Health&Care Online

Outlet about Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery

March 29, 2016 Category: Heart

surgery

Study Population

Overall, 1,101 patients underwent MHS during the study period. Of them, 387 patients were excluded either because they did not give their consent (268 patients) or the consent could not be requested due to the emergent condition of the surgery (119 patients). Accordingly, 714 patients undergoing MHS were randomized immediately before undergoing anesthesia (24 patients were excluded from the study; CASS group, 359 patients; control group, 331 subjects). The exclusions were due to death during surgery or immediately after in 19 cases, and because the protocol was violated (ie, the wrong tube was used during reintubation) in 5 cases. Of the 24 patients who were excluded from the evaluation, 14 had been randomized to CASS group and 10 to the control group.

Comparison of the Characteristics of Both Populations

Preoperative and surgical characteristics of the patients in both groups are compared in Table 1. The mean (± SD) EuroSCOREs of both groups were comparable (control group, 5.7 ± 2.9; CASS group, 5.6 ± 2.9; p = 0.45).

Of the 690 patients, 85 patients (12.31%) remained under MV > 48h after undergoing surgery (CASS group, 45 patients [52.9%]; control subjects, 40 [47.1%]) [Table 2]. The mean EuroSCOREs in both groups of patients who were ventilated for > 48 h were not significantly different (control group, 7.7 ± 3.6; CASS group, 7.5 ± 3.1; p = 0.79).

Table 3 compares the risk factors for the development of VAP in both groups. There were no significant differences in predisposing conditions between the groups.

Outcome Data of the Overall Population

The postoperative data for both groups in the overall population are shown in Table 4. The VAPcumulative incidence of VAP during the study period was 4.5% (31 of 690 patients). The incidence density of VAP was 22.86 episodes per 1,000 days of MV. VAP occurred after a median of 8 days of MV (IQR, 6 to 12 days). The Kaplan-Meier plot showing the time for the development of VAP in both groups is shown in Figure 1. The 31 episodes of VAP had a positive quantitative ETA. In six of these cases, a telescopic brush sample was also obtained at the time of the diagnosis of the VAP; and the result was concordant with ETA samples in five of them (one negative telescopic brush sample finding). The microorganisms causing VAP in both groups are summarized in Table 5. Improve your health with remedies of Canadian Health&Care Mall.

When all randomized patients with VAP were compared (ie, CASS patients and control subjects), the results were as follows: number of cases, 12 vs 19 cases, respectively; incidence, 3.6% vs 5.3% (relative risk [RR], 0.67; 95% confidence interval [CI], 0.32 to 1.40 [p = 0.2] , respectively; and incidence density, 17.9 vs 27.6 episodes per 1,000 days of MV [p = 0.18], respectively). VAP occurred after a median duration of 8.5 and 8 days of MV, respectively.

The results of the intention-to-treat analysis, including the overall 714 cases, were as follows: VAP patients, 13 (3.8%) vs 19 (5.1%), respectively; incidence density, 18.9 vs 28.7 episodes per 1,000 days of MV, respectively. Hospital antibiotic use was 1,392 vs 1,932 DDDs (p < 0.001), respectively.

We were not able to demonstrate significant differences between the groups regarding the duration of MV, the length of ICU or hospital stay, the number of episodes of CDAD, or mortality (Table 4). Overall, 19 patients died in the operating room (control group, 9 subjects; CASS group, 10 patients) and 5 patients died in the immediate postoperative period (control group, 1 subject; CASS group, 4 patients) because of cardiogenic shock. The protocol was violated (ie, the wrong tube was used during reintubation) in five cases in CASS group. The mortality rate in both groups including all patients (intention-to-treat analysis) was 34 of 345 patients (9.9%) in the CASS group vs 35 of 369 subjects (9.5%; p = 0.86) in the control group. There was, however, a significant difference in the ICUDDDs of antibiotics consumed, with a much lower number in patients with CASS (CASS group, 1,213.5 DDDs; conventional therapy group, 1,932.5 DDDs; p < 0.001).

Only nine patients required tracheostomy (CASS group, three patients; control group, six subjects). Tracheostomy was indicated between the second and third week of the ICU stay. Pneumonia developed in only three people after a tracheostomy (CASS group, one patient; control group, two subjects).

