentially harming patients. In October 2018, our institution began a baseline of 8 cm H2O as the starting positive end-expiratory pressure (PEEP) protocol for mechanical ventilation but exempting neurosurgical patients. We sought to determine whether an 8 PEEP protocol is an effective strategy for reducing VAEs in our institution. Methods: We retrospectively examined patient data at our institution from January 2014 through February 2020. VAEs were separated by VAC only and IVAC positive (+), which are a combination of IVACs and PVAPs. Using the days between VAEs, a daily event probability can be calculated based on the geometric distribution. Furthermore, as VAEs occur, the likelihood of the event can be assessed as expected or unexpected using a strict probability limit of 0.99865 to reduce type 1 errors. Results: In total, 307 patients were identified in our hospital’s VAE surveillance. Of those, 180 met CDC-defined VAC-only criteria, and 127 patients met IVAC+ definitions. After implementation of an 8-PEEP protocol, the daily event probability for VACs decreased from 0.083 to 0.047. The last event occurred 162 days after the previous VAC, which was unexpected, because the probability of occurrence extended beyond the probability limit. With regard to IVAC+ events, the daily event probability decreased from 0.057 to 0.039 without significant reduction in the IVAC+ rate. Conclusions: Although a change in the VAC-only rate occurred, signified by a longer time between events, it took more than a year to achieve in our institution. Additionally, we did not see a reduction in the IVAC+ rate. These findings suggest that an 8-PEEP protocol may be able to reduce VAEs due to noninfectious etiologies, such as congestive heart failure and atelectasis.Funding: NoDisclosure: None

Knobmanship: Dialing Up Understanding of VAE Triggers

Background: Mechanical ventilation is a lifesaving therapy for critically ill patients. Hospitals perform surveillance for the NHSN for ventilator-associated events (VAE) by monitoring mechanically ventilated patients for metrics that are generally thought to be objective and preventable and that lead to poor patient outcomes. The VAE definition is met in a stepwise manner; initially, a ventilator-associated condition (VAC) is triggered with an increase in positive end-expiratory pressure (PEEP, &gt;3 cm H2O) or fraction of inspired oxygen (FIO2, 0.20 or 20 points) after a period of stability or improvement on the ventilator. We believe that many reported VAEs could be avoided by provider and respiratory therapy attention to “knobmanship.” We define knobmanship as knowledge of the VAE definition and trigger points combined with appropriate clinical care for mechanically ventilated patients while avoiding unnecessary triggering of the VAE definition by avoiding small unneeded changes in PEEP or FIO2. Methods: We performed a chart review of 283 patients who had a reported VAE to the NHSN between January 1, 2019, and December 31, 2020. We collected data including type of VAE, VAE triggering criteria, and clinical course. Results: Of the 283 VAEs, 59 were triggered by a PEEP increase from 5 to 8 with stable or decreasing FIO2. Of the 59 VAEs, 33 were VACs, 18 were infection-related ventilator- associated complications (IVACs), and 8 were possible ventilator-associated pneumonia (PVAP). Most of these transient changes in PEEP were deemed clinically unnecessary. A 21% reduction of VAEs reported to the NSHN over the 2-year review period could have been avoided by knobmanship. Conclusions: The VAE definition may often be triggered by provider bias to the ventilator settings rather than what the patient’s clinical-condition requires. Attention to knobmanship may result in substantial decrease in reported VAE.Funding: NoDisclosures: None

