Advertisement

Factors associated with ventilator-associated events: an international multicenter prospective cohort study

  • Jordi Rello
  • Sergio Ramírez-Estrada
  • Anabel RomeroEmail author
  • Kostoula Arvaniti
  • Despoina Koulenti
  • Saad Nseir
  • Nefise Oztoprak
  • Lila Bouadma
  • Loreto Vidaur
  • Leonel Lagunes
  • Yolanda Peña-López
  • for the EUVAE Study Group
Original Article

Abstract

A secondary analysis of a prospective multicenter cohort was performed in six intensive care units (ICU) in four European countries (France, Greece, Spain and Turkey). The main objective was to identify factors associated with ventilator-associated events (VAEs) in adults who underwent mechanical ventilation (MV) ≥ 48 h. Secondary objectives were to identify: variables influencing VAE in the subpopulation with endotracheal intubation and in those subjects who were ventilated > 7 days. Subjects who had undergone MV ≥ 48 h were included. In subjects with multiple episodes of MV, only the first one was eligible. The adult definitions for VAEs were adjusted to the 2015 update of the CDC’s 2013 National Healthcare Safety Network Association. Factors associated with VAE were estimated through multivariate Cox proportional hazards analysis. Among 163 adults (42 tracheostomies), 76 VAEs (34.9 VAEs/1,000 ventilator-days) were documented: 9 were Ventilator-Associated Conditions (VAC) and 67 Infection-related Ventilator-Associated Complications (IVAC)-plus (9 only IVAC and 58 Possible Ventilator-Associated Pneumonia). VAEs developed after a median of 6 days (interquartile range: 4–9). VAEs were independently associated with long-acting sedative/analgesic drugs (Hazard Ratio [HR]: 4.30), selective digestive decontamination (SDD) (HR: 0.38), and surgical/trauma admission (HR: 2.30). Among 116 subjects with endotracheal tube, SDD (HR: 0.21) and surgical/trauma admission (HR: 3.11) remained associated with VAE. Among 102 subjects ventilated >7 days, only long-acting sedative/analgesic agents (HR: 8.69) remained independently associated with VAE. In summary, SDD implementation and long-acting analgesic/sedative agents restriction prescription may prevent early and late VAEs, respectively. Bundles developed to prevent VAEs should include these two interventions.

Keywords

Ventilator-associated pneumonia Selective digestive decontamination Midazolam Prevention bundles Mechanical ventilation Safety 

Notes

Acknowledgments

We thank Michael Maudsley for providing assistance with English language corrections to this manuscript. We also thank Santiago Pérez-Hoyos from the Statistics and Bio informatics Unit (UEB) at Vall d’Hebron Research Institute (VHIR) for giving statistical advice. This research was carried out as part of a PhD program in Health Science at the Universitat Autónoma de Barcelona, Spain, and was supported by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infections in Critically Ill Patients (ESGCIP), Basel, Switzerland, and by Centro de Investigación Biomédica en Red—CIBERES CB06/06/036, Madrid, Spain.

We thank all EUVAE collaborators for collecting the data or scientific advice: Benito Almirante (Hospital Universitari Vall d’Hebron, Barcelona, Spain), Aliye Bastug (Ankara Numune Training and Research Hospital, Turkey), Mateo Bassetti (Santa Maria Misericordia Hospital, University of Udine, Udine, Italy), Ilkay Bozkurt (Ondokuz Mayis University, Samsun, Turkey), George Dimopoulos (Attikon University Hospital, Athens, Greece), Asuman Inan (Haydarpasa Numune Hospital, Istanbul, Turkey), Marina Oikonomou (Papageorgiou General Hospital, Thessaloniki, Greece), Garyphallia Poulakou (Attikon University Hospital, Athens, Greece), David Thompson (RBWH), Estefania Torrivilla (RBWH), Izarne Totorika (Hospital Universitario de Donostia, Donostia, Spain), and Vipin Varghese (RBWH).

Funding

Supported in part by grants from the European Society of Clinical Microbiology and Infectious Diseases—ESCMID, Study Group for Infections in Critically Ill Patients—ESGCIP, Basel, Switzerland, and by Centro de Investigación Biomédica en Red—CIBERES 06/06/036, Instituto Salud Carlos III, Madrid, Spain, and Fundació Catalana de Pneumologia—FUCAP, Barcelona, Spain.

Compliance with ethical standards

Conflict of interest

Dr. Rello has served on the speakers’ bureau and as a consultant for Cubist, Bayer, ROCHE, Medimmune, Pfizer, Anchoagen, and Aridis. The other authors report no conflicts of interest relevant to this article.

