Risk factors for ventilator-associated events: A prospective cohort study

Pulmonary Versus Nonpulmonary Cause for Intubation and Development of Ventilator-Associated Events

Background: The Centers for Disease Control and Prevention surveillance algorithm identifies complications associated with invasive mechanical ventilation as ventilator-associated events (VAE). There is little known about reason for intubation and VAE risk. We aim to evaluate the association between reason for intubation and development of VAE. We hypothesize that subjects with primary pulmonary reasons for intubation have increased risk of VAE compared with subjects whose reason for intubation is nonpulmonary in origin. Methods: This is a single-center retrospective study of medical intensive care unit (MICU) subjects mechanically ventilated ≥4 days and admitted between January and December 2019, at an urban university hospital. Subjects were categorized as primary pulmonary versus nonpulmonary based on reason for intubation. For the primary predictor of VAE, we performed multivariate logistic regression adjusting for Mortality Probability Model (MPM0-III) variables. We accounted for the time-varying risk of VAE using a Cox proportional hazard model. Secondary outcomes included hospital and ICU mortality and stay. Results: After exclusions, there were 250 subjects in our sample 98 (39.2%) in the pulmonary and 152 (60.8%) in the nonpulmonary groups for comparison. Subjects in the nonpulmonary group had higher severity-of-illness as measured by the MPM0-III (P = .002). There was no difference in crude VAE rates between groups. In the fully adjusted model, there was no higher incidence of VAE among subjects intubated for primary pulmonary reasons (OR: 0.78, 95% CI: 0.34-1.78, P = .55). Time to VAE was not impacted by reason for intubation. There was no difference in mortality and stay. Conclusions: Our results do not suggest an association between reason for intubation and risk for VAE. This reinforces the validity of the VAE surveillance algorithm by shifting focus to modifiable therapeutic choices during a course of invasive mechanical ventilation to reduce VAE risk.

Risk factors of ventilator-associated events in patients on mechanical ventilation: A scoping review

BACKGROUND

Ventilator-associated events (VAE) are associated with higher mortality rates. Understanding the risk factors for VAE provides preventive strategies for reducing them. Several studies have been conducted on VAE risk factors. However, the findings were inconsistent.

AIM

This scoping review aimed to explore the existing evidence on risk factors of VAEs in intensive care unit (ICU) patients.

STUDY DESIGN

Searches were performed across eight databases including Pubmed, ProQuest, Scopus, ScienceDirect, BMJ, Web of Science, Taylor & Francis and Ebsco from 26 March to 5 April 2024, complemented by backward and forward citation tracking-eligible studies criteria: participants aged 18 years and older reporting on VAE risk factors. The publication must have occurred between 2013 and 2024, be available as full text and be written in English. A total of 19 studies met the inclusion criteria and were analysed.

RESULTS

Forty-four risk factors were identified. Decreased level of consciousness, chronic lung diseases, invasive operation, duration of MV, trauma, fluid overload, reintubation, enteral feeding, administration of sedation and stress ulcer prophylaxis were the most frequently reported risk factors for VAE.

CONCLUSIONS

This review identified several potential risk factors for VAE; some factors have varying results or lack evidence. Further research is needed to confirm the role of these factors in reducing VAE or to clarify inconsistent findings.

RELEVANCE TO CLINICAL PRACTICE

These findings provide information on the risk factors for VAE. Nurses must identify the presence of these risk factors in all adult ICU patients receiving invasive mechanical ventilation (IMV) and manage them to prevent the occurrence of VAE.

Clinical Outcomes of Erector Spinae Plane Block for Midline Sternotomy in Cardiac Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the benefit of single-shot erector spinae plane block (ESPB) on pain at postoperative hours 4 and 12, duration of mechanical ventilation, hospital length of stay, intensive care unit (ICU) length of stay, cumulative postoperative opioid usage, and incidence of postoperative nausea and vomiting (PONV) after cardiac surgery via sternotomy DESIGN: A systematic review and meta-analysis of randomized controlled trials and prospective clinical trials.

SETTING

Studies were identified through the search of PubMed and EMBASE on July 19, 2023.

