CORONARY CARE

introduction to coronary care 

CARDIOLOGY DEPARTMENT

The Department of Cardiology has comprehensive acute coronary care unit (CACCU), wards and cath labs. CACCU is divided into ICU-I and ICU-II and is fully equipped with bedside multifunction hemodynamic monitors, defibrillators, transcutaneous pacing facility, infusion pumps, ventilators, ECG machine, cardiac reader, activated clotting time machine etc. The patients who receive care in cardiology include patients with unstable angina, acute myocardial infarction, post myocardial infarction complication, pulmonary edema, cyanotic spell, life threatening arrhythmias and patients who have undergone interventional procedures like coronary interventions including primary precutaneous transluminal  coronary angioplasty (PTCA) and stenting, non-coronary interventions including dilatation of stenosed valves and arteries: percutaneous transluminal mitral commisurotomy (PTMC), balloon mitral valvotomy (BMV), balloon pulmonary valvotomy (BPV), balloon aortic valvotomy (BAV), device closure of congenital defects like atrial septal defect (ASD) and ventricular septal defect (VSD), patent ductus arteriosus (PDA), radiofrequency ablation (RFA); dilatation of severe tricuspid valve stenosis or coarctation of aorta; cardiac catheterisation and coronary angiogram. Percutaneous interventions include atherectomy using rotablater device. Neonates and infants who need emergency life saving procedures like balloon atrial septostomy and balloon dialatation of aortic and pulmonary valve is also done here.

Cardiology beds

There are 35 beds in the ward including pediatric beds for management of less critically ill cardiac patients including admission for invasive and interventional procedures. We have three cardiac catheterization labs and one 2D Echo color doppler laboratory adjacent to CACCU functioning continuously from 8am to 5pm on all working days. Sophisticated procedures like transesophageal echo, pharmacologic stress echo (dobutamine), and tissue doppler imaging are performed here. The non-invasive cardiac laboratory provide holter monitoring system with advanced features like signal averaging, pacemaker analysis, and monitoring heart rate variability.

Equipments in intensive care unit

Operation of any equipment should be tested before it is being used. It is also important to keep them in good condition in proper place. Nurses should have thorough knowledge about all the equipments in critical care unit, because they have the responsibility for its proper use and maintenance.

Arterial blood gas machine: Arterial blood gas is a blood test that is performed by using arterial blood. This test is done to determine pH, PO2, PCO2, bicarbonate, lactate, hemoglobin and electrolytes. This machine is very handy.

Bair hugger provides warmth and prevents hypothermia

Cardiac monitors

Monitors are kept mounted on the wall near the head end of the patient. This position gives a clear view to the person who is looking after the patient. These monitors have the facility to display ECG, heart rate, arterial blood pressure, central venous pressure, pulmonary arterial pressure, left atrial pressure, pulmonary capillary wedge pressure, non-invasive blood pressure, temperature, SPO2 and respiratory rate. Accessories of cardiac monitors are cable, ECG lead wires and electrodes. Monitors are not shifted from one place to another to avoid damage to the equipment. Alarm and screen display setup must be functioning properly. Make sure that the personnel from Biomedical Engineering department (BME) are checking the systems daily. Do not allow any liquid into the system.

Cardiac output monitor               

It is used for evaluating the hemodynamic status of a patient, for measuring the forward flow of blood in the vascular system. Flow track transducer is being used to monitor the cardiac output continuously.

Cardiac reader       

It is used for fast, point-of-care results for diagnosis of acute coronary syndrome, deep vein thrombosis, pulmonary embolism and heart failure. The cardiac reader enables healthcare providers to determine troponin T, myoglobin, D-dimer and pro BNP (brain natriuretic peptide or B-type natriuretic peptide) levels from a single heparinized whole blood sample in minutes.

Chest vibrator is a device used to assist expectoration of retained secretion.

Defibrillator is an electronic device that creates a sustained myocardial depolarisation of a patient's heart in order to stop cardiac arrhythmias by administering electric shock. (For details please refer to “Cardioversion and defibrillation”).

Deep vein thrombosis prophylaxis machine

It is a device to promote circulation of blood and lymph in the disabled region of the arm and leg. It helps to reduce pulmonary embolism and deep vein thrombosis. Do not block the ventilation slots located on both sides of the machine. Lack of ventilation may cause the cardiograph to overheat and components to fail.

