Development Of Ventilator-associated Pneumonia Research Articles

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Introduction: Continuous infusion sedation is associated with adverse outcomes such as prolonged mechanical ventilation, extubation failure, increased risk for development of ventilator-associated pneumonia, and increased intensive care unit and hospital lengths of stay in critically ill adults. The purpose of this study was to examine excess sedation and incidence of extubation failure in pediatric patients. Methods: Data were retrospectively collected on consecutive patients who received mechanical ventilation longer than 48 hours with a continuous infusion benzodiazepine and/or opioid infusion longer than 24 hours between January 1, 2009 through October 31, 2012. The primary outcome was incidence of extubation failure in patients who were oversedated (defined by State Behavioral Scale (SBS) score of -3 or -2) within 72 hours of extubation compared to patients who were not oversedated. Secondary outcomes included evaluation of risk factors associated with oversedation and extubation failure. The primary endpoint was evaluated using a one-sided chi-square test at a significance level of p = 0.05. The risk factor analysis utilized univariate and multivariate logistic regression. Covariance-adjusted odds ratios and their corresponding 95% confidence intervals were estimated for the final set of risk factors in the models. Results: One hundred eight patients were included in the analysis, representing 62 oversedated patients and 46 non-oversedated patients. Groups were well matched with regards to baseline characteristics. Most patients received fentanyl and midazolam continuous infusions. There was no difference in extubation failure in oversedated patients versus non-oversedated patients [14 patients (22.58%) versus 7 patients (15.22%), respectively; p = 0.33]. After adjusting for potential risk factors, patients with lower Glasgow Coma Scale (GCS) scores prior to intubation (OR 1.15; 95% CI 0.74-0.97) and higher maximum benzodiazepine dose per day (OR 1.93; 95% CI 1.01-3.71) were associated with an increased risk of oversedation. Longer durations of mechanical ventilation (OR 1.10; 95% CI 0.97-1.25) and higher maximum benzodiazepine dose per day (OR 1.47; 95% CI 0.71-3.05) were associated with an increased risk of extubation failure. Conclusions: Rates of extubation failure were similar among oversedated versus non-oversedated patients. Higher maximum benzodiazepine dose per day was associated with increased risk for oversedation and extubation failure. Benzodiazepine dosing should potentially be re-evaluated in this population.

Bacteremia and Ventilator-Associated Pneumonia: A Marker for Contemporaneous Extra-Pulmonic Infection

Ventilator-associated pneumonia (VAP) is a well-known complication of mechanical ventilation in severely injured patients. A subset of patients with VAP develop an associated bacteremia (B-VAP), but the risk factors, microbiology, morbidity, and mortality in this group are not well described. The goal of this study was to examine the incidence, predictors, and outcome of B-VAP in adult trauma patients. We conducted a retrospective review of trauma patients who developed VAP or B-VAP from January 2007 to December 2009 at a single, university-affiliated medical center. Ventilator-associated pneumonia was defined as a clinician-documented instance of VAP together with confirmed positive respiratory cultures (bronchoalveolar lavage [BAL] fluid specimen with ≥10(4) colony forming units (CFU)/mL or tracheal aspirate with moderate-to-many organisms and polymorphonuclear neutrophils [PMN]). Bacteremia associated with VAP (B-VAP) was defined as the blood culture of an organism that matched the pulmonary pathogen in a case of VAP. We reviewed the demographic data, injury severity, transfusion data, and microbiology of patients who developed VAP and B-VAP. Outcome data included the number of days of care in the intensive care unit (ICU) and hospital length of stay, number of days of mechanical ventilation, and survival. A Student t-test, χ(2) test, or logistic regression was used as appropriate for data analysis. During the 36-mo period of the study, 4,018 adult patients were admitted to the hospital. Ventilator-associated pneumonia was diagnosed in 206 (5%) of these patients, and 26 of these latter patients (13%) had an associated bacteremia. The mean time from admission to the development of VAP was 5 d (95% CI 4.6-5.8). Patients who had B-VAP received significantly more units of red blood cell concentrates (PRBC) than those who did not have B-VAP (23 units vs. 9 units of PRBC, respectively, p<0.05). Patients with B-VAP also had higher rates of simultaneous non-pulmonary infections than those with VAP alone (69% vs. 38%, respectively), a greater number of days of mechanical ventilator support (24 d vs. 14 d, respectively, p<0.05), a greater number of days in the ICU (26 d vs. 17 d, respectively, p<0.05), and a greater hospital length of stay (50 d vs. 30 d, respectively, p<0.05). Patients with B-VAP showed a trend toward lower survival than those without B-VAP, but B-VAP was not an independent predictor of mortality. Trauma patients with B-VAP have a similar mortality but greater morbidity than those with VAP alone. The number of PRBC received is the most significant risk factor for developing B-VAP. More than two-thirds of patients with B-VAP have contemporaneous extra-pulmonic infections. Trauma patients with B-VAP may benefit from increased surveillance for additional concomitant infections and from more aggressive empiric antimicrobial coverage.