Ethical approval/informed consent

The study protocol was approved by the institutional review board on human research at each participating center and at Vall d’Hebron Barcelona Hospital Campus, the coordinating center [PR(AG)25/2014]. Patients (or the relatives of unconscious patients) were asked to provide written consent prior to participation in the study.

Supplementary material

10096_2019_3596_MOESM1_ESM.docx (36 kb)
ESM 1 (DOCX 36 kb)

References

  1. 1.
    Klompas M, Li L, Kleinman K, Szumita PM, Massaro AF (2016) Associations between ventilator bundle components and outcomes. JAMA Intern Med 176(9):1277–1283CrossRefGoogle Scholar
  2. 2.
    Rello J, Afonso E, Lisboa T, Ricart M, Balsera B, Rovira A et al (2013) A care bundle approach for prevention of ventilator-associated pneumonia. Clin Microbiol Infect 19(4):363–369CrossRefGoogle Scholar
  3. 3.
    [No Authors listed] (2005) IHI proposes six patient safety goals to prevent 100,000 annual death. Qual Lett Healthc Lead 17(1):11–2, 1Google Scholar
  4. 4.
    Wittekamp BH, Plantinga NL, Cooper BS, Lopez-Contreras J, Coll P, Mancebo J et al (2018) Decontamination strategies and bloodstream infections with antibiotic-resistant microorganisms in ventilated patients: a randomized clinical trial. JAMA 320(20):2087–2098CrossRefGoogle Scholar
  5. 5.
    Peña-López Y, Pujol M, Campins M, Lagunes L, Balcells J, Rello J (2018) Assessing prediction accuracy for outcomes of ventilator-associated events and infections in critically ill children: a prospective cohort study. Clin Microbiol Infect 24(7):732–737CrossRefGoogle Scholar
  6. 6.
    Ramírez-Estrada S, Lagunes L, Peña-López Y, Vahedian-Azimi A, Nseir S, Arvaniti K et al (2018) Assessing predictive accuracy for outcomes of ventilator-associated events in an international cohort: the EUVAE study. Intensive Care Med 44(8):1212–1220CrossRefGoogle Scholar
  7. 7.
    CDC’s National Healthcare Safety Network (2015) Ventilator-associated event (VAE). Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/10-vae_final.pdf. Accessed 14 January 2019
  8. 8.
    Magill S, Rhodes B, Klompas M (2014) Improving ventilator-associated event surveillance in the national healthcare safety network and addressing knowledge gaps: update and review. Curr Opin Infect Dis 27(4):394–400CrossRefGoogle Scholar
  9. 9.
    Ramsay MA, Savege TM, Simpson BR, Goodwin R (1974) Controlled sedation with alphaxalone-alphadolone. Br Med J 2(5920):656–659CrossRefGoogle Scholar
  10. 10.
    Spronk PE, Riekerk B, Hofhuis J, Rommes JH (2009) Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 35(7):1276–1280CrossRefGoogle Scholar
  11. 11.
    Krewulak KD, Stelfox HT, Leigh JP, Ely EW, Fiest KM (2018) Incidence and prevalence of delirium subtypes in an adult ICU: a systematic review and meta-analysis. Crit Care Med 46(12):2029–2035CrossRefGoogle Scholar
  12. 12.
    Zhang Z, Chen K, Ni H, Zhang X, Fan H (2017) Sedation of mechanically ventilated adults in intensive care unit: a network meta-analysis. Sci Rep 7:44979CrossRefGoogle Scholar
  13. 13.
    Wang H, Wang C, Wang Y, Tong H, Feng Y, Li M et al (2018) Sedative drugs used for mechanically ventilated patients in intensive care units: a systematic review and network meta-analysis. Curr Med Res Opin 35(3):435–446 1–12CrossRefGoogle Scholar
  14. 14.
    Liu J, Zhang S, Chen J, Mao Y, Shao X, Li Y, et al. (2018) Risk factors for ventilator-associated events: a prospective cohort study. Am J Infect ControlGoogle Scholar
  15. 15.
    Wyncoll D, McKenzie C (2010) Sedation versus no sedation in the intensive-care unit. Lancet 375(9721):1159 author reply 1160CrossRefGoogle Scholar
  16. 16.
    Weatherall M, Aantaa R, Conti G, Garratt C, Pohjanjousi P, Lewis MA et al (2017) A multinational, drug utilization study to investigate the use of dexmedetomidine (Dexdor®) in clinical practice in the EU. Br J Clin Pharmacol 83(9):2066–2076CrossRefGoogle Scholar
  17. 17.
    Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF et al (2013) Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 41(1):263–306CrossRefGoogle Scholar
  18. 18.
    Barr J, Kishman CP, Jaeschke R (2013) The methodological approach used to develop the 2013 Pain, Agitation, and Delirium Clinical Practice Guidelines for adult ICU patients. Crit Care Med 41(9 Suppl 1):S1–S15Google Scholar
  19. 19.
    Trogrlić Z, van der Jagt M, Lingsma H, Gommers D, Ponssen HH, Schoonderbeek JFJ et al (2019) Improved guideline adherence and reduced brain dysfunction after a multicenter multifaceted implementation of ICU delirium guidelines in 3,930 patients. Crit Care Med 47(3):419–427CrossRefGoogle Scholar
  20. 20.
    Zegers M, Hesselink G, Geense W, Vincent C, Wollersheim H (2016) Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. BMJ Open 6(9):e012555CrossRefGoogle Scholar
  21. 21.
    Nora D, Póvoa P (2017) Antibiotic consumption and ventilator-associated pneumonia rates, some parallelism but some discrepancies. Ann Transl Med 5(22):450CrossRefGoogle Scholar
  22. 22.
    Lewis SC, Li L, Murphy MV, Klompas M, Prevention Epicenters CDC (2014) Risk factors for ventilator-associated events: a case-control multivariable analysis. Crit Care Med 42(8):1839–1848CrossRefGoogle Scholar
  23. 23.
    Mekontso Dessap A, Katsahian S, Roche-Campo F, Varet H, Kouatchet A, Tomicic V et al (2014) Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest 146(1):58–65CrossRefGoogle Scholar
  24. 24.
    Sim JK, Oh JY, Min KH, Hur GY, Lee SH, Lee SY et al (2016) Clinical significance of ventilator-associated event. J Crit Care 35:19–23CrossRefGoogle Scholar
  25. 25.
    Harris BD, Thomas GA, Greene MH, Spires SS, Talbot TR (2018) Ventilator bundle compliance and risk of ventilator-associated events. Infect Control Hosp Epidemiol 39(6):637–643CrossRefGoogle Scholar
  26. 26.
    Guess R, Vaewpanich J, Coss-Bu JA, Phongjitsiri S, Kennedy C, Starke J et al (2018) Risk factors for ventilator-associated events in a PICU. Pediatr Crit Care Med 19(1):e7–e13Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Jordi Rello
    • 1
    • 2
    • 3
  • Sergio Ramírez-Estrada
    • 4
    • 5
  • Anabel Romero
    • 1
    • 2
    Email author
  • Kostoula Arvaniti
    • 3
    • 6
  • Despoina Koulenti
    • 3
    • 7
    • 8
    • 9
  • Saad Nseir
    • 10
  • Nefise Oztoprak
    • 11
  • Lila Bouadma
    • 12
  • Loreto Vidaur
    • 13
  • Leonel Lagunes
    • 3
    • 14
  • Yolanda Peña-López
    • 2
    • 15
  • for the EUVAE Study Group
  1. 1.Centro de Investigación Biomédica en Red—Enfermedades Respiratorias (CIBERES)Vall d’Hebron Research InstituteBarcelonaSpain
  2. 2.Vall d’Hebron Research Institute (VHIR)BarcelonaSpain
  3. 3.European Society of Clinical Microbiology and Infectious Diseases—Study Group for Infections in Critically Ill Patients (ESGCIP-ESCMID)BaselSwitzerland
  4. 4.Intensive Care DepartmentClinica CorachanBarcelonaSpain
  5. 5.Medicine DepartmentUniversitat Autònoma de BarcelonaBarcelonaSpain
  6. 6.Intensive Care UnitPapageorgiou HospitalThessalonikiGreece
  7. 7.Critical Care DepartmentAttikon University HospitalAthensGreece
  8. 8.UQ Centre for Clinical Research, Faculty of MedicineThe University of QueenslandBrisbaneAustralia
  9. 9.Royal Brisbane Clinical Unit, Faculty of MedicineThe University of QueenslandBrisbaneAustralia
  10. 10.Critical Care CenterHospital Universitaire LilleLilleFrance
  11. 11.Department of Infectious Diseases and Clinical Microbiology ClinicAntalya Education and Research HospitalAntalyaTurkey
  12. 12.Medical and Infectious Diseases ICU, Bichat-Claude-Bernard HospitalAssistance Publique-Hôpitaux de ParisParisFrance
  13. 13.Intensive Care DepartmentDonostia Univertsitate Ospitalea/CIBERESDonostiaSpain
  14. 14.Intensive Care Department Hospital Especialidades MédicasSan Luís PotosíMexico
  15. 15.Paediatric Critical Care DepartmentHospital Universitari Vall d’HebronBarcelonaSpain

Personalised recommendations