Glucometer

It is a medical device for determining the approximate concentration of glucose in the blood. It is easy to use and handle and result is ready within seconds.

Hemodialyzer

It is known as “artificial kidney.” The dialyzer is a hollow plastic tube about a foot long and three inches in diameter that contains many tiny filters. There are two sections in the dialyzer; the section for dialysate and the section for the blood. A semi-permeable membrane divides the two sections so that they don't mix together.

Incentive spirometer

It is a medical device used to improve the functioning of the lungs. It promotes maximum inspiration and loosens secretions.

Intra Aortic Balloon Pump (IABP) is a device that provides physiologic assistance to the failing heart by decreasing myocardial oxygen demand and improving coronary perfusion. (For details please refer to care of patient on IABP).

Nebulizer is used to provide inhalation to the patient. It converts water into minute molecules that mimics fumes, which helps loosen the pulmonary secretion.

Negative pressure wound assist therapy machine

It is used to enhance circulation and remove waste from the lymphatic system. It provides a minimally invasive method of promoting wound healing and works by the local application of sub atmospheric pressure. Wound assist system comprises console providing the suction, disposable container to collect the exudates and a sterile dressing pack.

Pressure bag  

It is a special bag used with deflatable intravenous bottle. The pressure pump is used to help the IV fluids either run faster or continuously flow to the patients. This helps to provide rapid administration of fluids and blood in emergency situations.

Pressure transducer converts mechanical energy to electrical energy, used in all invasive pressure lines.

Pulse oxymeter is a device to monitor arterial oxygen saturation percentage and pulse rate.

Self-inflatable alternating pressure releasing bed. It operates on an electric motor. It helps to prevent bed sore and provides comfort to the recumbent patient.

Suction equipment is a negative pressure system to suck out secretions. It may also be used to apply negative pressure to drainage system.

Syringe pump is a device designed to ensure continuous controlled administration of life supporting drugs intravenously like inotropic drugs, anticoagulant, chemotherapy medication etc. The pumps are controlled by microcomputer equipped with comprehensive alarm system.

Temporary pacemaker is a pulse generator used in the management of cardiac arrhythmias (For details please refer to “Care of patient with atrio-ventricular disorder”).

Ventilator is a device that provides artificial respiration. (For details please refer to “Care of patient on ventilator”).

Maintenance of equipment

All devices with rechargeable battery should be kept charged even when it is not in use. No fluid should be poured over the syringe pump because it may produce electric short circuit. If any irregularity is detected in functioning, stop immediately and contact BME personnel. Check daily, whether the device is functioning normally. It needs periodical check up by the BME personnel also. Avoid direct sunlight, humidity, corrosive materials and extreme temperatures to all electronic and electric devices.

Avoid wetting the electrical connectors. The cardiograph can be damaged, if plugged into power socket with incorrect voltage. It can be set to operate at nominal voltages at 115 or 230 Volts. Probe of the pulse oxymeter is kept in its box. Do not twist the connector while attaching the probe. Keep the pacemaker in a separate box in switch off position with its leads. Check the charging of the battery frequently. Do not soak or immerse the system in any liquid.Keep the system always dry. Do not autoclave, pressure sterilize or gas sterilize. Periodical servicing is required for all equipment.

All equipments after use should be thoroughly cleaned and dried before replacing. Do not use strong disinfectant/ solvents or abrasive material for cleaning. Do not autoclave the electrical cable or immerse it in any disinfectant. If any fluid is spilt on the equipment, clean immediately with gauze and keep it dry. Clean the electrode jelly in the defibrillator paddles with gauze after the use, dry and keep it in the place provided for the paddles. The outside surface of the cardiograph and its accessories are to be cleaned with mild soap and water or isopropyl alcohol. Patient cable should not be cleaned with Isopropyl alcohol. Use weak soap solution to clean monitors and ECG leads. Follow manufacturer's instructions in cleaning and troubleshooting of all equipment.

CONCLUSION

The machine alone cannot save the life of the patient. The timely intervention of medical professionals, the maintenance of the equipment by the technicians and the meticulous monitoring and patient care by the nursing staff are crucially important factors which determine the  health of the patients.

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CLASSIFICATION OF SURGICAL SITE INFECTION

Classification of Surgical Site Infection

1.      Superficial incisional SSI: It occurs within 30 days after the operative procedure and involves only skin and subcutaneous tissue. This is again subdivided in to

·         superficial incisional Primary SSI and

·         superficial incisional Secondary SSI

2.      Deep incisional SSI: It occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure and involves deep soft tissues of the incision.