The presence of antibiotic-resistant nosocomial pathogens in endotracheal tube biofilms and corresponding surveillance cultures

Mechanically ventilated patients often develop ventilator-associated pneumonia (VAP). Soon after intubation, a mixed biofilm harboring microbial pathogens is formed on the endotracheal tube (ET). It is believed that this biofilm contributes to the development of VAP. Unfortunately, the causative agent is often not known at the time VAP is suspected, and early therapy often relies on the identification of surveillance cultures (SC). It is thus important to know whether these SC can predict the microbial flora in ET biofilms. In this study, we compare the presence of a number of antibiotic-resistant nosocomial bacteria (Enterobacter aerogenes, Escherichia coli, Micrococcus luteus, Pseudomonas aeruginosa, Staphylococcus aureus, and Staphylococcus epidermidis) and of Candida albicans in cultures from ET biofilms and SC (i.e. sputum samples, nose swabs, and throat swabs) of 20 mechanically ventilated patients. Our data indicate that there is a good correlation between the presence of (antibiotic-resistant) pathogens in ET biofilms and SC.

Relationship between nasal colonization and ventilator-associated pneumonia and the role of the environment in transmission of Staphylococcus aureus in intensive care units

This study assessed the relationship between nasal colonization and ventilator-associated pneumonia (VAP) by Staphylococcus aureus, as well the role of the environment in the transmission of this organism. We performed a cohort study of patients with VAP caused by methicillin-resistant S aureus (MRSA) or methicillin-sensitive S aureus during 2 years in an adult intensive care unit (ICU). All patients had nasal swab specimens obtained at admission and during the ICU stay. Clinical samples also were collected for analysis, as were samples from the hands of health care professionals and the environment, and were typed using pulsed-field gel electrophoresis. S aureus VAP represented 12.5% of the cases, and statistical analysis identified colonization as a risk factor for the development of this infection. MRSA was isolated from the environment and hands, indicating the existence of a secondary reservoir. Molecular typing revealed a polyclonal profile; however, clone J was the most frequent (45.5%) among isolates of MRSA tested, with a greater profile of resistance than the other isolates. There was strong evidence suggesting transmission of MRSA to patients from the environment. Nasal colonization for S aureus is a risk factor for development of VAP.

Pre-emptive broad-spectrum treatment for ventilator-associated pneumonia in high-risk patients

Patients requiring mechanical ventilation (MV) for >48 h after major heart surgery (MHS) are at a high risk of acquiring ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT). Most non-pharmacological interventions to prevent VAP in such patients are usually already implemented. The objective of this study was to evaluate the efficacy in preventing lower respiratory infections of antibiotics active against multidrug-resistant pathogens in this very high-risk population. We performed a prospective randomized open-label study of MHS patients requiring MV for >48 h. Patients were randomly allocated to one of two groups: the intervention group, which received a 3-day course of linezolid and meropenem, and the control group, which received the standard of care. The main outcome was the development of VAP or VAT. Overall, of the 78 patients included in the study, 40 were in the intervention group and 38 in the control group. Both groups were comparable. Data for the intervention and control groups respectively were as follows: VAP + VAT/1,000 days was 31.79 vs 64.78 (p = 0.03), median length of MV before the first episode of VAP or VAT 9 vs 4.5 days (p = 0.02). No significant differences were observed in median length of stay in the intensive care unit, median length of hospital stay, antibiotic use, Clostridium difficile infection, and overall mortality rate. We detected linezolid-resistant coagulase-negative and coagulase-positive staphylococci in the MHS intensive care unit after the study period. A pre-emptive approach with broad-spectrum antibiotics may be effective in reducing the incidence and delaying the onset of VAP + VAT after MHS. The ecological consequences have to be carefully evaluated in future trials.

