paediatric intensive care unit... · culture -organisms (legionella, aspergillus, mycobacteria,...

of 13 Title: Prevention of Ventilator Associated Pneumonia V:2 Approved by: PICU Clinical Practice Group: October 2019 Next Review: October 2022 Trust Ref No: C43/2016 NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.

Paediatric Intensive Care Unit

Ventilator Associated Pneumonia UHL Childrens Intensive Care Guideline

Staff relevant to: Medical and Nursing staff caring for children in the PICU

Approval date: October 2019

Version: 2

Revision due: October 2022

Written by: Revised by:

Simon Robinson, Claire Westrope Pompa Dutta

Trust Ref: C43/2016

Related Guidelines and Policies:

B54/2017 UHL Paediatric NG tube policy

C90/2016 Feeding guidelines for Children on Intensive Care Units

1. Introduction and who this guideline applies to

The aim of this guideline is to prevent the development of ventilator associated pneumonia (VAP) in the critically ill neonate or child. This guideline is relevant to all medical and nursing staff involved in patient care on the paediatric critical care unit and children’s intensive care unit at University Hospitals of Leicester NHS Trust.

VAP remains an important cause of morbidity and mortality in the critically ill and post-operative patients receiving mechanical ventilation. Far less is known about the risk factors, epidemiology, and outcomes of VAP in infants and children than in adults. There is no gold standard definition of VAP in adults or paediatrics 1.

VAP is the second most common hospital acquired infection in paediatric intensive care unit (PICU) patients, accounting for 20% of such infections in this population. In the US National Nosocomial Infection Surveillance (NNIS) hospitals, the mean paediatric VAP rate was 2.9/1000 ventilator days for PICU patients – approximately half of the adult rate. The highest age-specific rates of VAP

occurred in the 2-month to 12-month age group, and the most common causative organism was P aeruginosa, which accounted for 22% of cases. In both the PICU and NICU, VAP increases the number of days the child spends on mechanical ventilation, length of stay, mortality, and hospital costs2-4. In the PICU, VAP extends hospital stay by an average of 8.7 days and has been shown in the US to increases hospital cost by $51,157. One paediatric study demonstrated mortality increasing from 7.2 to 19.1% in those who developed a VAP3.


Figure 1.

NO YES YES NO

NO YES

NO YES YES NO

Not a VAP Not a VAP

Not a VAP

Clinically Defined

VAP VAP with specific

laboratory findings

Not a VAP

Patient currently or within 48 hours of discontinuation of invasive ventilation (via ETT or tracheostomy)?

AGE <1 YEAR

AGE >1 YEAR

Symptoms of VAP? Worsening gas exchange (E.g. desaturation, ↑FiO2 requirements by ≥ 10% or ↑ ventilation demand) and 3 of:

Temperature > 38.5oC or

< 36oC

Leukopenia/leukocytosis (defined by age)

New or ↑amount/purulence of secretions

New or ↑ respiratory distress, tachypnoea, or apnoeas

Tachycardia (HR > 170) or bradycardia(HR < 100)

Symptoms of VAP? At least 3 of:

Worsening gas exchange (e.g. desaturation, ↑FiO2 requirements by ≥ 10% or ↑ventilation demand)

Temperature > 38.5oC or

< 36oC

Leukopenia/leukocytosis (defined by age)

New or ↑amount/purulence of secretions

New or ↑respiratory distress, tachypnoea, or apnoeas

Underlying Pulmonary or Cardiac Disease?

Radiographic Evidence of VAP? One or more serial CXRs with 1 of: New/progressive pulmonary infiltrates

Consolidation

Cavitation

Pneumatoceles

Radiographic Evidence of VAP? Two or more serial CXRs with 1 of: New/progressive pulmonary infiltrates

Consolidation

Cavitation

Microbiological Evidence of VAP? -BSI* not related to another source of infection

4 cfu/ml

nia or positive on culture

-organisms (Legionella, Aspergillus, mycobacteria, mycoplasma, Pneumocystis carinii) :

- positive detection of viral antigen or PCR from respiratory secretions

- positive viral culture or visualisation by immunofluorescence from bronchial secretions or tissue

- four-fold rise in paired sera (IgG) - e.g. influenza viruses, Legionella, Chlamydia

- detection of antigens in urine - Legionella

In addition, if immunocompromised (including steroids >2 weeks):

- matching positive blood & sputum cultures# with Candida spp. - BAL evidence of fungi or Pneumocystis carinii (microscopy or culture)


2.1 Definition: Ventilator Associated Pneumonia (VAP) is pneumonia occurring in a patient 48 hours or more after intubation with an endotracheal tube or tracheostomy tube and which was not present before (2005). This definition was further revised and classified into 3 categories (PNU1, PNU2, PNU3) with alternative criteria for infants and children.

