Medicine of the Future in America

Preventing Ventilator-Associated Pneumonia in Adults: Patient Position

Preventing Ventilator-Associated Pneumonia in Adults: Patient PositionIn contrast to rotational beds, semirecumbent patient position is a low-cost, easily accessible intervention, and may be a more practical and more tolerable approach than rotational beds or prone body position. Maintaining patients who are receiving mechanical ventilation or who are enterally fed in a 30° to 45° semirecumbent position, particularly during enteral feeding, continues to be strongly recommended based on the VAP reduction in one randomized study. so
A more recent study by van Nieuwenhoven et al, in which patients receiving mechanical ventilation were randomly assigned to backrest elevation of 45° vs the standard of 10°, demonstrated barriers to implementing this strategy. Backrest elevation was measured continuously during the first week of ventilation with a monitoring device. The targeted backrest elevation of 45° was not reached; the actual achieved difference was 28° vs 10°, which did not reduce VAP. Similarly, Grap and Munro monitored patient position in ICU patients using a bed frame elevation gauge or electronic bed readout and found very low compliance with maintaining semirecum-bent patient position, with a mean backrest elevation of only 19.2° with 70% of subjects maintained in a supine position. Maintaining patients receiving mechanical ventilation or who are enterally fed in a semirecumbent position may need to evaluate more realistic targets.
Hypergylcemia, relative insulin deficiency, or both may directly or indirectly increase the risk of complications and poor outcomes in critically ill patients. Initial randomized studies of intensive insulin therapy to maintain blood glucose levels between 80 and 110 mg/dL in surgical ICU patients had lower overall mortality (4.6% vs 8%, p < 0.04) and was greater for those with ICU stays > 5 days (10.6% vs 20.2%, p = 0.005), coupled with a 46% reduction of bloodstream infections, decreased acute renal failure, fewer antibiotic treatment days, and significantly shorter length of mechanical ventilation and ICU stay.
To address risk-benefit issues, Egi and col-leagues, using a retrospective outcome study of intensive insulin therapy (ITT), reported that hypoglycemia in SICU patients varied from 1.4 to 2.7%, and estimated that the number of patients needed to be treated to save one life varied from 38 to 113, whereas the rate of hypoglycemia (number needed to harm) varied from 7 to 13 patients.

This entry was posted in Pulmonary function and tagged antibiotics, evidence-based data, guidelines, infection control, Institute for Healthcare Improvement, intensive care, prevention of hospital-acquired pneumonia, ventilator-associated pneumonia.
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