PARTICIPANTS

Adults and children undergoing cardiac surgery via sternotomy.

INTERVENTIONS

Single-shot ESPB versus standard-of-care analgesia.

MEASUREMENTS AND MAIN RESULTS

A systematic review and meta-analysis of 10 studies (N = 695 patients). The single-shot ESPB arm exhibited statistically significant reductions in pain score at postoperative hour 4 (standardized mean difference [SMD] -2.95, 95% CI -5.86 to -0.04, p = 0.0466), duration of mechanical ventilation (SMD -1.23, 95% CI -2.21 to -0.24, p = 0.0145), cumulative postoperative opioid usage (SMD -1.48, 95% CI -2.46 to -0.49, p = 0.0033), and PONV incidence (risk ratio 0.4358, 95% CI 0.2105-0.9021, p = 0.0252). The single-shot ESPB arm did not exhibit a statistically significant reduction in pain score at postoperative hour 12, length of hospital stay, and length of ICU stay.

CONCLUSIONS

Single-shot ESPB improves near-term clinical outcomes in patients undergoing cardiac surgery via sternotomy. More randomized controlled trials are needed to validate these findings.

Ventilator-associated events: From surveillance to optimizing management

Mechanical ventilation (MV) is a life-support therapy that may predispose to morbid and lethal complications, with ventilator-associated pneumonia (VAP) being the most prevalent. In 2013, the Center for Disease Control (CDC) defined criteria for ventilator-associated events (VAE). Ten years later, a growing number of studies assessing or validating its clinical applicability and the potential benefits of its inclusion have been published. Surveillance with VAE criteria is retrospective and the focus is often on a subset of patients with higher than lower severity. To date, it is estimated that around 30% of ventilated patients in the intensive care unit (ICU) develop VAE. While surveillance enhances the detection of infectious and non-infectious MV-related complications that are severe enough to impact the patient's outcomes, there are still many gaps in its classification and management. In this review, we provide an update by discussing VAE etiologies, epidemiology, and classification. Preventive strategies on optimizing ventilation, sedative and neuromuscular blockade therapy, and restrictive fluid management are warranted. An ideal VAE bundle is likely to minimize the period of intubation. We believe that it is time to progress from just surveillance to clinical care. Therefore, with this review, we have aimed to provide a roadmap for future research on the subject.

Comparison of regional anesthetic techniques for postoperative analgesia after adult cardiac surgery: bayesian network meta-analysis

Background

Patients usually suffer acute pain after cardiac surgery. Numerous regional anesthetic techniques have been used for those patients under general anesthesia. The most effective regional anesthetic technique was still unclear.

Methods

Five databases were searched, including PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library. The efficiency outcomes were pain scores, cumulative morphine consumption, and the need for rescue analgesia in this Bayesian analysis. Postoperative nausea, vomiting and pruritus were safety outcomes. Functional outcomes included the time to tracheal extubation, ICU stay, hospital stay, and mortality.

Results

This meta-analysis included 65 randomized controlled trials involving 5,013 patients. Eight regional anesthetic techniques were involved, including thoracic epidural analgesia (TEA), erector spinae plane block, and transversus thoracic muscle plane block. Compared to controls (who have not received regional anesthetic techniques), TEA reduced the pain scores at 6, 12, 24 and 48 h both at rest and cough, decreased the rate of need for rescue analgesia (OR = 0.10, 95% CI: 0.016-0.55), shortened the time to tracheal extubation (MD = -181.55, 95% CI: -243.05 to -121.33) and the duration of hospital stay (MD = -0.73, 95% CI: -1.22 to -0.24). Erector spinae plane block reduced the pain score 6 h at rest and the risk of pruritus, shortened the duration of ICU stay compared to controls. Transversus thoracic muscle plane block reduced the pain scores 6 and 12 h at rest compared to controls. The cumulative morphine consumption of each technique was similar at 24, 48 h. Other outcomes were also similar among these regional anesthetic techniques.

Conclusions

TEA seems the most effective regional postoperative anesthesia for patients after cardiac surgery by reducing the pain scores and decreasing the rate of need for rescue analgesia.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, ID: CRD42021276645.