1) PNU1 (Clinical defined pneumonia) I) for any patient II)alternative criteria for infant <1year of age & for child >1year old or < 12 years old

2) PNU2 (Pneumonia with specific laboratory findings)

3) PNU3 (Pneumonia in Immunocompromised patients)

CDC offers an adult definition (2013), however this hasn’t been uniformly adopted by paediatric population.

Ventilator associated events (VAE) tier

Requirement and criteria

1 Ventilator associated condition (VAC)

Prerequirement: patient is required to have a baseline period of stability or improvement on ventilator for > 2 calendar days of stable or decreasing *daily minimum FiO2 or PEEP values. VAC criteria: 1. Increase FiO2 >0.2 or PEEP >3cmH2O; 2. Sustained for 2 days. *daily minimum defined by the lowest value of FiO2 or PEEP during a calendar day that is maintained for at least 1 h.

2 Infection – related ventilator associated complication (IVAC)

Prerequirement: patient is requird to meet the VAC criteria IVAC criteria: 1. Temperatures <36 or 38> or abnormal white blood cells count (<4000cells/ml or >12000cells/ml); 2.New antimicrobial agent is started and continued for >4 days within 2 days of the increase in PEEP or FiO2.

3 Possible ventilator – associated pneumonia (PVAP)

Prerequirement: patient is required to meet the IVAC criteria PVAP criteria: 1. Positive culture of respiratory secretion (via endotracheal aspirate, BAL, lung tissue, or protected specimen brush) met the quantitative or semiquantitative tresholds OR; 2. Purulent respiratory secretions and positive culture via specimens in criteria 1 but not meeting those tresholds for growth OR; 3.One positive test from pleural fluid or lung histopathology or diagnostic test for Legionella species or respiratory secretion positive for viral organism, within 2 calendar days of meeting the IVAC criteria.

2.2 Diagnosis: The clinical criteria used to diagnosis VAP in infants and children are different to adults. Although currently in use for diagnosis and surveillance, the clinical criteria for VAP in infants younger than 1 year are not specific for low birth weight infants and have not been validated in neonates. Despite having specific criteria, the recognition of VAP is more challenging in paediatric patients, particularly in ventilated neonates, who usually have coexisting pulmonary disease. These comorbid conditions can confound the diagnosis of VAP as well as VAP surveillance efforts. The flow diagram (Figure 1.) on page 2 has been developed to aid in the diagnosis and categorisation of ventilator associated pneumonia.


Excluded organisms that cannot be used to meet the PNEU/VAP definition are as follows:

a. “Normal respiratory flora,” “normal oral flora,” “mixed respiratory flora,” “mixed oral flora,” “altered oral flora” or other similar results indicating isolation of commensal flora of the oral cavity or upper respiratory tract

b. The following organisms unless identified from lung tissue or pleural fluid (where specimen was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube):

i. Any Candida species as well as a report of “yeast” that is not otherwise specified

ii. Any coagulase-negative Staphylococcus species

iii. Any Enterococcus species

*The exception to this is Candida species or yeast not otherwise specified identified from blood can be attributed as a secondary BSI to PNEU if PNU3 is met using the blood and a sputum, endotracheal aspirate, BAL or protected specimen brushing with matching Candida species and both specimens have a collection date in the Infection Window Period.

2.3 Risk factors for VAP:

In infants and children risk factors vary somewhat from those in adults, and in many instances are processes of care common in the ICU.

VAP in neonates is associated with -

duration of mechanical ventilation,

reintubation,

endotracheal suctioning,

treatment with opiates

In older infants and children, VAP is also associated with various conditions -

subglottic or tracheal stenosis,

trauma,

tracheostomy,

genetic syndromes

interventions (presence of a central line, multiple central venous catheters, bronchoscopy, thoracocentesis, burn debridement, and transport out of the ICU).