COVID-19 and Ventilator-Associated Event Discordance

Background: The COVID-19 pandemic has challenged healthcare facilities since its discovery in late 2019. Notably, the subsequent COVID-19 pandemic has led to an increase in healthcare-acquired infections such as ventilator associated events (VAEs). Many hospitals in the United States perform surveillance for the NHSN for VAEs by monitoring mechanically ventilated patients for metrics that are generally considered to be objective and preventable and that lead to poor patient outcomes. The VAE definition is met in a stepwise manner. Initially, a ventilator-associated condition (VAC) is met when there an increase in ventilator requirements after a period of stability or improvement. An IVAC is then met when there is evidence of an infectious process such as leukocytosis or fever and a new antimicrobial agent is started. Finally, possible ventilator-associated pneumonia (PVAP) is met when there is evidence of microbial growth or viral detection. Since the beginning of the COVID-19 pandemic, our hospital has seen an increase in VAEs, which is, perhaps, not unexpected during a respiratory illness pandemic. However, the NSHN definitions of VAE, and PVAP in particular, do not account for the novelty and nuances of COVID-19. Methods: We performed a chart review of 144 patients who had a VAE reported to the NHSN between March 1 and December 31, 2020. Results: Of the 144 patients with a VAE reported to NHSN, 39 were SARS-CoV-2 positive. Of the 39 patients, 4 patients (10.25%) met the NHSN PVAP definition due to a positive SARS-CoV-2 PCR that was collected in the prolonged viral shedding period of their illness (&lt; 90 days). One of the four patients also had a bacterial infection in addition to their subsequent positive COVID-19 result. All these patients were admitted to the hospital with a COVID-19 diagnosis and their initial PCR swab was performed upon admission. Conclusions: We believe that the PVAP definition was inappropriately triggered by patients who were decompensating on the ventilator due to a novel respiratory virus that was present on admission. Early in the pandemic, frequent swabbing of these patients was performed to try and understand the duration of viral shedding and to determine when it would be safe to transfer patients from isolation after prolonged hospitalization. The NSHN definition should take into consideration the prolonged viral shedding period of COVID-19 and natural history of the illness, and subsequent COVID-19 testing within 90 days of an initial positive should not require classification as a hospital-acquired PVAP.Funding: NoDisclosures: None

VENTILATOR ASSOCIATED PNEUMONIA IN INTENSIVE CARE UNIT OF A TERTIARY LEVEL HOSPITAL

Background: Ventilator associated pneumonia (VAP) is the most common nosocomial infection diagnosed in the intensive care units (ICUs). Hence the present study was undertaken to study the incidence, risk factors, case fatality rate of ventilator associated events (VAE) and VAP in ICU of a tertiary level hospital. Method: Total 100 patient of either sex, having the age of &gt;18 years and who was received mechanical ventilation more than 48 hrs for any indication over a period of 12-18 months in an ICU of a tertiary level hospital were studied. Results: The incidence of VAP was 38.0% and VAP rate was 59.6/1000 ventilator days. Post op status (71%) and trauma (22%) were the most common risk factors which lead to VAP and VAE. Acinetobacter spp (19%) and Klebsiella spp (12%) were the two most common microorganisms causing VAP. Mortality or case fatality rate was 42.10%. In ventilator associated events, 45% patients developed VAC (Ventilator associated condition), 44% patients developed IVAC ( Infection related Ventilator associated condition) and 38% patients developed possible VAP. Conclusion: VAP is a serious problem in the ICU leading to longer hospital stay higher treatment costs and increased mortality and morbidity. Prolonged mechanical ventilation is an important risk factor.

Automated Near Real-Time Ventilator Data Feedback Reduces Incidence of Ventilator-Associated Events: A Retrospective Observational Study.

Objectives:Critical care teams are encouraged to follow best practice protocols to help wean mechanically ventilated patients from the ventilator to reduce ventilator-associated events including ventilator-associated conditions, probable ventilator-associated pneumonias, and infection-related ventilator-associated conditions. Providers monitor for alerts suggestive of possible ventilator-associated events and advise when patients should undergo spontaneous breathing trials. Compliance with protocols in most units is suboptimal.Design:Retrospective review of clinical data over 24 months.Setting:St. Joseph Mercy Hospital Candler Hospital Medical-Surgical ICU.Patients:All mechanically ventilated patients.Interventions:The Respiratory Knowledge Portal was implemented in our ICU. For 13 months, Respiratory Knowledge Portal data were ported to ICU workstations (control). For the following 11 months, Respiratory Knowledge Portal data were also presented on tablet computers (intervention) for use during multidisciplinary rounds. We performed a retrospective review of Respiratory Knowledge Portal data from before and after the implementation of the tablet computers.Measurements and Main Results:Data were collected from 337 patients (187 control group, 150 intervention group). A decrease in the occurrence of ventilator-associated events was observed during the intervention group compared with the control group. Only 2.0% of patients in the intervention group experienced any category of ventilator-associated event, while 11.2% of patients in the control group experienced one event (p = 0.003). Intervention patients experienced less ventilator-associated conditions (p = 0.002), infection-related ventilator-associated conditions (p = 0.026), and probable ventilator-associated pneumonias (p = 0.036) than control patients. Twenty-one of the 24 patients with any ventilator-associated events were in the control group. There was no significant difference between the days spent on ventilation nor hospital length of stay in the control compared with intervention group patients.Conclusions:Fewer ventilator-associated events, ventilator-associated conditions, infection-related ventilator-associated conditions, and probable ventilator-associated pneumonias were seen during the period when Respiratory Knowledge Portal monitoring data was presented on tablet computers. There was no difference in time on ventilator nor overall length of stay.