There are two types of deep incisional surgical site infection.

·         Deep Incisional Primary , and

·         Deep Incisional Secondary

3.      Organ / Space SSI:  occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure.

Causes of surgical site infection

Wounds are able to heal despite the presence of quite large number of bacteria. Pathogens that cause SSI are acquired either endogenously from patient’s own flora or exogenously from contact with operating room personnel or the environment. The four main sources that require to be addressed to prevent SSI are personnel, equipment, the environment, and patient’s risk factors which interact in a complex way to foster the development of infection.

Endogenous factors

Predisposing factors

Host’s intrinsic ability to defend itself against microbial invasion, is an important determinant of the risk of infection following surgery. Extreme age, obesity, malnutrition, smoking, other immunosuppressive conditions like diabetes mellitus, malignancy, chronic lung diseases and, renal failure etc lead to impaired host defense mechanisms, and thus increase the risk for post operative wound infection. Low albumin, malnutrition, recent weight loss, immunosuppressive therapies are all contributing factors. Diabetes Mellitus and obesity are independently associated especially with sternal or mediastinal surgical site infections.

           In addition, risk factors for serious sternal surgical site infections or mediastinitis following cardiovascular surgeries include prolonged intensive care unit stay, mechanical ventilation, smoking, preexisting chronic pulmonary disease, prolonged cardiopulmonary bypass, and re-exploration. Selection of arteries used for bypass also contributes to the rate of SSI following coronary bypass surgery. The patient’s own flora  contiguous to the site of operation accounts for the majority of SSIs.

Pre-existing remote site infections

Surface micro flora can migrate from distant sites and get access into the operation site.  Untreated UTI, skin and respiratory tract infections are the three most common remote infections that have been associated with an increase in the rate of SSI. Otitis media, nasal or oral carriage of organisms, systemic infections etc. also can cause SSI. Surgery involving a site with pre existing infection, or where necrosed tissue is present, is significantly more likely to result in SSI.

Exogenous factors

·         Pre-operative hospital stay: Prolonged pre operative stay may promote proliferation of the endogenous microorganisms which can contaminate the wound heavily during the procedure. The longer the patient stays in the hospital before an operative procedure, the greater the chances for colonization of multi drug resistant hospital pathogens, eventually causing SSI.

·         Pre operative shaving: Disruptions in the skin barrier caused by the razor, promotes colonization or actual invasion with resident or exogenous microorganisms at the incision site. Shaving can cause small nicks and breaks, leaving the skin bruised and traumatized which increases the risk of colonization. Clipping of hair prior to surgery using electric clippers rather than shaving reduces the rate of SSI.

·         Improper glucose control: Control blood glucose level during surgery and postoperatively.

·         Personnel: Cleanliness and carrier stage of surgical team is an important factor in preventing SSI. Hands of surgical team harbor microorganisms that can contaminate the surgical site by direct inoculation during the operative procedure. Contamination of the site can happen through recognized and unrecognized breaks in surgical gloves. The hair and scalp, nares and oropharynges of the operating room personnel also has been shown to harbor potentially pathogenic organisms that  can be shed in large droplets and contaminate the operating field during the procedure.

·         Breaks in aseptic technique: Intact skin and mucous membranes are the body’s first line of defence against infection. But a portal of microorganism is created if the integrity of the skin is interrupted. Hence, contaminated instruments, antiseptic solutions and dressings, and technical errors can contribute to SSI. The important principle behind aseptic technique is that the susceptible site should not come in contact with any item that is not sterile and that any contaminated item should not come in contact with other area. It prevents micro organisms on hands, surfaces or equipment being transferred to operating site.

·         Antibiotic prophylaxis: Inappropriate selection of antimicrobial prophylaxis, improper timing of pre-incision dose, inadequate dose based on body mass index etc are problems related to antibiotic therapy. The goal of prophylactic antibiotic is to eradicate or retard the growth of contaminant microorganisms such that SSIs can be avoided.

·         Technical skill: The skill of the surgeon also has a central role in minimizing surgical site infection. Degree of trauma to the tissues is a determining factor to its resistance to infection and healing of the wound. The risk is also minimized by maintaining good   blood supply, gentle traction and handling of tissues, removal of necrotic tissue and eradication of dead space. Finally, skilled surgeon can reduce the duration of surgery. Surgeons with more experience acquire better technique.