Impact of a national collaborative project to improve the care of mechanically ventilated patients

This prospective quasi-experimental study from the NASAM (National Approach to Standardize and Improve Mechanical Ventilation) collaborative assessed the impact of evidence-based practices including subglottic suctioning, daily assessment for spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), head of bed elevation, and avoidance of neuromuscular blockers unless otherwise indicated. The study outcomes included VAE (primary) and intensive care unit (ICU) mortality. Changes in daily care process measures and outcomes were evaluated using repeated measures mixed modeling. The results were reported as incident rate ratio (IRR) for each additional month with 95% confidence interval (CI). A comprehensive program that included education on evidence-based practices for optimal care of mechanically ventilated patients with real-time benchmarking of daily care process measures to drive improvement in forty-two ICUs from 26 hospitals in Saudi Arabia (>27,000 days of observation). Compliance with subglottic suctioning, SAT and SBT increased monthly during the project by 3.5%, 2.1% and 1.9%, respectively (IRR 1.035, 95%CI 1.007-1.064, p = 0.0148; 1.021, 95% CI 1.010-1.032, p = 0.0003; and 1.019, 95%CI 1.009-1.029, p = 0.0001, respectively). The use of neuromuscular blockers decreased monthly by 2.5% (IRR 0.975, 95%CI 0.953-0.998, p = 0.0341). The compliance with head of bed elevation was high at baseline and did not change over time. Based on data for 83153 ventilator days, VAE rate was 15.2/1000 ventilator day (95%CI 12.6-18.1) at baseline and did not change during the project (IRR 1.019, 95%CI 0.985-1.053, p = 0.2812). Based on data for 8523 patients; the mortality was 30.4% (95%CI 27.4-33.6) at baseline, and decreased monthly during the project by 1.6% (IRR 0.984, 95%CI 0.973-0.996, p = 0.0067). A national quality improvement collaborative was associated with improvements in daily care processes. These changes were associated with a reduction in mortality but not VAEs. Registration The study is registered in clinicaltrials.gov (NCT03790150).

Relationship between ventilator bundle compliance and the occurrence of ventilator-associated events: a prospective cohort study

Background

Instead of ventilator-associated pneumonia (VAP), the modern definition of ventilator-associated events (VAEs) has been introduced to identify infectious and noninfectious respiratory complications. Some studies revealed that compliance to the ventilator bundle is associated with decreased occurrence of VAP, but little is known about its association with the decrease of VAEs occurrence.

Methods

A prospective cohort research design was used. Data were collected over eight months from May 2019 to February 2020 in five general intensive care units. The researchers assessed the compliance to ventilator care bundle using the Institute for Healthcare Improvement ventilation bundle checklist. Mechanically ventilated patients were prospectively assessed for the occurrence of VAEs using a pre-validated calculator from the Centers for Disease Control and Prevention. All are non-invasive tools and no intervention was done by the authors.

Results

A total of 141 mechanically ventilated patients completed the study. The odds ratio of having VAEs in patients who received ventilator bundle was -1.19 (95% CI, -2.01 to -0.38), a statistically significant effect, Wald χ2(1) = 8.18, p = 0.004.

Conclusion/ implications for practice

Ventilator bundle compliance was associated with a reduced risk for VAEs occurrence. Nurses should comply with the ventilator bundle because it is associated with decreased VAEs occurrence.

The effect of simulation-based flipped classroom on acquisition of cardiopulmonary resuscitation skills: A simulation-based randomized trial

BACKGROUND

Cardiopulmonary resuscitation (CPR) is an essential skill required by critical care nurses. Evidence has shown that the use of a novel method called simulation-based flipped classroom (SBFC) can save training time in nursing laboratories and, to some extent, enhance social distancing during the current COVID-19 pandemic.

AIM

To evaluate the effects of SBFC on nursing students' acquisition of CPR skills.

STUDY DESIGN

A two-parallel prospective, single-centre, simulation-based, randomized, controlled trial.

METHODS

The total sample size was 326 students. A CPR video was recorded and uploaded on Microsoft Teams channel for the SBFC group only. Thereafter, both groups demonstrated and redemonstrated the CPR procedure. Both groups were then compared according to the simulation experience satisfaction scale and CPR skills acquisition checklist.