2.4 Prevention of VAP: In adult intensive care patients, VAP is believed to be caused by aspiration of oropharyngeal secretions, inhalation of contaminated aerosols, or bacterial translocation from a contaminated gastrointestinal tract. It is not known whether these same mechanisms operate in mechanically ventilated infants and children, but in the absence of definitive data, they are used as the basis for VAP prevention interventions. Recommended adult VAP care bundle (currently in practice as per the Glenfield Adult ITU Guideline) Elevation of head of bed to 35-40 degrees

Sedation holds

Deep vein prophylaxis

Gastric ulcer prophylaxis

Glucose control


Appropriate humidification of inspired gas

Appropriate tubing management

Suction of respiratory secretions as per local policy

Routine oral hygiene as per local policy Practices to prevent VAP, initially developed for the adult population, have often been modified for neonatal and paediatric application, but few of these recommendations have been formally studied. Because the epidemiology of VAP in infants and children is not as well understood as it is in adults, many currently recommended prevention measures not extrapolated from adult guidelines are based on biological plausibility and common sense.

2.4 Recommended prevention measures in PICU: a) Reducing the duration of ventilation

The principle of continuous assessment for readiness to wean - and extubation as soon as possible - to reduce the duration of intubation is very important in paediatric and neonatal patients. While daily sedation holidays are not yet validated in paediatric patients and not recommended due to the risk of unplanned extubation, it is important to have a sedation guideline (COMFORT Scoring in the Leicester PICUs) that prevents over-sedation. Unplanned extubation and reintubation has been shown to be a contributing factor to VAP4. Heavy sedation and decreased respiratory drive precludes ventilator weaning and clinical practice should include a daily assessment of readiness for extubation.

b) Preventing micro-aspiration of contaminated secretions

In adults, most cases of VAP are thought to be preceded by micro-aspiration of contaminated oropharyngeal secretions. In infants and children, in the absence of a cuffed tube, it is theoretically easier for secretions to be aspirated into the lung. In the presence of cuffed tubes, secretions pool above the cuff and become a source of contamination. Naso and oropharyngeal secretions should always be removed in intubated patients and the mouth should always be suctioned before the nose using an uncontaminated suction device. Where multi-use suction devices are used they should be placed in a clean non-sealed plastic bag when not it use.

c) Eliminate routine use of saline to clear secretions

Whilst common practice as it is believed to prevent blockage of the ET tube and lower airways, there is no evidence to support its practice5, 6. There is however evidence that flushing the ET tube may deposit the biofilm coating on the tube into the lung and therefore contribute to VAP7, 8. The change of practice relating to this recommendation has proved challenging to many units as it has been ingrained in routine care.

d) ET tube care

An endotracheal tube increases the risk for bacterial colonization and infection and limits the defence mechanisms of the upper airway by interfering with the normal actions - coughing, mucociliary clearance and swallowing. All Aspects of ETT tube care, including intubation should include good habits and practice that minimises risk of contamination (Wash Hands, Wear Apron and Gloves, Single use laryngoscope blades, protect ETT tube if problems inserting etc)


e) Elevating head of bed

Elevation of the head of the bed has been shown to be beneficial in adults and positioning has been shown to be beneficial in neonates at reducing VAP9. The supine position is believed to contribute to micro-aspiration of both gastrointestinal contents and oral secretions10. Consequently, a primary VAP prevention recommendation for adults is to keep the patient in a semi-recumbent position. As in adult patients, the head of bed (HOB) of paediatric patients should be elevated to a 30 to 45-degree angle unless contraindicated by the patient's condition.

In neonates, a similar effect is achieved by positioning the incubator or radiant warmer mattresses in the reverse Trendelenburg position at an angle of 15-30 degrees (rather than 30-45 degrees) because the greater angle is difficult to maintain in very small patients.

f) Prevent contamination of equipment

NICU and PICU staff should follow all of the same general infection control measures related to respiratory equipment, ventilator circuits, suction systems, hand washing, and environmental decontamination that are observed when caring for adults. Hand hygiene must be meticulous before handling respiratory equipment or performing any type of airway care. Changing ventilator circuits and in-line suction catheters on a routine schedule is not currently recommended - instead, they should be changed when visibly soiled. However, research regarding the effectiveness of these practices in paediatric and neonatal populations is lacking. Care of the ventilator includes clearing the circuit of condensate and preventing condensate from draining into the patient's airway and washing the biofilm into the patient’s lungs9 – see Figure 2 below. Clearing the tubing and checking tube positioning should take place on a routine basis (e.g. every 2 hours) and before a patient is repositioned or moved for transport. This should occur without disconnecting the circuit. Heated ventilator circuits are preferred in infants and children.

