Measures for the prevention of pneumonia associated with mechanical ventilation in neurological patients

Introduction

Pneumonia associated with ventilation (VAP) develops after 48 hours of orotracheal intubation (OTI) and mechanical ventilation (MV). It develops because of the imbalance between the patient's defense mechanisms and the microbial agent. The patient using OTI loses the natural barrier, eliminating the cough reflex and promoting the accumulation of secretions above the cuff, and therefore could facilitate colonization and the aspiration of contaminated secretions. The incidence of VAP is high, varying between 6% and 52%, depending on the studied population, on the type of UTI and on the type of diagnosis technique used; therefore, in spite of being an extremely important infection, it is one of the most difficult diagnoses in critically ill patients. When compared with other nosocomial infections, such as the one of the urinary tract and skin, where the mortality is between 1% and 4%, VAP becomes an important mortality predictor, since this varies between 24% and 50%, and could be more than 70% when caused by multiresistant microorganisms. Patients seriously ill with diagnoses of trauma – it reviles cerebral, vascular accident – are of particularly larger risk for VAP, the incidence estimated to be between 40 and 50%. Programs of basic education have been recognizing that the occurrence of VAP can be reduced in 50% or more using several interventions to prevent the colonization and the aspiration of secretions as well as gastric content. The increasing frequency of resistant microorganisms represents a serious health problem. The ICU is a great source of resistant micro-organisms. Therefore, prevention should be part of the strategies of handling VAP. The mortality of this pathology can be reduced by the identification of the risk factors and of the prevention.

Objective

To determine the impact of nurse care prevention of VAP in the neurological patient.

Methods

The study was accomplished in the ICU. The sample constituted patients admitted to the ICU that required MV for more than 48 hours with neurologic disorders. The following data were collected: nurse order and accomplishment of oral hygiene and use of clorohexedine 0.2%, six times per day in the patients with neurological problems; the adhesion was controlled by the ICU Nurses Neurological Team and accompanied the infection control for VAP.

Results

The results in the period of August 2008 to January 2009 were 92 patients with neurological disorders, and the ICU maintained a rate of patients/day of 1,272.8, with MV/day of 236. In this period new cases of VAP were not registered; in comparison with the same period of 2007, there were 32 cases notified with a rate of patients/day of 754, with MV/day of 275 and 86 patients with neurological diagnoses. The ICU patients are submitted to the institutional and managed protocols of quality for the multiprofessional team, each one should receive care in the ICU infection prevention, and this care expresses the nurse care to warranty the aim of the prevention measures. Also, execution and measurement for improvement of nurse care were shown.

Conclusion

In this study, submitted MV patients presented a decrease of VAP when the package of care was instituted and the main nurse guaranteed the nurse order and the accomplishment of oral hygiene adapted for the MV patient. We suggest the implantation of care and these routines can help in the prevention of infections in the ICU.