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122 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

BOX 6.5 Invasive device management TABLE 6.14 Strategies to prevent VAP
● Does the patient need the invasive device for effective Measure Interventions
management of their condition?
● Is the chosen device is the most suitable for the individual Infection control ● hand hygiene
measures
● active surveillance
patient, e.g. size and type of device? ● appropriate PPE when managing
● Are the healthcare professional/s trained to safely insert ventilation related devices, e.g. ETT,
and manage the device? ventilator circuits, tracheal suctioning
● Use the appropriate aseptic procedure for device Gastrointestinal ● oral hygiene
insertion. tract ● stress ulcer prophylaxis
● Follow management protocols to minimise the risk of infec- ● avoid gastric over distention
tion while the device is in situ. ● enteral nutrition
● Monitor the patient for signs and symptoms of infection. Patient position ● semirecumbent with head raised to >30°
● Review the need for the device in the management of the ● rotational bed therapy
patient daily and remove as early as possible. Artificial airway ● respiratory airway care
● avoid unplanned extubations
Adapted from NHMRC Guidelines 119 ● secure tracheal airway cuff
● inline or intermittent subglottic secretion
removal
Mechanical ● maintenance of ventilation equipment,
provides some basic points to guide management of the ventilation heat and moisture exchangers, safe
use of medical devices in critical care. removal of condensate from circuits
● minimise ventilation time
The commonest healthcare associated infections, in order ● daily assessment for readiness to wean
of incidence, are surgical sites, urinary tract, lower respira- therapy and/or extubate
tory tract and bloodstream. 142 For the critically ill patient ● non-invasive mechanical ventilation
intravascular cannulas including central venous catheters, PPE = personal protective equipment; ETT = endotrachael tube
urinary catheters, enteral or nasogastric tubes and artifi-
cial airways and ventilation are some of the healthcare
devices associated with risk. See the section on urinary
catheters for information regarding catheter-associated inconsistent reduction in ICU mortality, and there
urinary tract infections. remains concern about the promotion of antimicrobial
resistance with its prolonged use. Related information
148
Ventilator-Associated Pneumonia on respiratory failure and ventilation can be found in
Ventilator-associated pneumonia (VAP) is common in Chapters 14 and 15.
intensive care and usually occurs within 48 hours of ini-
tiating ventilation. 143 There are several measures that Central Line Associated Bacteraemia
should be taken to reduce VAP. 144 A number of strategies Bloodstream infection is a serious complication often
that are effective in helping to prevent infection 143 are caused by intravascular catheters, particularly those that
identified in Table 6.14, of which the simplest and most terminate close to the heart. 149 The use of central lines is
effective is raising the head of the bed. Effective analgesia common in critical care areas. Catheter-related sepsis is
and minimising sedation while avoidance of muscle- defined by the International Sepsis Forum as at least one
relaxant medications along with early mobilisation are peripheral positive blood culture plus at least one of the
some of the other strategies which may contribute to the following: a positive catheter tip culture, a positive hub
reduction of VAP. Provided a heat and moisture exchanger or exit-site culture, or a positive paired central and periph-
(HME) is used, it is not necessary to routinely change eral blood culture where the central culture is positive
ventilator circuits. 145 The US Centers for Disease Control ≥2 hours earlier than the peripheral culture or has five
150
recommend changing the ventilator circuit only when it times the growth. Central line associated bactaeremia
is visibly soiled or malfunctioning, and should not be (CLAB) is one of the most important and severe infec-
151
changed more often than every 48 hours unless it is tions that can occur in ICU, and as many as 90% of
soiled or malfunctions. 146 The use of a closed suction bloodstream infections may be attributable to intravascu-
system for endotracheal suction does not decrease the lar catheters. 152 Renal failure may significantly increase
153
incidence of nosocomial infection, 147 but it does afford the risk of infection. Berenholtz et al. demonstrated
a protective barrier to the nurse performing the that implementing quality improvement measures to
procedure. ensure adherence to evidence-based infection control
guidelines results in a significant reduction of catheter-
Selective digestive decontamination has been studied related bloodstream infection. 154
extensively. In theory, the use of antimicrobial agents to
reduce gut flora in intubated intensive care patients The use of antibiotic-impregnated catheters has been
reduces the risk of pneumonia due to microaspiration shown to reduce bacteraemia, 155 and although it is
(see Chapter 19). While most studies have demonstrated common practice in many critical care units to
a reduction in the incidence of VAP, there has been an routinely change intravenous administration sets, with