Ventilator Associated Pneumonia: Evolving Definitions and Preventive StrategiesDiscussion

Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections occurring in intubated patients. Because VAP is associated with higher mortality, morbidity, and costs, there is a need to solicit further research for effective preventive measures. VAP has been proposed as an indicator of quality of care. Clinical diagnosis has been criticized to have poor accuracy and reliability. Thus, the Centers for Disease Control and Prevention has introduced a new definition based upon objective and recordable data. Institutions are nowadays reporting a VAP zero rate in surveillance programs, which is in discrepancy with clinical data. This reduction has been highlighted in epidemiological studies, but it can only be attributed to a difference in patient selection, since no additional intervention has been taken to modify pathogenic mechanisms in these studies. The principal determinant of VAP development is the presence of the endotracheal tube (ETT). Contaminated oropharyngeal secretions pool over the ETT cuff and subsequently leak down to the lungs through a hydrostatic gradient. Impairment of mucociliary motility and cough reflex cannot counterbalance with a proper clearance of secretions. Lastly, biofilm develops on the inner ETT surface and acts as a reservoir for microorganism inoculum to the lungs. New preventive strategies are focused on the improvement of secretions drainage and prevention of bacterial colonization. The influence of gravity on mucus flow and body positioning can facilitate the clearance of distal airways, with decreased colonization of the respiratory tract. A different approach proposes ETT modifications to limit the leakage of oropharyngeal secretions: subglottic secretion drainage and cuffs innovations have been addressed to reduce VAP incidence. Moreover, coated-ETTs have been shown to prevent biofilm formation, although there is evidence that ETT clearance devices (Mucus Shaver) are required to preserve the antimicrobial properties over time. Here, after reviewing the most noteworthy issues in VAP definition and pathophysiology, we will present the more interesting proposals for VAP prevention.

Incidence and risk factors of ventilator associated pneumonia in a tertiary care hospital

Ventilator associated pneumonia (VAP) is a type of nosocomial pneumonia associated with increased morbidity and mortality. Knowledge about the incidence and risk factors is necessary to implement preventive measures to reduce mortality in these patients. A prospective study was conducted at a tertiary care teaching hospital for a period of 20 months from November 2009 to July 2011. Patients who were on mechanical ventilation (MV) for more than 48 hours were monitored at frequent intervals for development of VAP using clinical and microbiological criteria until discharge or death. Of the 76 patients, 18 (23.7%) developed VAP during their ICU stay. The incidence of VAP was 53.25 per 1,000 ventilator days. About 94% of VAP cases occurred within the first week of MV. Early-onset and late-onset VAP was observed in 72.2% and 27.8%, respectively. Univariate analysis showed chronic lung failure, H2 blockers usage, and supine head position were significant risk factors for VAP. Logistic regression revealed supine head position as an independent risk factor for VAP. VAP occurred in a sizeable number of patients on MV. Chronic lung failure, H2 blockers usage, and supine head position were the risk factors associated with VAP. Awareness about these risk factors can be used to inform simple and effective preventive measures.

Impact de la position du patient sur le risque de pneumonie acquise sous ventilation mécanique

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit. Oropharynx-trachea/endotracheal tube axis plays a significant role on VAP development. Accordingly, the positioning could be a way to prevent VAP. This review is an update on the impact of semi-recumbent position, rotational beds and prone position on VAP prevention.

Risk factors for ventilator-associated pneumonia in a surgical ICU

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in ICU patients who require mechanical ventilation support. The aim of this study was to determine predictors for the development of VAP in surgical ICU patients admitted to Baskent University Hospital.