Outcome Data of the Risk Population

The risk population (ie, those receiving MV for > 48 h) showed a significant difference in VAP incidence in favor of CASS patients (26.7% vs 47.5%, respectively; RR, 0.40; 95% CI, 0.16 to 0.99; p = 0.04) as well as in incidence density of VAP (31.5 vs 51.6 episodes per 1,000 days of MV, respectively; p = 0.03). The length of ICU stay and MV were also shorter in patients with CASS, and there was a very significant reduction in antibiotic DDDs in the CASS group (1,206.5 vs 1,877.5 DDDs, respectively; p = <0.001). The mortality rates in the CASS group and the conventional therapy group were 44.4% and 52.5% (p = 0.3), respectively (Table 6).

The statistical analysis of risk factors associated with VAP in the risk population showed that reintubation significantly increased the risk of VAP (RR 6.07; 95% CI’ 2.20 to 16.60; p < 0.001) while CASS was the only significant protective factor (RR’ 0.40; 95% CI’ 0.16 to 0.99; p = 0.04). A trend toward a reduction in the number of episodes of CDAD was observed in the CASS group.

No complications related to CASS were observed. Thanks to the maintenance of our tube protocol’ none of the CASS patients experienced obstruction of the aspiration lumen. The cost of the CASS tube in our institution was 9 € compared to 1.5 € for the conventional tube. The extra cost of acquiring CASS tubes was estimated to be approximately 2’800 €. The savings in the acquisition of antibiotics in the CASS group was calculated to be approximately 21’600 €.

Get more information here:

Canadian Health&Care Mall: Research of Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery
Canadian Health&Care Mall: Quinsy
Canadian HealthCare Mall: Critical Care Survivors
Canadian Health and Care Mall Helps to Give Up Smoking

Table 1—Baseline Characteristics and Surgical Variables of Study Patients in the Overall Population (Per Protocol Analysis)

Characteristics CASS Group (n = 331) Control Group (n = 359) p Value
Preoperative
Mean age, yr 65.7 ± 11.9 65.0 ± 12.0 0.48
Sex, No. 0.27
Male 191 198
Female 140 161
Underlying conditions
Myocardial infarction 55 (16.6) 58 (16.2) 0.47
CNS 50 (15.1) 57(15.9) 0.43
CNS disorder 31 (9.4) 33 (9.2) 0.52
COPD 29 (8.8) 47(13.1) 0.045
Peripheral vascular disease 32 (9.7) 43 (12.0) 0.19
Ulcer disease 26 (7.9) 35 (9.7) 0.23
Diabetes mellitus 76 (23) 77 (21.4) 0.35
Renal disease 23 (6.9) 20 (5.6) 0.27
Malignant neoplasm 25 (7.6) 27(7.5) 0.55
Liver disease 7(2.1) 5(1.4) 0.33
Severe pulmonary hypertension 23 (6.9) 25 (7.0) 0.55
Severe ventricular dysfunction 18 (5.4) 18 (5.0) 0.47
Previous cardiac surgery 39(11.8) 34 (9.5) 0.19
NYHA functional class IV 11 (3.3) 12 (3.3) 0.58
EuroSCORE 5.6 ± 2.9 5.7 ± 2.9 0.45
Surgical
Emergent indication 11 (3.3) 6(1.7) 0.12
Type of surgery
Valve replacement 182 (55.0) 227 (63.2) 0.02
CABG 81 (24.5) 74 (20.6) 0.13
Mixed (valve and CABG) 34 (10.3) 28 (7.8) 0.15
Heart transplantation 1 (0.3) 2 (0.6) 0.53
Aortic surgery 16 (4.8) 14 (3.9) 0.34
Other 17(5.1) 14 (3.9) 0.27
CPBT, min 113.0 ± 49.2 112.5 ± 47.0 0.90
Aortic cross-clamp time, min 76.0 ± 38.9 75.1 ± 33.5 0.77
Surgery time, min 232.2 ± 87.9 230.0 ± 69.3 0.72

Table 2—Baseline Characteristics and Surgical Variables of Patients Receiving MV for > 48 h