RESULTS

Two equally randomly selected groups of 163 undergraduate nursing students completed the study. The SBFC group had a significantly better satisfaction with the simulation experience than the traditional simulation (TS) group (p = 0.03). As regards the mean score of the CPR checklist after simulation, the SBFC group had a significantly higher score than TS group (p = 0.01).

CONCLUSIONS

SBFC using a pre-recorded video can be an effective method that can reduce the time needed for CPR clinical simulation and can be used for the CPR simulation among critical care nurses.

RELEVANCE TO CLINICAL PRACTICE

This study provides critical care nursing educators with a deep understanding regarding the benefits and value of utilizing the SBFC method in the clinical training of CPR skills. SBFC can be used to increase critical care nurses' satisfaction and skill acquisition during CPR training.

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Ventilator-Associated Events: Epidemiology, Risk Factors, and Prevention

The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events in 2013 to increase the objectivity and reproducibility of surveillance and to encourage quality improvement programs to focus on preventing a broader array of complications. Ventilator-associated events are associated with a doubling of the risk of dying. Prospective studies have found that minimizing sedation, increasing spontaneous awakening and breathing trials, and conservative fluid management can decrease event rates and the duration of ventilation. Multifaceted interventions to enhance these practices can decrease ventilator-associated event rates.

Analysis of diagnostic criteria for ventilator-associated pneumonia: a cohort study

OBJECTIVES

to analyze the diagnostic criteria for ventilator-associated pneumonia recommended by the Brazilian Health Regulatory Agency and the National Healthcare Safety Network/Centers for Disease Control and Prevention, as well as its risk factors.

METHODS

retrospective cohort study carried out in an intensive care unit throughout 12 months, in 2017. Analyses included chi-square, simple linear regression, and Kappa statistical tests and were conducted using Stata 12 software.

RESULTS

the sample was 543 patients who were in the intensive care unit and under mechanical ventilation, of whom 330 (60.9%) were men and 213 (39.1%) were women. Variables such as gender, age, time under mechanical ventilation, and oral hygiene proved to be significant risk factors for the development of ventilator-associated pneumonia.

CONCLUSIONS

patients submitted to mechanical ventilation need to be constantly evaluated so the used diagnostic methods can be accurate and applied in an objective and standardized way in Brazilian hospitals.

Fluid Balance and Ventilator-Associated Events Among Patients Admitted to ICUs in China: A Nested Case-Control Study

Supplemental Digital Content is available in the text.

Fluid therapy is an important component of intensive care management, however, optimal fluid management is unknown. The relationship between fluid balance and ventilator-associated events has not been well established. This study investigated the dose-response relationship between fluid balance and ventilator-associated events.

Subglottic suction frequency and adverse ventilator-associated events during critical illness

OBJECTIVE

Tracheal intubation and mechanical ventilation provide essential support for patients with respiratory failure, but the course of mechanical ventilation may be complicated by adverse ventilator-associated events (VAEs), which may or may not be associated with infection. We sought to understand how the frequency of subglottic suction, an indicator of the quantity of sputum produced by ventilated patients, relates to the onset of all VAEs and infection-associated VAEs.

DESIGN

We performed a case-crossover study including 87 patients with VAEs, and we evaluated 848 days in the pre-VAE period at risk for a VAE.

SETTING AND PARTICIPANTS

Critically ill patients were recruited from the medical intensive care unit of an academic medical center.

METHODS

We used the number of as-needed subglottic suctioning events performed per calendar day to quantify sputum production, and we compared the immediate pre-VAE period to the preceding period. We used CDC surveillance definitions for VAE and to categorize whether events were infection associated or not.

RESULTS

Sputum quantity measured by subglottic suction frequency is greater in the period immediately prior to VAE than in the preceding period. However, it does not discriminate well between infection-associated VAEs and VAEs without associated infection.

CONCLUSIONS

Subglottic suction frequency may serve as a valuable marker of sputum quantity, and it is associated with risk of a VAE. However, our results require validation in a broader population of mechanically ventilated patients and intensive care settings.