Proteomic Profiling of Bronchoalveolar Lavage Fluid in Critically Ill Patients with Ventilator-Associated Pneumonia

RationaleVentilator-associated pneumonia (VAP) is a common complication in patients with acute lung injury (ALI) and can lead to increased morbidity and mortality. Identifying protein profiles specific to VAP in bronchoalveolar lavage fluid (BALF) may aid in earlier diagnosis, elucidate mechanisms of disease, and identify putative targets for therapeutic intervention.MethodsBALF was obtained from 5 normal subjects and 30 ALI patients: 14 with VAP (VAP+) and 16 without VAP (VAP–). Each sample underwent shotgun proteomic analysis based on tandem mass spectrometry. Differentially expressed proteins between the groups were identified using statistical methods based on spectral counting. Mechanisms of disease were explored using functional annotation and protein interaction network analysis. Supervised classification algorithms were implemented to discover a proteomic classifier for identifying critically ill patients with VAP.ResultsALI patients had distinct BALF proteomic profiles compared to normal controls. Within the ALI group, we identified 76 differentially expressed proteins between VAP+ and VAP–. Functional analysis of these proteins suggested activation of pro-inflammatory pathways during VAP. We identified and validated a limited proteomic signature that discriminated VAP+ from VAP– patients comprised of three proteins: S100A8, lactotransferrin (LTF), and actinin 1 (ACTN1).ConclusionsCombining proteomic with computational analyses is a powerful approach to study the BALF proteome during lung injury and development of VAP. This integrative methodology is a promising strategy to differentiate clinically relevant subsets of ALI patients, including those suffering from VAP.

National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients

Since its introduction by the Institute for Healthcare Improvement, the ventilator bundle (VB) has been credited with a reduction in ventilator-associated pneumonia (VAP). The VB consists of stress ulcer prophylaxis, deep venous thrombosis prophylaxis, head-of-bed elevation, and daily sedation vacation with weaning assessment. While there is little compelling evidence that the VB is effective, it has been widely accepted. The Centers for Medical and Medicaid Services has suggested that VAP should be a "never event" and may reduce payment to providers. To provide evidence of its efficacy, the National Trauma Institute organized a prospective multi-institutional trial to evaluate the utility of the VB. This prospective observational multi-institutional study included six Level I trauma centers. Entry criteria required at least 2 days of mechanical ventilation of trauma patients in an intensive care unit (ICU). Patients were followed up daily in the ICU until the development of VAP, ICU discharge, or death. Compliance for each VB component was recorded daily, along with patient risk factors and injury specifics. Primary outcomes were VAP and death. VB compliance was analyzed as a time-dependent covariate using Cox regression as it relates to outcomes. A total 630 patients were enrolled; 72% were male, predominately with blunt injury; and mean age, Injury Severity Score (ISS), and 24-hour Glasgow Coma Scale (GCS) score were 47, 24, and 8.7, respectively. VAP occurred in 36%; mortality was 15%. Logistic regression identified male sex and pulmonary contusion as independent predictors of VAP and age, ISS, and 24-hour Acute Physiology and Chronic Health Evaluation as independent predictors of death. Cox regression analysis demonstrated that the VB, as a time-dependent covariate, was not associated with VAP prevention. In trauma patients, VAP is independently associated with male sex and chest injury severity and not the VB. While quality improvement activities should continue efforts toward VAP prevention, the Institute for Healthcare Improvement VB is not the answer. Financial penalties for VAP and VB noncompliance are not warranted. Therapeutic study, level III.