Figure 2.

Positioning of Endotracheal tube and Ventilator Tubing - To minimise water from vent circuit entering the patient

ETT Vertical with tubing below Minimal ‘condensate’ will drain into patient

ETT Connector below patient entry point ‘Condensate’ will drain to the connector with the ventilator tubing


g) Correct NG or OG tube placement and care

The proper placement of a nasal or oral gastric tube decreases the chance of stomach contents being aspirated. By both noting what length the NG tube is inserted and aspirating it every 4 hours, the risk of misplacement can be minimised and feed tolerance can be assessed11,12. High residual volumes of gastric contents have been shown to increase the likelihood of regurgitation and aspiration13. However, several studies have shown that measurement of gastric residuals correlates poorly with aspiration risk and is associated with a decrease in calorie delivery. 27-29 The rate of VAP is not higher in patients who did not undergo monitoring of gastric residuals. Based on that, routine check of gastric residual volumes in asymptomatic patients receiving tube feeding is not recommended.29

h) Oral Hygiene

Oral hygiene in children is essential for the development of strong, healthy teeth and to minimize the risk of infection (Thomson, Ayers, & Broughton, 2003). In the critical care setting, poor oral hygiene has been associated with increased dental plaque accumulation, bacterial colonization of the oropharynx, and higher nosocomial infection rates, particularly ventilator-associated pneumonia14-16. The Institutue for Health Improvement (IHI)'s VAP prevention paediatric supplement recommends "comprehensive mouth care appropriate to the age of the patient”. i) Stress Ulcer Prophylaxis

Whilst a routine part of adult VAP prevention bundles, there is no evidence to suggest its use prevents VAP in the paediatric population17, 18. The latest evidence (all in adults) suggests that:

among patients NOT receiving early enteral nutrition, H2 blockers (Ranitidine) reduce incidence of GI bleeding; effect on mortality or hospital acquired pneumonia is not significant

among patients on early enteral feeding, H2 blockers (Ranitidine) may increase mortality and incidence of hospital acquired pneumonia, without reducing the rate of GI bleeding –

early enteral feeding may reduce the risk of GI bleeding25 There is good evidence that Ranitidine therapy is associated with increased rate of infections, NEC (incidence with Ranitidine is 37.4%; without Ranitidine 9.8%) and mortality in premature neonates (nearly 6times more likely to die if they received ranitidine)26. To summarise:

Ranitidine should be used as SUP for critically ill children to prevent GI bleeding in our unit except premature neonates.

Ranitidine should be considered with prolonged or high doses of glucocorticoids (Dexamethasone…)

Ranitidine should be stopped once feeding has been established – agreement in our unit is 2/3 of full feeds.

2.5 Surveillance: Surveillance is standardised across both adults and paediatric intensive care with the rate calculated per 1000 ventilator days. All suspected cases of VAP should be reviewed and strictly determined in agreement with the defined criteria to ensure consistency of the data. The action of surveillance and implementation of a VAP bundle has been shown to reduce


the rate of VAP occurrence. Target rates of adherence to the VAP bundle and reduction in the rate of VAPs occurring will be set out through the PICU Clinical Risk Committee and Clinical Practice Meetings. The recording and any reduction in rate of VAP would be a suitable CQUIN. Monitoring VAP Bundle Compliance

VAP Rate per 1000 ventilator days.

3. Education and Training

Training and raising awareness are on-going processes. On-going awareness is promoted through the induction and continuous bedside teaching. Training is provided for medical staff during lunchtime teaching (Wednesdays) and other sessions, and at junior doctors’ induction training. Nursing education is supported by the Practice Development teams, and nursing educators.

4. Monitoring Compliance

What will be measured to monitor compliance

How will compliance be monitored

Monitoring Lead

Frequency Reporting arrangements

None identified at present

5. Supporting References

1. Gauvin F, Dassa C, Chaibou M, Proulx F, Farrell CA, Lacroix J. Ventilator-associated pneumonia in intubated children: comparison of differentdiagnostic methods. Pediatr Crit Care Med. 2003; 4(4): 437-43.