Outcomes of Adjunctive Therapy with Intravenous Cefoperazone-Sulbactam for Ventilator-Associated Pneumonia Due to Carbapenem-Resistant Acinetobacter baumannii

Introduction

The efficacy of adjunctive therapy with cefoperazone-sulbactam (CEP-SUL) for ventilator-associated pneumonia (VAP) due to carbapenem-resistant A. baumannii (CRAB) is unclear.

Methods

We retrospectively analyzed the therapeutic effect of adding CEP-SUL to standard regimens for VAP due to CRAB. Patients with VAP due to CRAB strains that were susceptible to CEP-SUL were enrolled into the study. The patients were divided into two groups: those who receive cefoperazone-sulbactam (CEP-SUL⁺), and those who did not receive cefoperazone-sulbactam (CEP-SUL). Mortality rates and resource utilization of these two groups were compared. Factors associated with mortality were explored.

Results

Eighty patients were enrolled into the study, 52 CEP-SUL⁺ and 28 CEP-SUL^-. The baseline characteristics of the two groups were comparable, except for median Acute Physiology and Chronic Health Evaluation (APACHE) II score which was significantly higher for CEP-SUL⁺. Thirty-day, and in-hospital mortality rates for CEP-SUL⁺ were significantly lower than CEP-SUL^- with values of 35%, 39% and 61%, 68%, for CEP-SUL⁺ and CEP-SUL^-, respectively. The survival rate for CEP-SUL⁺ was significantly higher compared with CEP-SUL^- (P < 0.001). The number of hospital days, ventilator days since diagnosis of VAP and hospital costs were lower for CEP-SUL⁺.

Conclusion

Overall results suggested that patients with VAP due to CRAB strains who received adjunctive therapy with CEP-SUL had lower mortality rates and resource utilization compared with CEP-SUL^-.

Evaluation of ventilator associated events in critically ill patients with invasive mechanical ventilation: A prospective cohort study at a resource limited setting in Northern India

PURPOSE

The primary aim of this study was to identify the modifiable risk factors for acquiring ventilator associated events (VAE). Secondary aims were to investigate the intensive care unit (ICU) course and impact of VAE on patient outcome.

METHODS

This prospective, observational single center cohort study included 247 patients on mechanical ventilation for 4 calendar days at a 20-bed ICU between January 2018-June 2019.

RESULTS

VAE occurred in 59 episodes (rate 11.3 per 1000 ventilator-days). The Ventilator Utilization Ratio (VUR) was 0.57. The median time to onset of VAE was 6 days. Sepsis was the most common reason for initiating patients on invasive mechanical ventilation (IMV). Cumulative fluid balance ≥2 l (Odds Ratio 30.92; 95% CI 9.82-97.37) and greater number of days with vasopressor support (Odds Ratio 1.92; 95% CI 1.57-2.36) within 7 days of initiating IMV were significant risk factors for acquiring VAE (p < 0.001). VAE cases were ventilated for significantly more days (20 vs 14 days, p = 0.001, had longer days of ICU stay (29 vs 18 days; p = 0.002) and higher hospital mortality (p = 0.02). Klebsiella pneumoniae was the most common isolate (N = 28) and 32.1% were colistin resistant.

CONCLUSIONS

Prospective intervention studies are needed to determine if targeting these risk factors can lower VAE rates in our setting.

The epidemiology and clinical outcomes of ventilator-associated events among 20,769 mechanically ventilated patients at intensive care units: an observational study

Background

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection (HAI) in intensive care units (ICUs). Ventilator-associated event (VAE), a more objective definition, has replaced traditional VAP surveillance and is now widely used in the USA. However, the adoption outside the USA is limited. This study aims to describe the epidemiology and clinical outcomes of VAEs in China, based on a prospectively maintained registry.

Methods

An observational study was conducted using an ICU-HAI registry in west China. Patients that were admitted to ICUs and underwent mechanical ventilation (MV) between April 1, 2015, and December 31, 2018, were included. The characteristics and outcomes were compared between patients with and without VAEs. The rates of all VAEs dependent on different ICUs were calculated, and the pathogen distribution of patients with possible VAP (PVAP) was described.

