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ABSTRACT
- Presentare con logica multiprofessionale, utilizzando come indicatore
di efficacia assistenziale il contenimento delle infezioni nosocomiali in
area critica, le modalità di gestione di alcune problematiche legate al
bisogno di:
- a) respirazione meccanica
- “Prevenzione delle infezioni polmonari nel paziente in ventilazione
artificiale meccanica”
- Luca Peressoni, Grazia Miconi – Udine,
- Maria Benetton – Treviso
-
- ABSTRACT
- Il supporto ventilatorio meccanico rappresenta una metodica di frequente
utilizzo nell’assistenza ai pazienti critici. Considerata strategia
salvavita, la ventilazione artificiale (VAM) è altresì invasiva, costosa e
gravata da una varietà di potenziali complicanze. Il rischio di contrarre
un’infezione polmonare legata a ventilazione (VAP) è direttamente correlata
alla durata della VAM (es. 48h), con incidenze variabili in rapporto alla
patologia (es. 28-40% nei traumi cranici). La diagnosi è spesso problematica
per l’aspecificità e la variabilità dei segni clinici e radiologici.
- Obiettivo dell’elaborato è declinare interventi appropriati
nell’approccio alla VAP attraverso revisione bibliografica internazionale.
L’applicazione di strategie preventive di comprovata efficacia, associate ad
interventi terapeutici precoci, rappresenta l’indicatore di qualità per
un’assistenza infermieristica di eccellenza nell’ambito dei livelli
essenziali definiti (LEA).
- Un presidio infermieristico multifocale, che muove da azioni semplici ma
efficaci sino a comprendere indicazioni ad alta variabilità e complessità.
- • Gestione efficace dei presidi per il supporto ventilatorio (filtri,
circuiti, sistemi di umidificazione ed aspirazione, …);
- • Profilassi dell’inalazione, aspirazione o “leakage” di secreti;
- • Incremento della capacità difensiva dell’organismo attraverso
un’apporto nutrizionale precoce;
- • Impiego di protocolli di svezzamento (weaning) per l’approccio
multidisciplinare;
- • Status dei pazienti, dalla posizione laterale sino alla pronazione.
- Pratica basata sull’evidenza scientifica, qualità di risultato,
accessibilità ed appropriatezza delle risorse rappresentano gli item
d’analisi e chiave di lettura applicativa al processo
-
- BIBLIOGRAFIA
- POSIZIONE SUPINA VERSUS POSIZIONE SEMISEDUTA
- 1. Lode H., “Nosocomial pneumonia: epidemiology, pathogenesis, diagnosis,
treatment and prevention”, Curr. Opin. Infect. Dis. 2000 Aug;13(4):377-384.
- 2. Reeve B., “Semirecumbency among mechanically ventilate ICU patients:
a multicenter observational study”, Clinical Intensive Care 2000, Specia
Issue: 31-34.
- 3. Torres A., “Supine body position as a risk factor for nosocomial
pneumonia in mechanically ventilated patients: a randomised trial”, Lancet
1999;354:1851-1858.
- 4. Collard H “Prevention of ventilator-associated pneumonia”:; http://ahrq.gov/clinic/ptsafety/chap17a.htm
-
- OSCILLAZIONE CONTINUA
- 1. Trever G.A., “Continous oscillation: outcome in critical ill patients”
J Crit care 1995; 10: 97-103
- 2. Choi S.C., “Kinetic therapy in critically ill patients: combined
results based on meta-analysis”, J Crit care 1992; 7: 57-62
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Crit care 1989; 4: 45-53
-
- PRONAZIONE
- 1. Beuret, “Prone position for the prevention of lung infection”,
Minerva An. 2002;68:266-8
- 2. Murray T. et al., “Prone positioning of trauma patients with ARDS and
open abdominal incision”, Critical Care Nurse 2002;22:52-56.
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Crit. Care., 2002;165:1359-1363.
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patients with acute respiratory failure”, N Engl. J. Med.,
2001;345(8):568-573.
- 5. Meade M., “Prone position improves oxygenation but not survival in
patients with respiratory failure”, Evid. Based Nurs. 5:52-52.
-
- PULIZIA DEL CAVO ORALE
- 1. Limeback H., “Implication of oral infection on systemic deseases in
the institutionalized elderly with a special focus on pneumonia” Ann
Periodontol 1998 Jul; 3 (1): 262 – 275
-
- WEANING
- 1. Epstein CD., “Weaning older Patients from long-term mechanical
ventilation: a pilot study”, Am. J. Of Crit. Care. 2002;11:369-377.