·         Duration of operation: There is a direct link between the length of operation and the infection rate with clean wound rate, doubling every hour. This is because the bacterial contamination increases over time and the operative tissues are damaged by drying and other surgical manipulations. Increase in the amount of suture and electrocoagulation in prolonged surgeries may reduce the local resistance of the wound and increase suppression of host defences from blood loss and shock. The longer a wound is open, and the longer it is drained, the greater the risk of contamination.

·         Increased blood loss and number of transfusions can add to SSI. This is thought to be due to an adverse effect on cell-mediated immunity. The risk increases for each unit administered but is significantly lower when autologous blood is used.

·         Excessive OR traffic: People remain the most important source of microorganism in the environment. Excessive presence and movement of staff contributes to an increase in air-borne bacterial particles.  Microorganisms become air borne, also as a result of conversation, as it causes aerosolization of bacteria from the oropharynx. Shedding from hair or exposed skin also  increases the number of bacteria in the field.

·         Operating room ventilation: An effective ventilation system is essential to prevent patients and personnel from breathing potentially contaminated air, which can predispose them to infection. Dust accumulated on surfaces also may be disturbed and become airborne. Properly designed, installed and maintained air-conditioning system effectively reduces the number of airborne organisms by removing dust and aerosol particles.

·         Humidity and temperature also play an important role in containing SSI. Air and dust are vehicles of particles laden with microorganisms. Particulates bearing microorganisms become airborne and settle in the open wound. The potential for contamination increases each time the door to the OR opens and closes.

·         Linen: Friction of woven fibers against each other liberates lint. Disintegrated paper from disposable nonwoven products is another source of lint on fabrics. Contaminated lint on linen used for surgery, is thought to be contributing to wound infection.

Post operative Factors

·         Wound drains: Wound drains provide access to entry of organisms by hands and by colonization.

·         Wound dressing: Ineffective wound dressing protocol can contribute to SSI. A properly applied dressing can decrease pain, enhance healing, and improve cosmetic results.  Primary healing of the wound take place when tissue is cleanly cut and the margins are reapproximated well. Clean undrained wounds seal within 48 hours and are unlikely to be infected. New capillary circulation bridges the wound in 3-4 days, and once normal tissue oxygenation is achieved, the wound is considered to be healed.

Diagnosis of Surgical Site infection

Clinically a surgical site may be considered infected when purulent discharge is present at the incision site. The local manifestations of SSI include pain, tenderness at operated site, erythema, indurations, poor healing, dehiscence and presence of purulent discharge or abscess formation. However, local signs and symptoms always may not be present, nor are they necessarily due to infection when they are present. Systemic manifestations commonly include fever and other signs of sepsis. Either of the following is essential for the diagnosis of SSI. However, a positive culture is not necessary for diagnosis of a SSI.

1.   Purulent discharge from the surgical site.

2.   Positive culture report.

3.   Identification of infection by reopening and debridement of the wound.

Prevention

Because the critical event that initiates the process leading to SSI mainly occurs pre or peri-operatively, surgical site infections can be prevented by a) improving the host's defences b) reducing the amount and type of microbial contamination during surgery and c) improving wound condition at the end of the procedure through better surgical technique.

i) Preoperative measures

Adequately control blood sugar level in all diabetic patients before elective operation and maintain it at <200mg/dl during the operation and in the immediate post operative period. Instruct patients to abstain from tobacco for at least 30 days before surgery. Obesity, malnutrition, systemic diseases and other immunocompromised conditions if any, should be treated and brought under control before surgery. Identify and treat infections at other body sites. UTI, respiratory tract and skin infections, otitis media, nasal or oral carriage of organisms, systemic infections etc. if any, should be corrected before an elective operative procedure. Pre operative hospitalization to be kept to a minimum. The ideal for elective operations would be to admit the patients to the hospital on previous day or on the day of surgery. Set criteria for hair removal based on the need to view or access the operative site rather than to reduce bacteria.  If shaving is thought to be necessary for any reason, it should be performed immediately before the procedure, to reduce the risk of infection. Pre operative bathing with an antimicrobial product (povidone iodine 7.5%) is recommended at the night before and morning of the operation.Thoroughly wash and clean at and around the incision site to remove gross contamination before shifting the patient to theatre. Sterile occlusive drapes may then be used to prevent recontamination of the area. Administer antibiotic relevant for the proposed procedure an hour prior to making incision. Repeat it at 3 hrs in procedures of >3 hours duration.