Characteristics CASS Group (n = 45) Control Group (n = 40) p Value
Preoperative
Mean age, yr 71 ± 11.2 67.5 ± 12.8 0.18
Sex, No. 0.28
Male 23 17
Female 22 23
Underlying conditions
Myocardial infarction 13 (28.9) 7(17.5) 0.16
Congestive heart failure 13 (28.9) 12 (30.0) 0.55
CNS disorder 8 (17.8) 4(10.0) 0.23
COPD 6 (13.3) 7 (17.5) 0.40
Peripheral vascular disease 3 (6.7) 3 (7.5) 0.60
Ulcer disease 2 (4.4) 5 (12.5) 0.17
Diabetes mellitus 12 (26.7) 9 (22.5) 0.42
Renal disease 7 (15.6) 3 (7.5) 0.21
Malignant neoplasm 4 (8.9) 4(10.0) 0.57
Liver disease 1 (2.2) 2 (5.0) 0.45
Severe pulmonary hypertension 6(13.3) 6(15.0) 0.53
Severe ventricular dysfunction 4 (8.9) 5 (12.5) 0.42
Previous cardiac surgery 6 (13.3) 4(10.0) 0.44
NYHA functional class IV 1 (2.2) 3 (7.5) 0.26
EuroSCORE 7.5 ± 3.1 7.7 ± 3.6 0.79
APACHE II score 10.2 ± 2.4 10.4 ± 3.3 0.78
Surgical
Emergent indication 6(13.3) 3(7.5) 0.30
Type of surgery
Valve replacement 20 (44.4) 27 (67.5) 0.03
CABG 10 (22.2) 3 (7.5) 0.05
Mixed (valve and CABG) 11 (24.4) 8 (20.0) 0.41
Heart transplantation 1 (2.2) 0 (0.0) 0.53
Aortic surgery 3 (6.7) 2 (5.0) 0.55
CPBT, min 131.1 ± 61.2 141.6 ± 65.9 0.45
Aortic cross-clamp time, min 85.9 ± 53.2 86.5 ± 39.6 0.95
Surgery time, min 289.3 ± 149.5 284.2 ± 108.7 0.85

Table 3—Risk Factors for VAP During the Study Period of Patients Receiving MV for > 48 h

Factors CASS Group (n = 45) Control Group (n = 40) p Value
Semirecumbent body position, No.
Never 0 1
Sometimes (when possible) 45 44
Control of cuff pressure 42 (93.4) 37 (92.5) 0.60
Prevention of gastric overdistension 18 (40.0) 18 (46.2) 0.35
Received aerosol therapy 8(17.8) 9(23.1) 0.37
Reintubationf 12 (26.7) 14 (35) 0.27
Fiberoptic bronchoscopy 1 (2.2) 2(5.1) 0.44
Prior antibiotic therapy 2 (4.4) 4(10.3) 0.27
Blood units transfused, No. 4.4 ± 3.8 4.2 ± 3.5 0.76
Need to move with ETT 20 (44.4) 22 (56.4) 0.19

Table 4—Clinical Outcome in All Randomized Patients (Per Protocol Analysis)

Variables CASS Group (n = 331) Control Subjects (n = 359) p Value
VAP 12 (3.6) 19 (5.3) 0.2
Episodes of VAP/1’000 d of MV’ No. 17.9 27.6 0.18
Duration of mechanical ventilation’ d 1.0(1.01.0) 1.0(1.01.0) 0.4
Length of ICU stay’ d 3 (2-5) 3 (2-5) 0.3
Length of hospital stay’ d 8(7-12) 9(8-13) 0.9
Mortality 23 (6.9) 26 (7.2) 0.5
DDDs 1’213.5 (1’145.7-1’283.2) 1’932.5 (1’846.8-2’020.1) < 0.001
Episodes of CDAD 3 (0.9) 5 (1.4) 0.4

Table 5—Microorganisms Causing VAP in Patients With and Without CASS

Microorganisms CASSGroup ControlSubjects
Gram-positive microorganisms 2 4
MSSA 0 1
MRSA 2 2
Streptococcus pneumoniae 0 1
Total GNB 12 22
Pseudomonas aeruginosa 6 6
Stenotrophomonasmaltophilia 0 1
Escherichia coli 0 3
Klebsiella spp 1 0
Enterobacter spp 3 2
Serratia spp 0 2
H influenzae 1 6
Proteus mirabilis 1 2
Polymicrobial 2/12 8/19