- 2. Mehta S., “Noninvasive ventilation”, Am. J. Respir. Crit. Care Med.
2001 Feb; 163 (2): 540-577.
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patients by Respiratory Care Practioners Nurses”, Chest 2000;118:459-467.
- 4. Agency for Healthcare Research and Quality June 2000; “Criteria for
weaning from mechanical ventilation” Pubblication n. 00-E, http://ahrq.gov
-
- FISIOTERAPIA RESPIRATORIA
- 1. Ntoumenopoulos G., “Chest physiotherapy for the prevention of
ventilator-associated pneumonia”, Intensive Care Med. 2002 Jul; 28 (7):
850-856.
- 2. Raoof S. et al., “Effect of combined kinetic therapy and percussion
therapy on the resolution of actelectasisi in critically ill patients”,
Chest 1999;115:1658-1666.
- CASS – ASPIRAZIONE CONTINUA DELLE SECREZIONI SOTTO GLOTTIDEE
- 1. Kollef M.H., “A randomized clinical trial of continus aspiration of
subglottic secretions in cardiac surgery patients”. Chest 1999; 116:
1339-1346
- 2. Vallés J:, “Continous aspiration reduced ventilator-associated
pneumonia” Ann Intern Med 1995 Feb ; 122:179-186
- 3. Mahul P., “ Prevvention of nosocomial pneumonia in intubated patients:
respective role of mechanical subglottic secretion drainage and stress ulcer
prophylaxis”. Intensive Care Med 1992; 18: 20-25
-
- POLMONITE – MISCELLANEA
- 1. Chastre J., “Ventilator-associated Pneumonia”, Am. J. Respir. Crit.
Care Med.2002; 165:867-903.
- 2. Fabregas N., “Pulmonary infection in the brain injured patient”,
Minerva An. 2002;68:285-90.
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An. 2002;68:258-60.
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Minerva An. 2002;68:261-5.
- 5. Ferrer R., “Clinical review: non-antibiotic strategies for preventing
VAP”, Crit. Care 2002 Feb; 6 (1): 45-51.
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prophylaxis”, Med. Clin. North. Am. 2001 Nov; 85(6):1545-63.
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Ventilator-Associated Pneumonia”, Chest 2000;117:177S-181S
- 8. Craven D.E., “Epidemiology of Ventilator-Associated Pneumonia”, Chest
2000; 117:186S-187S
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ventilated patients with traumatic and medical head injury”, Am. J. Respir.
Crit. Care Med. 1999;159:188-198.
- 10. Kollef M., “The prevention of Ventilator-Associated Pneumonia”, The
New England Journal of Medicine 1999; 340:627-634
- 11. Hixson S., “Nursing strategies to prevent VAP”, AACN Clin. Issues
1998;9(1):76-90.
- 12. Center of Desease Control and Prevention di Atlanta, “Linee Guida
per la prevenzione delle polmoniti nosocomiali” 1997
-
- ALIMENTAZIONE
- 1. Montejo JC., “Multicenter, prospective, randomized, single-blind
study comparing the efficacy and gastrointestinale complications of early
jejunal feeling with early gastric feeling in critically ill patients”, Crit.
Care Med.2002 Apr; 30 (4): 796-800.
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prevention strategies, bedside detection, and practice change”, Medsurg.
Nurs. 2000 Feb;9(1):27-31.
- 3. Prod’hom G., “Nosocomial pneumonia in mechamical ventilated patients
receiving antacid, ranitidine or sucralfate as profhylaxis for stress ulcer.
A randomized controlled trial.” Ann Intern Med 1994 April ; 120: 653- 662.
-
- CIRCUITI ESTERNI - VENTILATORI MECCANICI
- 1. Hess D., “Infection control in the ICU: the role of the ventilator
circuit”, Minerva An. 2002;68:356-9.
- 2. Cook D., “Ventilator circuit and secreton management strategies: a
Franco-Canadian survey”, Crit. Care Med. 2000;28(10):3547-54.
- 3. Fink J.B., “Extending ventilator circuit change interval beyond 2
days reduces the likelihood of VAP”, Chest 1998;113:405-11.
- 4. Ricard JD, “Ventilator circuit changes: “wu wei” may save time labor
and money”, Respir. Care 2001 Sept; 46(9):888-90.