ii)  Intra-operative measures

Laminar flow ventilation system, a controlled, unidirectional, positive pressure stream of air and high-efficiency particulate air (HEPA) filters further reduces the airborne contamination to very low levels. The door to the operating room should be closed at all times to avoid mixing corridor air with the operating room air, which would increase the microbial load. To prevent contaminated air from reaching the operating theatre, a properly designed, air-conditioning system is recommended. The minimum air exchanges required for operation room is 15 air changes per hour of which 3 should be of fresh air. The air within the operating room should be at a positive pressure compared with other areas of operating suit with movement from clean to less clean areas. Introduce all air vent at the ceiling and exhaust near the floor. Air filters need to be replaced regularly according to manufacturer's instructions. The temperature required for operating room is 20-23 0C. The designated relative humidity is 30 to 60%. Levels greater than 60% promote fungal growth.

Restrict the number of people allowed in the operating room, and the activity of the personnel, including talking, to an absolute minimum. Carriers of bacteria and people with septic lesions should refrain from entering theatre. Infected cases should preferably be placed last in the list. Waste removal, concurrent cleaning and disinfection of operating room should be done between each cases. All clinical waste should be disposed of according to the guidelines. Wet-mop the floor of the operating room with a disinfectant between cases to minimize the risk of the operating room environment and floors as a source of infection. When large soiling or contamination, with blood or other body fluids, of surface or equipment occurs during an operation, use 1% sodium hypochlorite solution to clean the affected area before the next operation.

Terminal cleaning and disinfection of theatre is to be performed daily after the cases are over. A more thorough wet cleaning / vacuuming of the entire suit at the end of the day provide a sufficiently clean environment. Weekly washing of theatre suit and all its equipment using a detergent disinfectant followed by disinfection of operating rooms is recommended to keep the theatre free of contamination. Fogging is recommended after a patient having airborne pathogens is encountered. Whenever contamination with air borne pathogen is suspected, institute policy recommends fogging, using hydrogen peroxide in silver nitrate base (ecoshield). Required strength is 20%.  However, cleaning, pre and post to fogging, plays the important role.

To avoid transfer of pathogens in to the operating site, operating room apparel must be worn only within the surgical suite. If it happens to be taken outside, it should be removed before the person reenters the suite. The surgical hand scrub is intended to reduce the number of both transient and resident microorganisms on hands of personnel who comes directly in contact with the wound. Remove hand jewels and wrist watch before performing hand scrub. Finger nails should be kept short and clean underneath each fingernail before performing hand scrub. Scrub is to be performed before the sterile field, sterile instruments or the patient's prepared skin is touched. Scrub should include hands and forearms up to the elbows. Thorough surgical scrub for 3-5 minutes helps to prevent transfer of microorganisms from personnel to patient. Team members having any weeping lesions or dermatitis on hand should refrain from duty.

Barrier devices are meant to prevent wound contamination from shedding of skin squames embedded with organisms by operating room personnel. All those who enter operating theatre ought to wear mask. Double layered face mask prevent aerosolization of droplets generated during conversation. A fresh mask must be worn for each operation as the wet mask is potential for transferring organism. Hair must be completely covered by a close fitting cap and beard cover (if indicated). Plastic over shoes that is washable and covers the whole foot is recommended in the operating suite. Protective eye wear or face shields safeguard the team members from exposure to splashes / droplets of blood / body fluids likely to be generated during the procedure. The operating team should wear sterile gown having long sleeves at surgery. Change scrub suit when visibly soiled, contaminated, and / or penetrated by blood or other potentially infectious materials.

iii)  Aseptic surgical technique

Good operative technique includes: expeditious surgery, use of aseptic barriers, gentle handling of tissue, reduction of blood loss and hematoma formation, elimination of dead tissue, debridement of devitalized tissue, removal of all purulent material by irrigation or suction and removal of all foreign material from the wound before closing. Use delayed primary closure or leave incision open to close by secondary intention, if the site is heavily contaminated. If drain is indicated, use a closed suction drain and place the drain through a separate incision. Remove the drain as soon as possible.