Early nonbronchoscopic bronchoalveolar lavage

Ventilator-associated pneumonia is a problem in trauma and emergency general surgery patients. Our hospital-acquired infection prevention committee approved the use of early nonbronchoscopic bronchoalveolar lavage (screening-BAL) in the surgical intensive care unit (SICU) to identify ventilated patients with bronchiolar bacteria before 48 hours. We reviewed the results of this quality improvement initiative. All ventilated patients in the SICU (March 2011 to June 2012) underwent a screening-BAL 36 hours to 48 hours after intubation; quantitative culture results (>5 × 10(4) colony-forming unit per milliliter) were used to identify positive specimens. Clinical pneumonia was defined as clinical pulmonary infection score greater than 6 with a subsequent positive diagnostic-BAL result. Sequential organ failure assessment scores were averaged for the first 48 hours in the SICU. Continuous and dichotomous data were compared, and a multivariate regression analysis was performed on the screening-BAL and pneumonia results. Screening-BALs were performed in 150 patients (99 trauma and 51 emergency general surgery patients), 72 of these specimens had positive findings. Fifty-three clinical pneumonias were diagnosed, and 45 (positive predictive value, 0.85) identified the same organism as the screening-BAL. Clinical pneumonia developed in eight patients with a negative screening-BAL (negative predictive value, 0.85). Antibiotic therapy at the time of the screening-BAL was associated with a negative screen (odds ratio, 0.44; p = 0.026). Pneumonia developed on median postintubation Day 4 (2-15 days) in patients with a positive screening-BAL results as compared with day 7.5 in the patients with a negative screening-BAL results (3.5-15 days; p = 0.007). Field intubation is an independent risk factor (odds ratio, 3.5; p = 0.004). Positive screening-BAL results in trauma and emergency general surgery patients are associated with the development of ventilator-associated pneumonia by the same organism and may play a role in identifying patients at risk for pneumonia. Further studies must be conducted to evaluate the role of screening-BAL in this patient population. Diagnostic/prognostic study, level III.

Determinants of ventilator associated pneumonia and its impact on prognosis: A tertiary care experience

Background:Ventilator associated pneumonia (VAP) is a major cause of poor outcome among patients in the intensive care units (ICU) world-wide. We sought to determine the factors associated with development of VAP and its prognosis among patients admitted to different ICUs of a Tertiary Care Hospital in India.Methodology:We did a matched case control study during October 2009 to May 2011 among patients, ≥18 years with mechanical ventilation. Patients who developed pneumonia after 48 h of ventilation were selected in the case group and those who did not develop pneumonia constituted the control group. Patients’ history, clinical and laboratory findings were recorded and analyzed.Results:There were 52 patients included in each group. Among cases, early onset ventilator associated pneumonia (EVAP) occurred in 27 (51.9%) and late onset ventilator associated pneumonia (LVAP) in 25 (48.1%). Drug resistant organisms contributed to 76.9% of VAP. Bacteremia (P = 0.002), prior use of steroid/immunosuppressant (P = 0.004) and re-intubations (P = 0.021) were associated with the occurrence of VAP. The association of Acinetobacter (P = 0.025) and Pseudomonas (P = 0.047) for LVAP was found to be statistically significant. Duration of mechanical ventilation (P = 0.001), ICU stay (P = 0.049) and requirement for tracheostomy (P = 0.043) were significantly higher in VAP. Among each case and control groups, 19 (36.5%) expired.Conclusion:We found a higher proportion of LVAP compared with EVAP and a higher proportion of drug resistant organisms among LVAP, especially Pseudomonas and Acinetobacter. Drug resistant Pseudomonas was associated with higher mortality.

Tracheotomy Tubes with Suction above the Cuff Reduce the Rate of Ventilator-Associated Pneumonia in Intensive Care Unit Patients

We evaluated the effect of tracheotomy tubes that enable suction immediately above the cuff on the development of ventilator-associated pneumonia (VAP). Patients without preexisting pneumonia who required tracheotomy were randomly assigned to receive a tracheotomy tube with or without above-the-cuff suction. The suction tube provided 10 mm Hg of continuous wall suction while the tracheotomy tube cuff was inflated. Data regarding the development of VAP, time on the ventilator, and length of stay in the intensive care unit (ICU) were recorded and compared between groups. Eighteen patients were randomized and prospectively evaluated. Nine patients received standard tracheotomy tubes, and 9 received suction-above-the-cuff tracheotomy tubes. The prevalences of VAP were 56% in the control group and 11% in the suction tracheotomy group (p = 0.02). The mean times on the ventilator were 18 +/- 14 days in the control group and 11 +/- 11 days in the suction group (p = 0.12). The mean lengths of ICU stay were 26 +/- 15 days in the control group and 18 +/- 15 days in the suction group (p = 0.14). Use of suction-above-the-cuff tracheotomy tubes significantly decreases the incidence of VAP in ICU patients. There were trends toward decreased time on the ventilator and decreased length of stay in the ICU.