2. Almuneef M, Memish ZA, Balkhy HH, Alalem H, Abutaleb A. Ventilator-associated pneumonia in a pediatric intensive care unit in Saudi Arabia: a30-month prospective surveillance. Infect Control Hosp Epidemiol. 2004;25(9): 753-8.

3. Bigham MT, Amato R, Bondurrant P, Fridriksson J, Krawczeski CD, RaakeJ, et al. Ventilator-associated pneumonia in the pediatric intensive careunit: characterizing the problem and implementing a sustainable solution. JPediatr. 2009; 154(4): 582-7 e2.

4. Elward AM, Warren DK, Fraser VJ. Ventilator-associated pneumonia inpediatric intensive care unit patients: risk factors and outcomes. Pediatrics.2002; 109(5): 758-64.

5. Morrow BM, Argent AC. A comprehensive review of pediatric endotrachealsuctioning: Effects, indications, and clinical practice. Pediatr Crit CareMed. 2008; 9(5): 465-77.

6. Shorten DR, Byrne PJ, Jones RL. Infant responses to saline instillationsand endotracheal suctioning. J Obstet Gynecol Neonatal Nurs. 1991;20(6): 464-9.

7. Freytag CC, Thies FL, Konig W, Welte T. Prolonged application of closedin-line suction catheters increases microbial colonization of the lowerrespiratory tract and bacterial growth on catheter surface. Infection. 2003;31(1): 31-7.

8. Kollef MH, Afessa B, Anzueto A, Veremakis C, Kerr KM, Margolis BD, etal. Silver-coated endotracheal tubes and incidence of ventilator-associatedpneumonia: the NASCENT randomized trial. JAMA. 2008; 300(7): 805-13.

9. Aly H, Badawy M, El-Kholy A, Nabil R, Mohamed A. Randomized,controlled trial on tracheal colonization of ventilated infants: can gravityprevent ventilator-associated pneumonia? Pediatrics. 2008; 122(4): 770-4.

10. Foglia E, Meier MD, Elward A. Ventilator-associated pneumonia inneonatal and pediatric intensive care unit patients. Clin Microbiol Rev.2007; 20(3): 409-25, table of contents.

11. Pruitt B, Jacobs M. Best-practice interventions: How can you preventventilator-associated pneumonia? Nursing. 2006; 36(2): 36-41; quiz -2.


12. Best C. Caring for the patient with a nasogastric tube. Nurs Stand. 2005;20(3): 59-65; quiz 6.

13. Metheny NA. Preventing respiratory complications of tube feedings:evidence-based practice. Am J Crit Care. 2006; 15(4): 360-9.

14. Fourrier F, Duvivier B, Boutigny H, Roussel-Delvallez M, Chopin C.Colonization of dental plaque: a source of nosocomial infections inintensive care unit patients. Crit Care Med. 1998; 26(2): 301-8.

15. Franklin D, Senior N, James I, Roberts G. Oral health status of children ina Paediatric Intensive Care Unit. Intensive Care Med. 2000; 26(3): 319-24.

16. Munro CL, Grap MJ. Oral health and care in the intensive care unit: stateof the science. Am J Crit Care. 2004; 13(1): 25-33; discussion 4.

17. Lopriore E, Markhorst DG, Gemke RJ. Ventilator-associated pneumoniaand upper airway colonisation with Gram negative bacilli: the role of stressulcer prophylaxis in children. Intensive Care Med. 2002; 28(6): 763-7.

18. Yildizdas D, Yapicioglu H, Yilmaz HL. Occurrence of ventilator-associatedpneumonia in mechanically ventilated pediatric intensive care patientsduring stress ulcer prophylaxis with sucralfate, ranitidine, and omeprazole.J Crit Care. 2002; 17(4): 240-5.

19. Brilli RJ, Sparling KW, Lake MR, Butcher J, Myers SS, Clark MD, et al.The business case for preventing ventilator-associated pneumonia inpediatric intensive care unit patients. Jt Comm J Qual Patient Saf. 2008;34(11): 629-38.

20. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition ofhealth care-associated infection and criteria for specific types of infectionsin the acute care setting. Am J Infect Control. 2008; 36(5): 309-32.

21. Fourrier F, Cau-Pottier E, Boutigny H, Roussel-Delvallez M, Jourdain M,Chopin C. Effects of dental plaque antiseptic decontamination on bacterialcolonization and nosocomial infections in critically ill patients. IntensiveCare Med. 2000; 26(9): 1239-47.