Ensure proper packaging, sterilizing, and maintaining of instruments sterility till the end of the procedure. All sterile packs should be opened using non touch technique. Either autoclaving or plasma sterilization is recommended for instruments. Do not perform flash sterilization.

iv) Post operative care

Protect primary closure incisions with sterile dressing for 24-48 hours post operatively and should not be opened in 48 hrs unless infection is suspected. Observe hand hygiene, aseptic technique and use sterile gloves and dressing material for wound dressing. Use woven gauze dressings, as it does not interact with wound and thus causes less wound irritation. Dry dressings are preferred for post operative incisions that are expected to be primary intention healing. Use separate swab for each cleansing stroke. Clean from least contaminated area to most contaminated. Frequency of dressing should be kept to a minimum.

Dispose the soiled dressings and drains according to the guidelines. Care of wound should be directed at encouraging rapid wound healing by providing adequate nutrition. A diet rich in protein, vitamins and minerals need to be advised. Avoid excess post operative stay and overcrowding of people in the post operative unit. Keep post operative unit clean and keep the patient away from infected or colonized patient. Surveillance of surgical site infection with regular feedback of appropriate data to the surgeon has been shown to be an important strategy to reduce the risk of SSI.

CONCLUSION

Every individual is accountable for his/her own role in infection control. The nurse has a major role in preventing the transmission of bacteria in wounds between patients and in minimizing the risk of developing SSI. As knowledge, technology, and health-care settings change, infection control and prevention measures also should change. 

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OPERATING DEVICE OR PROCEDURE ASSOCIATED INFECTIONS...

operating  device or procedure associated infections

INTRODUCTION

The device/procedure associated infections and preventive guidelines included in this chapter are ventilator associated pneumonia (VAP), catheter associated urinary tract infection (CAUTI), central line related blood stream infections (CRBSI) and surgical site infections (SSI). These are based on currently available centers for disease control and prevention (CDC) guidelines.

STANDARD OPERATING PROTOCOLS    

1. Ventilator associated pneumonia

VAP is one of the common health care associated infections in Intensive Care Units (ICUs). Clinical practice aimed at preventing VAP must be seen in the context of managing patients with respiratory failure and especially those who require artificial ventilation. VAP is pneumonia that occurs in a patient who was intubated and ventilated at the time of or within 48 hours before the onset of the pneumonia. A ventilator in this context is a device to assist or control respiration continuously, inclusive of the weaning period, through a tracheostomy or by entotracheal intubation. VAP arises when there is bacterial invasion of the pulmonary parenchyma in a patient receiving mechanical ventilation.

Strategies to prevent or minimize contamination of equipment used for caring patients receiving mechanical ventilation:

1.    Ensure hand hygiene before handling endotracheal tube (ETT) and ventilator circuits

2.    Follow asepsis during intubation and suctioning.

3.    Use sterile single use gloves and suction tubes.

4.    Use sterile water for humidification.

5.    Remove condensate from ventilator circuits frequently. It requires routine inspection. Take care not to allow condensate to drain towards the patient.

6.    Keep the circuits closed while removing condensate.

7.    Change the ventilator circuit and attached humidifier weekly unless it is found visibly soiled or malfunctioning.

8.    Thoroughly clean all equipment before sterilization or disinfection.

9.    Though high-level disinfection is adequate for semi critical items, first option adopted in this hospital is sterilization. Ventilator circuits are to be sterilized by hydrogen peroxide gas plasma sterilization. Autoclave laryngoscope blades. Use sterile water for rinsing ventilator accessories before sterilization and after chemical disinfection. Store sterilized items with utmost care that no recontamination takes place.

10. Orotracheal intubation is preferable to nasotracheal intubation as the later increases the chance of sinusitis which may increase the risk of VAP. Early ambulation of the patient helps him recover faster. Chest physiotherapy followed by drainage of secretion is initiated at the earliest and maintained throughout mechanical ventilation.

VAP prevention bundle

The ventilator care bundle is a series of interventions related to ventilator care that, when implemented together will achieve significantly better outcomes than when implemented individually.

1) Daily sedation vacation: Those patients who had daily interruptions/sedations are demonstrated to have reduced duration of ventilation and ICU stay. Each ICU has to examine their sedation practice and develop a system that allows a sedation hold policy. Sedation break should ideally occur before 10 AM. If possible switch it off early in the morning at the end of night shift. Though stopped, sedation is not disconnected from the patient.  Then allow the patient to wake up. If the patient is co-operative and able to understand commands leave the sedation off. Distressed or agitated patients may be recommenced on sedation but at half the previous rates. Sedation boluses may be administered as required to achieve safety. If possible it may be substituted by analgesics and attempt for this may be initiated before restarting sedation.

