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Critical Care Issues in Mechanical Ventilation 501

Other methods have been described in the prevention of VAP. However, the ef-
fectiveness of these methods does not have universal agreement, and their use is
controversial. More clinical studies may be needed to validate their use. In a 2006
publication, Koenig et al. do not support the routine use of ET tubes with subglot-
tic suction capabilities, rotational beds, inline suction systems, rotational antibi-
otic schemes, or selective gut decontamination. Selective gut decontamination is a
practice widely used in Europe in the prevention of VAP, but its effectiveness is not
universal in the United States. The reason may be attributed to the regional drug
resistance in the ICU (Darves, 2005). In the future, clinical experience and evidence
may add to the knowledge of VAP and the methods for prevention of VAP.

Treatment of VAP

In the management of VAP, most research studies recommend empiric broad-spec-
In the management of
VAP, most research studies trum antibiotics that cover pathogens resistant to multiple drugs. Modifications of
recommend empiric broad- drug therapy can be made after determination of the sensitivities of the causative
spectrum antibiotics that
cover pathogens resistant to organism. Knowledge of organisms that cause VAP (e.g., early- or late-onset VAP)
multiple drugs.
in the individual ICU and the pattern of antibiotic resistance can help to choose
the most appropriate and effective broad-spectrum antibiotics (Koenig et al., 2006;
Torres et al., 2004).

For patients already In general, for patients already onantibiotics at the time of suspected VAP, the an-

onantibiotics at the time of tibiotics chosen should be from different classes, as it is likely that resistance to “in-

suspected VAP, the antibiotics
chosen should be from use” antibiotics has already developed. Assessment of the presence of VAP should
different classes, as it is likely be repeated by day 3, using the modified clinical pulmonary infection score (CPIS)

thatresistance to “in-use”

antibiotics has already (Table 15-6). Any change in CPIS can guide clinical decisions on the continuing
developed. use, selection, or stoppage of antibiotics. Assessment of quantitative culture results

and sensitivities is also important. This assessment provides selection and use of
pathogen-specific antibiotics as well as the correct dosage. Improper use of antibiot-
ics may lead to drug resistance and prolonged hospitalization. (Koenig et al., 2006).
Any change in CPIS can

guide clinicaldecisions on the Since the knowledge of VAP and the use of antibiotics for the treatment of
continuing use, selection, or VAP are evolving, readers should refer to the most recent research findings for the
stoppage of antibiotics.
management of VAP.
HyPoXIC-ISCHEmIC EnCEPHALoPATHy (HIE)

hypoxic-ischemic encephalopa- Hypoxic-ischemic encephalopathy (HIE) is a condition caused by a severe lack
thy (HIE): A condition caused by a
severe lack of oxygen supply to the of oxygen supply to the brain, leading to damage to the cells and neurons of the
brain leading to damage to the cells brain and spinal cord. Although the term often refers to injury sustained by new-
and neurons of the brain and spinal
cord. borns (injury or complication during birth), HIE can be used to describe any in-
jury to the brain due to severe hypoxia (Kohnle, 2011). Three broad categories of
cerebral perfusion pressure acute cerebral hypoxia are: inadequate ventilation or oxygenation (e.g., respiratory
(CPP): The pressure required to
provide blood flow, oxygen, and arrest, carbon monoxide poisoning, drowning), inadequate perfusion (e.g., car-
metabolite to the brain; it is a diac arrest, shock, blocked or ruptured blood vessels), and decrease in cerebral
function of mean arterial pressure
(MAP) and intracranial pressure perfusion pressure (CPP) (e.g., decrease in mean arterial pressure or increase in
(ICP); CPP 5 MAP 2 ICP. intracranial pressure).

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