GlutamineSupplementedParenteralNutritiontoPreventVentilatorAssociated Pneumonia in the Intensive Care Unit

Ventilator-associated pneumonia (VAP) is a form of nosocomial pneumonia that increases patient morbidity and mortality, length of hospital stay, and healthcare costs. Glutamine preserves the intestinal mucosal structure, increases immune function, and reduces harmful changes in gut permeability in patients receiving total parenteral nutrition (TPN). We hypothesized that TPN supplemented by glutamine might prevent the development of VAP in patients on mechanical ventilator support in the intensive care unit (ICU). With the approval of the ethics committee and informed consent from relatives, 60 patients who were followed in the ICU with mechanical ventilator support were included in our study. Patients were divided into three groups. The first group received enteral nutrition (n=20), and the second was prescribed TPN (n=20) while the third group was given glutamine-supplemented TPN (n=20). C-reactive protein (CRP), sedimentation rate, body temperature, development of purulent secretions, increase in the amount of secretions, changes in the characteristics of secretions and an increase in requirement of deep tracheal aspiration were monitored for seven days by daily examination and radiographs. No statistically significant difference was found among groups in terms of development of VAP (p=0.622). Although VAP developed at a lower rate in the glutamine-supplemented TPN group, no statistically significant difference was found among any of the groups. Glutamine-supplemented TPN may have no superiority over unsupplemented enteral and TPN in preventing VAP.

Infection Route Analysis of Ventilator Associated Pneumonia

Abstract Objective A prospective study was conducted in a tertiary care center to identify the risk factors of ventilator associated pneumonia (VAP) through phenotypic and molecular biological methods. Methods The patients who were mechanically ventilated in the respiratory intensive care unit (RICU) and the neurological internal intensive care unit (NICU) were enrolled in our study, and samples were collected from the lower respiratory tract, oropharynx and stomach. Other samples, including the environmental air, swabs of nurses’ hands, subglottic secretion and ventilator circuit, were also collected. Microorganisms in the collected samples were recovered and identified at species level by biochemical detection. Genetic relationship of dominant species was further characterized by pulsed field gel electrophoresis (PFGE). Results Out of 48 enrolled patients, 22 cases developed VAP and bacterial cultures were recovered from the lower respiratory tract samples of 14 cases. The average hospitalization time with VAP was significantly longer than that of patients without VAP (P &lt; 0.05). Among the recovered bacteria cultures, multidrug-resistant Pseudomonas aeruginosa and Stenotrophomonas maltophilia were dominant. It was more likely that subglottic secretion and gastric juice samples contained the same isolates as recovered in the lower respiratory tract by PFGE analysis. Conclusions Mechanical ventilation in RICU and NICU was a high risk factor for VAP development. Special emphasis of VAP prophylaxis should be paid on subglottic secretion and gastric juice reflux.

Longer duration of mechanical ventilation was found to be associated with ventilator-associated pneumonia in children aged 1 month to 12 years in India

ObjectivesTo determine primarily (1) the incidence of ventilator-associated pneumonia (VAP) among ventilated patients aged 1 month to 12 years and secondarily (2) the risk factors for VAP and (3) common organisms causing VAP. Study Design and SettingProspective study in a tertiary care center in India. Consecutive ventilated patients aged ≥1 month and ≤12 years and requiring mechanical ventilation (MV) for ≥48 hours were included after written informed parental consent. For the diagnosis of VAP, National Nosocomial Infections Surveillance System criteria of 1996 were used. ResultsIncidence of VAP among patients aged 1 month to 12 years was 36.2% (38/105; 95% confidence interval [CI]: 27, 46). In unconditional logistic regression analysis controlling for the presence of underlying illnesses, risk factor for VAP was >4 days of MV (adjusted odds ratio, 3.76; 95% CI: 1.41, 10.02; P=0.008). Reintubation within 72 hours of extubation and more than two attendants at the time of recruitment showed increased tendency for the development of VAP but did not reach statistical significance. Endotracheal and endobronchial aspirates were positive for organism in 19.05% (20/105) and 37.14% (39/105) of patients, respectively. ConclusionAlmost one-third of ventilated patients develop VAP. Vigilance for the development of VAP has to be kept on those requiring >4 days of MV. Klebsiella and Staphylococcus aureus were common bacterial isolates in such patients.