2) All patients will be assessed for weaning and extubation each day: Standardised weaning protocols could reduce ventilator stay. Daily screening of the respiratory function of ventilated patients followed by trials of spontaneous breathing in appropriate patients reduces duration of mechanical ventilation and is associated with fewer complications than usual. Avoid unplanned extubation and re-intubation.

3) Avoid supine position aiming to have the patient at least 300 head up: Sitting ventilator patients up reduces oesophageal reflex, pulmonary aspiration, and may prevent VAP. Avoidance of the supine position particularly in patients being enterally fed is more important than semi recumbency. Backrest elevation should be done whenever practicable during patient care. Though it is very difficult to achieve 45 degree head end elevation, for a number of patients due to their disease condition, elevation to nearly 30 degree is possible.

4) Prevent aspiration of gastric contents: Critically ill intubated patients lack the ability to defend their airway. Therefore, oesophageal reflux and aspiration of gastric contents along the endotracheal tube may lead to bronchial colonization and pneumonia. Supine position and length of time patients stayed in that position are risk factors for gastric aspiration. Gastric over distension also can cause aspiration. Check for residual volume routinely before each feed and withhold feeding for one hour if it exceeds 100 ml. Residual gastric contents could cause vomiting or aspiration and resultantly VAP.

5) Use chlorhexidine as part of daily mouth care: Meticulous oral hygiene using chlorhexidine in each shift reduces oro-pharyngeal colonization and hence ventilator associated pneumonia.

6) Frequent suctioning of subglottic secretions in patients on ventilators: Deep glottic drainage of potentially contaminated oro-pharyngeal secretions from above the tracheal tube cuff may prevent aspirations, lower airway colonization and hence pneumonia. Presence of pooled subglottic secretions between the cuff of the endotracheal tubes and trachea will contribute to aspiration and it may be colonized by hospital pathogens. As and when made available ET tubes with subglottic drainage ports may be used.

7) Stress ulcer prophylaxis / Reduce colonization of aero digestive tract: Stress ulceration is the most common cause of gastro intestinal bleeding in patients in intensive care units. Peptic ulcer disease prophylaxis is therefore necessary. It may also precipitate pneumonia due to the decreased bacterial killing in the low acid environment as acid suppressive therapy may increase the colonization density of the aero digestive tract with potentially pathogenic organisms. Though its association with VAP is unclear, when applied as a package of interventions for ventilator care, stress ulcer prophylaxis with selective drug seems to decrease the rate of pneumonia.

VAP is often fatal, and is associated with increased mortality and morbidity, increased duration of mechanical ventilation, prolonged ICU and hospital stay, and increased cost of hospitalization. VAP is preventable through the use of evidence-based strategies intended to minimize endotracheal intubation, duration of mechanical ventilation and, the risk of aspiration of oro pharyngeal secretions.

2. Catheter associated urinary tract infection

Urinary tract infections (UTI) are the most common type of healthcare associated infections accounting for more than 30% of total HAI. Virtually, all catheter associated urinary tract infection are caused by instrumentation of the urinary tract. Though, the mortality and morbidity from CAUTI is considered to be relatively low compared to other HAIs, the high prevalence of catheter use leads to a large cumulative burden of infections.

Microbial pathogens can enter the urinary tract either by the extraluminal route, by migration along the outside of the catheter in the periurethral mucous sheath, or by the intraluminal route, by movement along the internal lumen of the catheter from a contaminated collection bag or catheter drainage tube junction. Formation of biofilms by urinary pathogens on the surface of the catheter and drainage system occurs with prolonged duration of catheterization. Over time, the urinary catheter becomes colonized with microorganisms living within the biofilm, rendering them resistant to antimicrobial and host defenses.

Standard operating protocol for care of patients having indwelling urinary catheter

These guidelines apply to adults and children and should be used in conjunction with the guidance on standard precautions. The guidelines mainly focus on preventing infection. Catheter insertion, catheter change and care should be documented. It includes date and time of catheter insertion, indications for catheter insertion, individual who inserted the catheter, date and time of removal/ change of catheter, reason for change of catheter etc.