Results

A total of 20,769 ICU patients received MV, accounting for 21,723 episodes of mechanical ventilators and 112,697 ventilator-days. In all, we identified 1882 episodes of ventilator-associated condition (VAC) events (16.7 per 1000 ventilator-days), 721 episodes of infection-related ventilator-associated complications (IVAC) events (6.4 per 1000 ventilator-days), and 185 episodes of PVAP events (1.64 per 1000 ventilator-days). The rates of VAC varied across ICUs with the highest incidence in surgical ICUs (23.72 per 1000 ventilator-days). The median time from the start of ventilation to the onset of the first VAC, IVAC, and PVAP was 5 (3–8), 5 (3–9), and 6 (4–13) days, respectively. The median length of hospital stays was 28.00 (17.00–43.00), 30.00 (19.00–44.00), and 30.00 (21.00–46.00) days for the three VAE tiers, which were all longer than that of patients without VAEs (16.00 [12.00–23.00]). The hospital mortality among patients with VAEs was more than three times of those with non-VAEs.

Conclusions

VAE was common in ICU patients with ≥ 4 ventilator days. All tiers of VAEs were highly correlated with poor clinical outcomes, including longer ICU and hospital stays and increased risk of mortality. These findings highlight the importance of VAE surveillance and the development of new strategies to prevent VAEs.

Regional anesthesia for cardiac surgery

PURPOSE OF REVIEW

Anesthesia for cardiac surgery has traditionally utilized high-dose opioids to blunt the sympathetic response to surgery. However, recent data suggest that opioids prolong postoperative intubation, leading to increased morbidity. Given the increased risk of opioid dependency after in-hospital exposure to opioids, coupled with an increase in morbidity, regional techniques offer an adjunct for perioperative analgesia. The aim of this review is to describe conventional and emerging regional techniques for cardiac surgery.

RECENT FINDINGS

Well-studied techniques such as thoracic epidurals and paravertebral blocks are relatively low risk despite lack of widespread adoption. Benefits include reduced opioid exposure after paravertebral blocks and reduced risk of perioperative myocardial infarction after epidurals. To further lower the risk of epidural hematoma and pneumothorax, new regional techniques have been studied, including parasternal, pectoral, and erector spinae plane blocks. Because these are superficial compared with paravertebral and epidural blocks, they may have even lower risks of hematoma formation, whereas patients are anticoagulated on cardiopulmonary bypass. Efficacy data have been promising, although large and generalizable studies are lacking.

SUMMARY

New regional techniques for cardiac surgery may be potent perioperative analgesic adjuncts, but well-designed studies are needed to quantify the effectiveness and safety of these blocks.

Prevalence, Clinical Characteristics, and Outcomes Related to Ventilator-Associated Events in Neurocritically Ill Patients

Background

The prevalence, characteristics, and outcomes related to the ventilator-associated event(s) (VAE) in neurocritically ill patients are unknown and examined in this study.

Methods

A retrospective study was performed on neurocritically ill patients at a 413-bed level 1 trauma and stroke center who received three or more days of mechanical ventilation to describe rates of VAE, describe characteristics of patients with VAE, and examine the association of VAE on ventilator days, mortality, length of stay, and discharge to home.

Results

Over a 5-year period from 2014 through 2018, 855 neurocritically ill patients requiring mechanical ventilation were identified. A total of 147 VAEs occurred in 130 (15.2%) patients with an overall VAE rate of 13 per 1000 ventilator days and occurred across age, sex, BMI, and admission Glasgow Coma Scores. The average time from the start of ventilation to a VAE was 5 (range 3–48) days after initiation of mechanical ventilation. Using Centers for Disease Control and Prevention definitions, VAEs met criteria for a ventilator-associated condition in 58% of events (n = 85), infection-related VAE in 22% of events (n = 33), and possible ventilator-associated pneumonia in 20% of events (n = 29). A most common trigger for VAE was an increase in positive end-expiratory pressure (84%). Presence of a VAE was associated with an increase in duration of mechanical ventilation (17.4[IQR 20.5] vs. 7.9[8.9] days, p < 0.001, 95% CI 7.86–13.92), intensive care unit (ICU) length of stay (20.2[1.1] vs. 12.5[0.4] days, p < 0.001 95% CI 5.3–10.02), but not associated with in-patient mortality (34.1 vs. 31.3%. 95% CI 0.76–1.69) or discharge to home (12.7% vs. 16.3%, 95% 0.47–1.29).

