Ventilator-Associated PNA - 29 Flashcards
1
Q
Most common organisms in ventilator-assoc PNA?
A
- Gram (-) Bacilli (57%)
- PA, Ecoli, Hemophilus - Gram (+) Cocci (42%)
- SA, Strep pneumo
2
Q
Measures to prevent VAP
A
- Oral decontamination w/ mouth-wash or chlorhexidine
- ONLY suction to clear present secretions from airway, NOT on a routine basis
- Clear subglottic secretions with specialized ET tubes
3
Q
Best ways to Dx VAP
A
- NOT - clinical criteria alone (fever, WBC, sputum)
- NOT - CXR, nonspecific, nonsensitive nature of infiltrates which could be edema, RDS, atalectasis
- After 2 days of being stable + worsening oxygenation: Inc FiO2 20%, inc PEEP 3cm for 2 days
- After 3 days of vent and 2 days of worsening: temp >38, 12, <4
4
Q
Methods for micro examination
A
- Microscopic analysis - ?contaminated by mouth secretions 10+ squamous epithelia/hpf
- Macrophages present = lower resp tract
- 25+ neutrophils/hpf = infection
- Qualitative cultures - ONLY a (-) culture can be used to r/o PNA
- Quantitative cultures - >10^5 CFU/ml had >specific but less sensitive than qualitative
5
Q
What is the most accurate method for dx VAP?
A
Brochoalveolar lavage
- 6 lavages 20ml each
- 10^4 CFU/ml
- intracellular organisms >3% = 90% chance of having PNA
- non-bronchoscopic lavage by a RT is = to bronchoscopy
- Protected specimen brush + is evidence of PNA
6
Q
Indications for thoracentesis
A
- Large or inc in size
- Air-fluid level in effusion or hydropenumothorax indicating a fistula or empyema
- Severe sepsis or shock w/ parapneumonic effusion
- Not responding to abx
7
Q
Indications to drain a parapneumonic effusion
A
- bronchoplerual air leak (hydropneumothorax)
- Purulent pleural aspirate
- pH <40mg/dl
8
Q
Empiric abx for VAP
A
Include SA coverage
- Pip/tazo or a carnepenem
- anti-pseudomonal (ceftazidime, cefepime) + vanco or linezolid
- 1 week good for most but up to 14-21d