22. Curley MA, Schwalenstocker E, Deshpande JK, Ganser CC, Bertoch D,Brandon J, et al. Tailoring the Institute for Health Care Improvement100,000 Lives Campaign to pediatric settings: the example of ventilator-associated pneumonia. Pediatr Clin North Am. 2006; 53(6): 1231-51.

23. Grap MJ, Munro CL, Elswick RK, Jr., Sessler CN, Ward KR. Duration ofaction of a single, early oral application of chlorhexidine on oral microbialflora in mechanically ventilated patients: a pilot study. Heart Lung. 2004;33(2): 83-91.

24. Susan E Coffin MM, Michael Klompas MD, David Classen MM, KathleenM. Arias MC, Kelly Podgorny RMC, Deverick J. Anderson MM, et al.Strategies to Prevent Ventilator-Associated Pneumonia in Acute CareHospitals. Infection Control and Hospital Epidemiology. 2008; 29(S1): S31-S40.

25. Marik P. Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis. Crit Care Med 2010;38(11):2222.

26. Terrin G, Passariello A, De Curtis M, Canana RB. Ranitidine is associated with infections, NEC, and fatal outcome in newborns.Pediatrics 2012,129;1-6.

27. McClave SA, Lukan JK, Gleeson K. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med 2005;33(2):324

28. Kuppinger DD, Rittler P, Hartl WH. Use of gatric residual volume to guide enteral nutrition in critically ill patients: a brief systematic review of clinical studies. Nutrition 2013, 29 (9) 1075-9.

29. Elke G, Felbinger TW, Heyland DK. Gastric residual volume in critically ill patients: a dead marker or still alive. Nutr Clin Pract 2015, 30 (1) 59 - 71.

6. Key Words

Ventilator associated pneumonia, VAP, ventilator associated condition, VAC

_________________________________________________________


The Trust recognises the diversity of the local community it serves. Our aim therefore is to provide a safe environment free from discrimination and treat all individuals fairly with dignity and appropriately according to their needs. As part of its development, this policy and its impact on equality have been reviewed and no detriment was identified.

CONTACT AND REVIEW DETAILS

Guideline Lead (Name and Title) C Westrope – Consultant P Dutta - Consultant

Executive Lead Chief Nurse

Details of Changes made during review: 2.1 Definition Added – 3 categories of classification of VAP Added – CDC Definition Figure 1 Flow diagram diagnosis and categorisation of ventilator associated pneumonia moved to front of document Added - In addition, if immunocompromised (including steroids >2 weeks):

Added section 2.2 - Diagnosis, including information regarding excluded organisms Added section 2.3 – Risk factors Added section 24. – Prevention of VAP 2.4 Recommended prevention measures in PICU g) However, several studies have shown that measurement of gastric residuals correlates poorly with aspiration risk and is associated with a decrease in calorie delivery.

27-29

The rate of VAP is not higher in patients who did not undergo monitoring of gastric residuals. Based on that, routine check of gastric residual volumes in asymptomatic patients receiving tube feeding is not recommended.

29

i)Stress Peptic Ulcer Prophylaxis

Amended/Added - Whilst a routine part of adult VAP prevention bundles, there is no evidence to suggest its use prevents VAP in the paediatric population

17, 18. However, it may be used as part of routine PICU care and

increasing the gastric pH may theoretically decrease the pulmonary inflammatory response if aspiration occurs. The latest evidence (all in adults) suggests that:

among patients NOT receiving early enteral nutrition, H2 blockers (Ranitidine) reduce incidence of GI bleeding; effect on mortality or hospital acquired pneumonia is not significant

among patients on early enteral feeding, H2 blockers (Ranitidine) may increase mortality and incidence of hospital acquired pneumonia, without reducing the rate of GI bleeding –

early enteral feeding may reduce the risk of GI bleeding25

There is good evidence that Ranitidine therapy is associated with increased rate of infections, NEC (incidence with Ranitidine is 37.4%; without Ranitidine 9.8%) and mortality in premature neonates (nearly 6times more likely to die if they received ranitidine)

26.

To summarise:

Ranitidine should be used as SUP for critically ill children to prevent GI bleeding in our unit except premature neonates.

Ranitidine should be considered with prolonged or high doses of glucocorticoids (Dexamethasone…)

Ranitidine should be stopped once feeding has been established – agreement in our unit is 2/3 of full feeds.