Conclusions

VAE are prevalent in the neurocritically ill. They result in an increased duration of mechanical ventilation and ICU length of stay, but may not be associated with in-hospital mortality or discharge to home.

Electronic supplementary material

The online version of this article (10.1007/s12028-019-00910-5) contains supplementary material, which is available to authorized users.

Developing a Registry of Healthcare-Associated Infections at Intensive Care Units in West China: Study Rationale and Patient Characteristics

Purpose

Limited evidence is available to support the management of healthcare-associated infections (HAIs) in intensive care units (ICUs). Establishing a registry with complete and accurate information is urgently needed. The West China Hospital system has the most complete and largest data system for HAI in the ICU setting in China. By linking a multidimensional database, we developed a registry of HAI in ICU.

Methods

The ICU-HAI registry was established using a multi-source database that included electronic medical record (EMR), ICU system and ICU-HAI system in the West China Hospital healthcare system. Patients who were admitted to ICUs between 1 April 2015 and 30 March 2018 were included and data were extracted based on pre-designed, standardized data forms. We achieved the linkage of the three databases using a unique patient identification code, and cleaned the data based on standardized variable dictionaries and cleaning rules. We evaluated the quality of the registry through data verification and assessment of the quality of key variables.

Results

In total, 23, 062 patients were included. The ICU mortality and hospital mortality were 5.4% and 5.5% respectively. A total of 855 patients developed ICU-HAIs, 1540 patients developed ventilator-associated events (VAE), and 171 patients developed possible ventilator-associated pneumonia (PVAP). Quality assessment showed that the accuracy of data extraction and linkage was 100%. Furthermore, 98% of all patients had at least one important laboratory tests performed, and the median number of tests performed was 4 to 5 per admission.

Conclusion

A unique registry for HAIs in the ICU setting was successfully established, which contains complete and accurate information for all patients in the ICU. The registry, linked from multiple data sources, provides unique research insights into the management of HAIs in the ICU setting in China.

Factors associated with ventilator-associated events: an international multicenter prospective cohort study

A secondary analysis of a prospective multicenter cohort was performed in six intensive care units (ICU) in four European countries (France, Greece, Spain and Turkey). The main objective was to identify factors associated with ventilator-associated events (VAEs) in adults who underwent mechanical ventilation (MV) ≥ 48 h. Secondary objectives were to identify: variables influencing VAE in the subpopulation with endotracheal intubation and in those subjects who were ventilated > 7 days. Subjects who had undergone MV ≥ 48 h were included. In subjects with multiple episodes of MV, only the first one was eligible. The adult definitions for VAEs were adjusted to the 2015 update of the CDC's 2013 National Healthcare Safety Network Association. Factors associated with VAE were estimated through multivariate Cox proportional hazards analysis. Among 163 adults (42 tracheostomies), 76 VAEs (34.9 VAEs/1,000 ventilator-days) were documented: 9 were Ventilator-Associated Conditions (VAC) and 67 Infection-related Ventilator-Associated Complications (IVAC)-plus (9 only IVAC and 58 Possible Ventilator-Associated Pneumonia). VAEs developed after a median of 6 days (interquartile range: 4-9). VAEs were independently associated with long-acting sedative/analgesic drugs (Hazard Ratio [HR]: 4.30), selective digestive decontamination (SDD) (HR: 0.38), and surgical/trauma admission (HR: 2.30). Among 116 subjects with endotracheal tube, SDD (HR: 0.21) and surgical/trauma admission (HR: 3.11) remained associated with VAE. Among 102 subjects ventilated >7 days, only long-acting sedative/analgesic agents (HR: 8.69) remained independently associated with VAE. In summary, SDD implementation and long-acting analgesic/sedative agents restriction prescription may prevent early and late VAEs, respectively. Bundles developed to prevent VAEs should include these two interventions.