The epidemiology and clinical outcomes of ventilator-associated events among 20,769 mechanically ventilated patients at intensive care units: an observational study

BackgroundVentilator-associated pneumonia (VAP) is the most common hospital-acquired infection (HAI) in intensive care units (ICUs). Ventilator-associated event (VAE), a more objective definition, has replaced traditional VAP surveillance and is now widely used in the USA. However, the adoption outside the USA is limited. This study aims to describe the epidemiology and clinical outcomes of VAEs in China, based on a prospectively maintained registry.MethodsAn observational study was conducted using an ICU-HAI registry in west China. Patients that were admitted to ICUs and underwent mechanical ventilation (MV) between April 1, 2015, and December 31, 2018, were included. The characteristics and outcomes were compared between patients with and without VAEs. The rates of all VAEs dependent on different ICUs were calculated, and the pathogen distribution of patients with possible VAP (PVAP) was described.ResultsA total of 20,769 ICU patients received MV, accounting for 21,723 episodes of mechanical ventilators and 112,697 ventilator-days. In all, we identified 1882 episodes of ventilator-associated condition (VAC) events (16.7 per 1000 ventilator-days), 721 episodes of infection-related ventilator-associated complications (IVAC) events (6.4 per 1000 ventilator-days), and 185 episodes of PVAP events (1.64 per 1000 ventilator-days). The rates of VAC varied across ICUs with the highest incidence in surgical ICUs (23.72 per 1000 ventilator-days). The median time from the start of ventilation to the onset of the first VAC, IVAC, and PVAP was 5 (3–8), 5 (3–9), and 6 (4–13) days, respectively. The median length of hospital stays was 28.00 (17.00–43.00), 30.00 (19.00–44.00), and 30.00 (21.00–46.00) days for the three VAE tiers, which were all longer than that of patients without VAEs (16.00 [12.00–23.00]). The hospital mortality among patients with VAEs was more than three times of those with non-VAEs.ConclusionsVAE was common in ICU patients with ≥ 4 ventilator days. All tiers of VAEs were highly correlated with poor clinical outcomes, including longer ICU and hospital stays and increased risk of mortality. These findings highlight the importance of VAE surveillance and the development of new strategies to prevent VAEs.

Comparative Study of Demographic Profile, Mortality, Risk Factors, and Bacteriological Profile of Respiratory Isolates from Ventilated Patients: Ventilator-Associated Event versus NonVentilator-Associated Event Cases

Introduction: Ventilator-associated pneumonia (VAP) rate has long been considered a quality indicator (QI) in intensive care units (ICUs) for mechanically ventilated patients. However, ever since the Centers for Disease Control and Prevention (CDC) redefined VAP as ventilator-associated events (VAEs), its validity as a tool for use in quality assurance needs to be assessed. Aim: The aim of the study was to identify VAE rate in ICU, compare the demographic and respiratory isolate profile and mortality with non-VAE cases, and identify risk factors for VAE. Materials and Methods: All ICU patients on mechanical ventilation (MV) for >2 days were followed prospectively. VAE data were collected using a checklist obtained from the CDC website (the National Healthcare Surveillance Network VAE surveillance tool). The demographic profile, risk factors, and treatment for each patient were recorded in a proforma. VAE rates were estimated per 1000 ventilator-days. Results: The overall VAE rate was 38.1/1000 MV days. Among VAE subtypes, 18.7% were ventilator-associated condition (VAC), 43.7% were infection-related VAC (IVAC), and 37.5% were possible VAP (PVAP). Survival rate was 100% for patients with VAC alone, whereas only 14.2% and 16.6% of patients survived with IVAC and PVAP, respectively. No significant association was found between age, gender, mortality, bacterial isolate, and VAE cases. Depressed level of consciousness, immunosuppression, antibiotic use, and reintubation were significant risk factors associated with VAE cases (P = 0.0001). Conclusion: There is no significant difference observed between VAE and non-VAE cases regarding demographic profile, respiratory bacterial profile, and mortality. More research is required to establish the role of VAE as a QI for patient care in ICUs.