2.5 Surveillance Removed - Any suspected VAP should have a datix reporting form completed and will be reviewed both as part of the datix review system and by the PICU Clinical Risk Committee. This will ensure it meets the standardised criteria and will maintain a record VAPs to correlate with the number of ventilator days. Appendix 1 Removed -

Peptic Ulcer Prophylaxis

Appropriate to the age and clinical condition of the child

Currently used to clear or loosen secretions Added appendix 2 – Oral hygiene

Reformatted throughout


Appendix 1.

PICU VAP Care Bundle

Elevate the head of the bed to 15-30% for neonates

30-45% for infants and older

Daily assessment and documentation in rounds of ‘Readiness to Extubate’ Ensure sedation optimal and COMFORT Score target set

Perform Mouth Care every 2 hrs appropriate to age of patient Refer to the PICU/CICU oral hygiene policy (see appendix 2)

Keep ventilator circuit free of condensate by draining every 2-4hrs Without disconnection if possible

Dependent tubing Keep the ventilator tubing below the level of the patient so any condensate does not drain into the lungs

Stop routine saline flushing of the endotracheal tube

Change ventilator circuits and in line suction devices only when visibly soiled

Use meticulous hand hygiene before and after contact with ventilator circuits

Keep end of ventilator circuit, suction devices and manual bagging circuits and masks off the bed. Store in clean, non-sealed plastic bags when not in use

Correct positioning of Nasogastric Tube, avoid gastric over- distention

DVT Prophylaxis Appropriate to the age and clinical condition of the child


Appendix 2: Oral hygiene guideline for the ventilated patient or those with lowered CGS in PICU

Infants and children with teeth <6 years old

12 hourly Brush child’s teeth with

small, soft toothbrush and a smear of fluoride toothpaste-

suction out excess toothpaste but do not rinse

Explain procedure to patient and family

Wash and dry hands

Put on apron and gloves

ORAL ASSESSMENT-Brushed Teeth B-Bleeding (gums, mucosa, coagulation status?) R-redness (gums, stomatitis, tongue?) U-ulceration (size, shape, number, location, infected?) S-saliva (consistency, hyper/hyposecretion?) H-halitosis (character, acidosis, infected?) E-external factors (ETT tapes/ribbon, braces, angular cheilios) D-debris (plaque, thrush, foreign particles?) T-teeth (decay, loose, broken, swelling, abscess?)

Children with teeth >6 years old

6 hourly Cleanse mouth with soft foam swabs soaked in clean water, followed by swab soaked in Nystatin if the patient is on

antibiotics, coat lips with soft yellow paraffin.

6 hourly Cleanse mouth with soft

foam swabs soaked in clean water, followed by swab soaked in Nystatin if the

patient is on antibiotics, coat lips with soft yellow paraffin.

12 hourly Chlorhexidine mouth rinse

0.1%, irrigate with a syringe or wipe oral mucosa with foam

swab, suction out excess solution but do rinse. Use at

least 30 minutes after brushing teeth with toothpaste

6 hourly Cleanse mouth with soft foam swabs soaked in clean water, followed by swab soaked in Nystatin if the patient is on

antibiotics, coat lips with soft yellow paraffin.

Neonates and Infants with no teeth

12 hourly Brush child’s teeth with a small, soft toothbrush and a smear of fluoride toothpaste-suction out excess toothpaste but do not

rinse

Remove gloves, wash and dry hands, document assessment findings and procedure.




Oral hygiene guideline for highly dependant patients in a PICU or ward area.

HDU children that are eating and drinking regularly (full oral intake).

ORAL ASSESSMENT-Brushed Teeth B-Bleeding (gums, mucosa, coagulation status?) R-redness (gums, stomatitis, tongue?) U-ulceration (size, shape, number, location, infected?) S-saliva (consistency, hyper/hyposecretion?) H-halitosis (character, acidosis, infected?) E-external factors (ETT tapes/ribbon, braces, angular cheilios) D-debris (plaque, thrush, foreign particles?) T-teeth (decay, loose, broken, swelling, abscess?)

12 hourly Brush child’s teeth with a small soft toothbrush and a smear

of fluoride toothpaste (encourage child or family to do this)

Spit out excess toothpaste but do not rinse or allow them to

swallow

Document assessment findings and procedure.

paediatric intensive care unit... · culture -organisms (legionella, aspergillus, mycobacteria,...

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