A. Severance1, B. Floyd1, A. Kyle1, C.B. Stevens1, E. Bhanat1, M. Kutcher1 1University Of Mississippi, General Surgery, Jackson, MS, USA
Introduction: Injured patients requiring extended ventilatory support are at risk for ventilator-associated pneumonia (VAP), characterized by worsening ventilatory status in the presence of fever, leukocytosis, and imaging abnormalities with concurrent microorganisms on respiratory sampling. The incidence of VAP ranges from 5-40% of those on mechanical ventilation for >48hours, and is associated with a 24-60% mortality rate. These infections are reported to the National Healthcare Safety Network (NHSN), and several “bundles” have been created in an attempt to prevent and mitigate the effects of this disease process. Here we assess the demographics and risk factors associated with VAP development for trauma patients in a level 1 trauma center with a statewide rural catchment area.
Methods: 49 patients flagged by trauma program audit filters for review as possible VAP were prospectively collected; 24 were deemed VAP based on TQIP criteria, and the remainder were ruled out. Retrospective chart review was performed as part of a quality improvement project to assess for possible points of intervention, and descriptive analysis performed using standard univariate statistics.
Results: This exploratory analysis showed that longer ventilator days (18.5 vs 13.0 days, p=0.02) and lower pre-ETT GCS (non-significant trend, 7.6 vs. 9.8, p=0.09) are associated with development of VAP. Head of bed elevation (70% vs 88%, p >0.05) and oral care (83% vs 96%) were not associated with lower rates of VAP. However, days to initiation of oral care from intubation was longer in the VAP vs. non-VAP groups (3.8 vs. 0.8, p=0.05). Prehospital reports of oropharyngeal blood and aspiration are not associated with VAP, and are rarer in the VAP population than in the non-VAP population. No trend was identified in the pre-event administration of any antibiotics in those who did or did not go on to develop VAP (79% vs 84%, p=0.66).
Conclusion: In this small study, VAP appears to be associated with prolonged ventilation and lower pre-intubation GCS, but not with aspiration or oropharyngeal blood (all non-modifiable risk factors). Common prophylactic strategies (like head elevation and oral care) are not significantly associated with lower rates of VAP, challenging the idea that VAP is 'preventable'. For our population, many standard bundled interventions were not associated with improved outcomes. This work suggests that focusing on earlier intervention in patients at risk of VAP, as opposed to focusing on VAP prevention compliance, may be most beneficial.