- 5. Kollef M.H., “Mechanical ventilation with or without daily changes of
in-line suction catheter”, Am J Respir Crit Care Med 1997 Aug; 156; 466-472.
-
- FILTRI ANTIBATTERICI E UMIDIFICANTI - UMIDIFICATORI
- 1. Markowicz P., “Safety, efficacy, and cost-effectiveness of VAM with
humidifying filters changed every 48 hours: a prospective, randomized study”,
Crit. Care Med. 2000;28(3):665-671.
- 2. Thomachot L., “Changing HMEs after 96 hours rather than after 24
hours: a clinical and microbiological evaluation”, Crit. Care Med.
2000;28(3):714-720
- 3. Larsson A., “A new device for 100 per cent humidification of inspired
air”, Crit. Care 2000;4:54-60.
- 4. Salemi C., “HMEs used with biweekly circuit tubing changes: effect on
cost and pneumonia rates”, Infect. Control Hosp. Epid. 2000 Nov;
21(11):737-9.
- 5. Larsson A., “A new device for 100 per cent humidification of inspired
air”, Crit. Care 2000;4:54-60.
- 6. Kollef MH., “A randomized clinical trial comparing an extended-use
hygroscopic condensor humidifie with heated-water humidification in
mechanically ventilated patients”, Chest 1998;113:759-767.
- 7. Iotti G.A., “Effetti meccanici sfavorevoli degli scambiatori di
calore e di umidità nei pazienti ventilati”, Intensive Care Med.
1997;23:399-405
- 8. Hurni J.M., “Safety of combined HMEs filters in long-term mechanical
ventilation”, Chest 1997;111:686-91.
- 9. Kirton O.C., “A prospective, randomized comparison of an in-line HMEs
filter and Heated Wire humidifiers”, Chest 1997;112:1055-59.
- 10. Centers for Disease Control and Prevention, “Linee guida per la
prevenzione della polmonite nosocomiale”, 1997
-
- SISTEMI DI ASPIRAZIONE DELLE SECREZIONI
- 1. Maggiore S.M., “Closed versus open suctioning techniques”, Minerva An.
2002;68:360-4.
- 2. Smulders K. et al., “A randomized clinical trial of intermittent
subglottic secretion drainage in patients receiving mechanical ventilation”,
Chest 2002;121:858-862.
- 3. Shorr AF. Et al., “Continuous subglottic suctioning for the
prevention of VAP”, Chest 2001;119:228-235.
- 4. Combes P., “Nosocomial pneumonia in mechanically ventilate patients,
a prospective randomised evaluation of the Stericath closet suctioning
system”, Intensive Care Med. 2000;26:878-882.
- 5. Paul-Allen J., “Survey of nursing practices with closet-system
suctioning”, AACN American Journal of Critical Care 2000;9(1):9-19.
- 6. Kollef M.H., “A randomized clinical trial of continuous aspiration of
subglottic secretions in cardiac surgery patients”, Chest
1999;116:1339-1346.
- 7. Wunderink R.G., “Prevention of VAP: does one size fit all?”, Chest
1999;116:1155-1156.
- 8. Kollef M.H., “Mechanical ventilation with or without daily changes of
in-line suction catheters”, Am. J. Respir. Crit. Care Med. 1997;156:466-472
-
- SDD – DECONTAMINAZIONE SELETTIVA DIGESTIVA
- 1. Tennis C., “Prevention of ventilator-associated Pneumonia by SDDAm”,
J. Respir. Crit. Care Med. 2001; 164:382-388.
- 2. Limeback H., “Implication of oral infection on systemic deseases in
the institutionalized elderly with a special focus on pneumonia”., Ann
Periodontol 1998 Jul; 3 (1): 262 - 275
- 3. Gruppo Italiano di Studio sulle Infezioni Gravi, “Profilassi
antibiotica delle infezioni in Terapia Intensiva attraverso SDD”.
-
- SITI INTERNET CONSULTATI
- MedLine Banca Dati Online
- http://ahrq.gov Agency for
Healthcare Research and Quality
- http://acpjc.org American
College of Physicians JournalClub
- http://www.EBNOnline Evidence Based Nursing
- www.cdc.gov Center of
Desease of Atlanta
- www.cochrane.org
Cochrane Library
-
www.ioannabringgs.edu.au Evidence Based Nursing
- www.atsjournals.org
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