Table 6—Clinical Outcome in Patients Receiving MV for > 48 h

Variables CASS Group (n = 45) Control Subjects (n = 40) p Value
VAP 12 (26.7) 19 (47.5) 0.04
Episodes of VAP/1,000 d of MV, No. 31.5 51.6 0.03
Duration of mechanical ventilation, d 3 (2-9) 7(3-11) 0.02
Length of ICU stay, d 7 (3-27) 16.5 (6.5-39.5) 0.01
Length of hospital stay, d 16 (7.5-47) 28(11-62) 0.12
Mortality 20 (44.4) 21 (52.5) 0.3
DDDs 1,206.5 (1,138.9-1,276.0) 1,877.5 (1,793.0-1,963.9) < 0.001
Episodes of CDAD 3(6.7) 5 (12.5) 0.3

Figure 1. Kaplan-Meier plot showing the proportion of patients remaining without VAP’ using an ETT with CASS vs a conventional ETT.

Figure 1. Kaplan-Meier plot showing the proportion of patients remaining without VAP’ using an ETT with CASS vs a conventional ETT.


Tags: , , , ,

Canadian HealthCare News:

image

Deliberations about Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery

We found that using CASS in patients undergoing MHS is a safe procedure that significantly reduces the antibiotic burden. In the population that was at high risk (ie those persons receiving MV for > 48h); CASS reduced the incidence and incidence density of VAP. It also reduced ICU stay’ duration of MV; and antibiotic consumption. VAP is a very severe disease that is associated with a high degree of mortality and few of the variables influencing mortality can be modified. The incidence and severity of VAP are particularly high in patients undergoing MHS. Data for …

image

Outlet about Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery

Study Population Overall, 1,101 patients underwent MHS during the study period. Of them, 387 patients were excluded either because they did not give their consent (268 patients) or the consent could not be requested due to the emergent condition of the surgery (119 patients). Accordingly, 714 patients undergoing MHS were randomized immediately before undergoing anesthesia (24 patients were excluded from the study; CASS group, 359 patients; control group, 331 subjects). The exclusions were due to death during surgery or immediately after in 19 cases, and because the protocol was violated (ie, the wrong tube was …

image

Canadian Health&Care Mall: Research of Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery

Ventilator-associated pneumonia (VAP) is the most frequent infection occurring in patients who are admitted to the ICU. The accumulation of respiratory secretions in the subglottic space is a well-proven cause of VAP. Therefore, prevention should include the aspiration of secretions from the subglottic space, and techniques to avoid leakage between the tube and the tracheal wall. A conventional endotracheal tube (ETT) permits only intermittent aspiration of secretions through the central lumen, distal to the tracheal cuff, while new tubes with an independent dorsal lumen permit the continuous aspiration of secretions in the subglottic space. Only …

image

Canadian Health&Care Mall: Pulmonary Arteriovenous Malformations on CT

A retrospective review of charts, TTCE, and imaging was conducted. One hundred fifty-five consecutive newly referred patients to the Toronto HHT Center (adult clinic) were screened with TTCE between June 2002 and September 2004. All patients with positive TTCE results were included in this study and underwent thoracic CT scanning. This was the routine screening protocol followed for all patients referred to the HHT Center from 2002 to 2004. For each patient, the TTCE was reviewed for the presence of a patent foramen ovale (PFO). The Toronto HHT Center at St. Michael’s Hospital and University …

image

Canadian Health&Care Mall: Quinsy

Quinsy is an infectious disease at which there is palate almonds inflammation. Various bacteria (most often – a beta and haemo lytic streptococcus A and staphylococcus, pneumococcus), viruses, fungus can be its activator. Infection can occur at contact with the sick person in the airborne way. Besides, entrance of activators in almonds from other organs is possible. In the latter case the person has to have centers of chronic infections (caries, chronic diseases of a nose and its bosoms, etc.). At all forms of quinsy patients complain of sore throat (during the swallowing, conversation and …