الفهرس 
VENTILATOR ASSOCIATED PNEUMONIAOnly 14 pages are availabe for public view
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Abstract
T
he increased prevalence of ventilator associated pneumonia (VAP) in children and adolescents with its complications especially increased mortality rates among critically ill patients pushes us to search the most common risk factors causing VAP and the relation between Oropharyngeal colonization and VAP.
So the aim of the study was to assess the effect of Oropharyngeal colonization on the occurrence and outcome of VAP in critically ill children admitted to PICU.
This study comprised 50 children and adolescents admitted in pediatric intensive care unit Ain shams university. They were subdivided into 2 groups regarding acquisition of VAP.
Group 1: comprised 30 critically ill patients acquired VAP after being ventilated.
Group 2: comprised 20 critically ill patients did not acquire VAP after being ventilated.
All patients were subjected to the following:
1. Full detailed history focusing on the risk factors for Ventilator Associated Pneumonia(VAP):Use of sedation, Use of enteral tubes, Previous antibiotic therapy, Re-intubation, Young infants or age greater than 10 years, medical or surgical problems, other known risk factors for development of VAP in children include genetic syndromes, immune deficiency, transport out of the PICU, continuous enteral feedings, bronchoscopy, and medications specifically steroids, H2 receptor antagonists, immunosuppressant, and prior use antibiotics.
2. Full clinical examination: with special emphasis on vital data including heart rate, respiratory rate, temperature, blood pressure, and chest examination.
3. laboratoratory investigations: included complete blood picture, arterial blood gases analysis, serum sodium, serum potassium and serum bilirubin.
4. Assessment of critical illness by using:
A. PRISM score:
The Pediatric Risk of Mortality (PRISM) score: required for pediatric ICU (PICU) mortality risk assessment. It uses 14 parameters (physiological and laboratory data) and for each one was used the highest severity value recorded in the first 24 hours. The risk of death is calculated by a logistic regression equation using the value of the PRISM, patient age and need of surgery on admission to the PICU, but performance was not significantly influenced by the post-operative status of the patients.
B. clinical pulmonary infection score (CPIS):
A diagnostic algorithm that relies on clinical, radiographic, and microbiological criteria (tracheal aspirate cultures), is used as a practical objective tool for diagnosing ventilator-associated pneumonia was also applied on all ventilated patients with every culture of lung aspirate on day 0 ventilation, and on suspecting VAP either early within 48 hours of ventilation or late VAP within 96 hours of ventilation and on discharge from the PICU. The score varies from 0 to 12 points with a CPIS of more than 6 being associated with a high likelihood of pneumonia.
5. Microbiological assessment includes:
A. Microbiological assessment of Oropharyngeal colonization:
Oropharyngeal colonization was analyzed by using a qualitative microbiological culture assay of samples from the tonsillar area and the upper posterior part of the oropharynx. Samples were collected during the first 24 hours of PICU admission (day 0), at 48 hours (day 2), at 96 hours (day 4), and at the time of discharge from the PICU.
B. Microbiological assessment of tracheal lung aspirate:
Cultures of lung aspirate endotracheal tube aspirate (ETA)were done for all ventilated patients to detect incidence of ventilator associated pneumonia samples were collected during the first 24 hours of PICU admission (day 0), on suspecting VAP within 48hours and 96 hours of ventilation for detecting early and late VAP respectively, and at time of discharge from the PICU.
This study reveals the following results:
- Patients on Central nervous system suppressors were 5 times more at risk of acquiring VAP than the patients not using CNS suppressors.
- Patients using gastric PH modifiers were twice more at risk of acquiring VAP than the group not using any gastric PH modifiers.
- Using immunological suppressors increased the risk of acquiring VAP by 2 folds.
- Use of triple antibiotic therapy was significantly associated with VAP (P<0.05).
- Patients who developed VAP showed significantly higher emergency admission to the PICU (P<0.05).
- Patients with medical underlying conditions showed significantly higher rate of developing VAP than patients with surgical underlying conditions (P<0.05).
- Patients developed VAP showed highly significant increased History of previous intubation (P<0.01)
- There was significant difference between VAP group and non VAP group regarding microbiological profile of Oropharyngeal secretions on day2, day 4 and on discharge.
- Endotracheal culture on extubation showed significant difference among the 2 groups.
- The endotracheal culture done on suspecting VAP clinically, laboratory and radiologically showed relationship with Oropharyngeal swabs done on day 2 and day 4 admission proving that there is a relationship between Oropharyngeal colonization and occurrence of VAP in critically ill patients admitted to PICU.
- The most common organisms responsible for colonizing the oropharynx and responsible for VAP are gram negative organisms as klebsiella pneumonia, acintobacter baumanii and pseudomonas aeuraginosa.
- Most of patients acquired VAP, acquired early VAP during the first 48 hours of ventilation.
- The mortality rate due to VAP among our study group was 28% of the studied cases