Exhaled breath condensate pH in mechanically ventilated patients

ObjectivesIn this prospective clinical trial we aimed to answer if spontaneous exhaled breath condensate (EBC) in the trap of the expiratory arm of the ventilator could replace EBC collected by coolant chamber standardized with Argon as an inert gas. Second, if EBC pH could predict ventilator associated pneumonia (VAP) and mortality. PatientsWe included 34 critically ill patients (males=26), aged=54.85±19.86 (mean±SD) yrs, that required mechanical ventilation due to non-pulmonary direct cause (APACHE II score=23.58±14.7; PaO2/FiO2=240.00±98.29). SettingICU with 9 beds from a regional teaching hospital. Intervention and ResultsThe patients were followed up until development of VAP, successful weaning or death. There were significant differences between mean EBC pH from the 4 procedures with the exception of spontaneous EBC de-aerated with Argon (n=79; 6.74±0.28) and coolant chamber deaerated with Argon (n=79; 6.70±0.36; p=NS by Tukey's Multiple Comparison Test). However, none of the procedures were extrapolated between each other according to Bland & Altman method. The mean EBC pH from the trap without Argon was 6.50±0.28. From the total of 34 patients, 22 survived and were discharged and 12 patients died in the ICU. ConclusionSpontaneous EBC pH could not be extrapolated to EBC pH from coolant chamber and it did not change in subjects who dead, neither subject with VAP in comparison with baseline data. The lack of other biomarker in EBC and the lack of a control group determinate the need for further studies in this setting.

Infections after trauma are associated with subsequent cardiac injury

Trauma produces profound inflammatory and immune responses. A second hit such as an infection further disrupts the inflammatory cascade. Inflammatory responses, following traumatic injuries, infections, or both, are emerging as biologic mediators of cardiac disease including myocardial ischemia and infarction. Inflammation-induced and stress-related cardiac damage are increasingly recognized in patients with critical illness. It is believed that cardiac dysfunction is the result of alterations in the inflammatory and immune cascades. Urinary tract infections (UTIs) and ventilator-associated pneumonia (VAP) are associated with increased mortality in trauma patients. UTIs and VAPs induced inflammatory responses. We postulate that increased mortality seen in trauma patients with infections is caused by increased rates of cardiac injury. This is a retrospective review of prospectively collected data. All trauma patients admitted to the intensive care unit at our Level I trauma center during 5 years were included in the analysis. Proportional hazard regression analysis was performed to predict suspicion of cardiac injury (troponin ordered), any cardiac injury (troponin > 0.15 ng/mL), or severe cardiac injury (troponin > 1 ng/mL) using age, sex, Injury Severity Score (ISS), pulmonary disease (chronic obstructive pulmonary disease), heart failure, hypertension, diabetes, and the presence of a UTI or VAP. A similar proportion hazard regression was performed to predict mortality. In the model to predict any cardiac injury, chronic obstructive pulmonary disease (hazards ratio [HR], 1.9; p = 0.02), ISS (HR, 1.01; p = 0.04), VAP (HR, 5.6; p < 0.01), and UTI (HR, 2.4; p = 0.03) were significant. Neither VAP nor UTI predicted severe cardiac injury. In the model to predict death, any cardiac injury was not associated with mortality, but severe cardiac injury and UTI were associated with mortality as age increased. Infectious complications have been associated with increased mortality in trauma patients. Our data demonstrate that development of VAP or UTI is associated with an increased risk of developing cardiac injury in trauma patients, which may contribute to subsequent increased mortality. Prognostic/epidemiologic study, level III.

93 How can we Prevent Ventilator-Associated Pneumonia in PICU?

Ventilator-associated pneumonia (VAP) is a nosocomial infection that develops in patients on mechanical ventilation for 48 h or more. VAP has been classified into either early-onset pneumonia (EOP), if pneumonia...