The recommendations are divided into five distinct interventions:

1. Assessing the need for catheterization

Indwelling urinary catheters should be used only after alternative methods of management have been considered. Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk of CAUTI and patients with impaired immunity. The patient's clinical need for catheterization should be reviewed regularly. and the urinary catheter removed as soon as possible. Avoid urinary catheters for management of incontinence. Use urinary catheters in operative patients only as necessary rather than routinely and remove as soon as possible, postoperatively.

2. Catheter insertion

Unless otherwise clinically indicated, use the smallest bore catheter possible, consistent with good drainage, to minimize bladder neck and urethral trauma. Perform hand hygiene immediately before and after insertion or manipulation of the catheter device or site. Use sterile equipment and appropriate personal protective equipment (sterile gloves, drape, sponges, sterile antiseptic solution and lubricants) during catheterization. For urethral catheterization, the meatus should be cleaned before insertion of the catheter, with 10% povidone iodine /2% chlorhexidine gluconate. An appropriate sterile lubricant should be used during catheter insertion to minimize urethral trauma. The catheter balloon should be inflated with10 ml of sterile water in adults and 3-5 ml in children. Properly secure indwelling catheters after insertion to prevent its movement and urethral traction.

3. Catheter drainage options

Following aseptic insertion of the indwelling catheter, it should be connected to a sterile closed urinary drainage system.If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. Maintain unobstructed urine flow. To ensure this keep the catheter and collecting bag below the level of bladder and the tubing free from kinking, at all times. Empty the collecting bag regularly using a clean collecting container avoiding splash and contact of the drainage spigot with the non-sterile collecting container. Do not change indwelling catheter or drainage bags at routine fixed intervals, rather change it based on clinical indications such as infection, obstruction, or when the closed system is compromised.

CDC does not recommend routine bladder irrigation with antimicrobial unless obstruction of the tube is anticipated. If obstruction occurs, closed continuous irrigation may be done to prevent obstruction. If intermittent catheterization is used, perform it at regular intervals to prevent bladder over distension. Intermittent catheterization is preferred to an indwelling catheter if it is clinically appropriate and it is a practical option for the patient.

4. Catheter maintenance

Hands must be decontaminated and wear a new pair of sterile gloves before manipulating a patient's catheter, and decontaminate  hands after removing gloves. Urine samples must be aspirated from the catheter hub under aseptic technique without disconnecting the system. The meatus should be washed daily with soap and water. Each patient should have an individual care regimen designed to minimize the problems of blockage and encrustation. The tendency for catheter blockage should be documented in each patient. Catheters should be changed only when clinically necessary or according to the manufacturer's current recommendations.

5. Education of healthcare personnel

Healthcare personnel should be educated about and trained in techniques of insertion of catheters, and catheter management like maintenance, and removal. Provide education about CAUTI, other complications of urinary catheterization, and alternatives to indwelling catheters etc. Healthcare personnel should be assessed for their competence to carry out these types of procedures.

3. Central line related blood stream infection (CRBSI)

Central line is an intravascular (IV) catheter that terminates at or close to the heart or in one of the great vessels, which is used for infusion, withdrawal of blood or hemodynamic monitoring. Infections related to central venous catheter (CVC) include insertion site infection, blood stream infection and exit site infection (in case of tunneled catheters).

The most important infection associated with IV devices is blood stream infection (bacteremia). Although peripheral venous catheters are the devices most frequently used for vascular access, the incidence of local or bloodstream infections (BSIs) associated with it is usually low. However, the majority of serious catheter-related infections are associated with CVCs.

CVC is a foreign body which produces a reaction in the host. Following insertion of this vascular device, microbial bio-films are formed at inner and outer surfaces of the catheter. The presence of the device impairs the activity of the neutrophils and protects micro organisms embedded in the bio-film from the effect of antimicrobial agents. Bacteria are therefore, able to multiply freely in the biofilm on the catheter surface from where they are released into the bloodstream. Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip is the most common route of infection for peripherally inserted, short-term catheters. Contamination of the internal surface of the catheter usually begins at the hub and contributes substantially to intraluminal colonization of long-term catheters. They are responsible for a significant proportion of catheter associated infection and it increases when more than one hub (e.g. multiple lumen catheter) is used.

Occasionally, catheters might become hematogenously seeded from another focus of infection. Rarely, infusate contamination also leads to CRBSI. Although most intravenous device-associated infections are acquired endogenously from micro-organisms colonizing the patient's skin, they may also be introduced in to the hub, lumen or administration set during its manipulation.

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