X

X

+ goggles or face shield

Table 54.1. Precautions for invasive procedures.

X = recommended; (X) = useful in some cases, not required; CVC = central venous catheter (includes Swan-Ganz catheters);

^# Contact time according to manufacturer’s recommendation, e.g., 60 seconds;

* Use sterile covers and sterile gel for ultrasound probes if used to guide the procedure;

** For long arterial lines (e.g., PICCO^® catheter), arterial sheaths for interventional radiology or intra-aortic balloon pumps or access lines for extracorporeal circulation (e.g., extracorporeal membrane oxygenation [ECMO], Novalung^®) use maximal barrier precautions as with CVC insertion.

Vaccination of all staff members against HBV should be enforced. A written policy for the management of exposure to HIV and post-exposure prophylaxis should be in place. The logistics to provide antiviral drugs within the recommended timeframe of 2 hours after exposure need to be determined to achieve best results.

Unsterile gowns and fluid impermeable aprons are worn when contamination with body fluids is possible.

Masks and face shields will protect staff from droplets, and special masks with higher protection grades (e.g., N95 or FFP2 respirator) need to be worn if airborne precautions are necessary, as in patients with open lung tuberculosis or SARS.

All personal protective equipment should be stored close to the point of care but protected from contamination and dust.

Dispensers for alcoholic hand rub should be easily accessible at the bedside and when entering and leaving a room. Personalized bottles carried by the team members can be an alternative.

Tap water may carry high-risk micro-organisms and should be accordingly tested for Legionella or Pseudomonas aeruginosa contamination (and treated accordingly). It should never be used for oral care, inhalation therapy or filling of humidifying devices in the breathing circuit (sterile water required).

Routine cleaning of the ICU by trained personnel is important. This should be done at least once a day and each time a visible contamination occurs. In addition, contaminated surfaces need to be disinfected with an approved surface disinfectant at the correct concentration (e.g., knobs and contact displays three times a day). All contact surfaces close to the patient need to be disinfected daily and immediately when visibly soiled.

Medical equipment and reusable products need to be cleaned and disinfected or sterilized after use according to the risk (Spaulding classification: critical, semi-critical, non-critical) and the manufacturer’s recommendations by trained staff utilizing a validated process.

Surveillance of nosocomial infections according to standardized definitions (www.cdc.gov/nhsn; www.nrz-hygiene.de/surveillance/surveillance.htm) is a useful tool in quality management in the neurocritical care unit.

At least ventilator-associated pneumonia (VAP) and central line-associated bloodstream infections (CLABSI) should be monitored. Oftentimes a surveillance program will lower the rate of infectious complications simply by increasing awareness (“Hawthorne effect”).

In order to prevent the development of multidrug-resistant organisms (MDRO), an antibiotic stewardship program should be established and guidelines for the empiric therapy of important infections (as outlined below) should be in place. An updated unit-specific antimicrobial resistance profile and treatment options should be available to clinicians prescribing antibiotics (e.g., pocketcard).

The differential diagnosis of fever is especially crucial in the neurocritical care unit because many patients have fever not related to an infectious cause. Examples are: intracranial bleed, stroke, drug fever (especially phenytoin-induced), blood product transfusion, adrenal insufficiency, fat emboli, cytokine-related fever, pancreatitis, acalculous cholecystitis, pneumonitis without infection, pulmonary emboli/infarction, venous thrombosis, acute myocardial infarction, dressler syndrome (pericardial injury syndrome), tumour lysis syndrome, gout, thyroid storm, malignant hyperthermia, malignant neuroleptic syndrome, serotonin syndrome, withdrawal of certain drugs (especially benzodiazepines, opioids).

54.3 Ventilator-associated Pneumonia (VAP)

Tables 54.2 and 54.3 show the data for ventilator-associated pneumonia (VAP) and central line-associated bloodstream infections (CLABSI) from the German National Surveillance System (Krankenhaus-Infektions-Surveillance-System: KISS; www.nrz-hygiene.de/surveillance/surveillance.htm).

Table 54.2. Ventilator-associated pneumonia (VAP) surveillance data (KISS January 2005-June 2006).

NA = no data available; UR = Utilization ratio per 100 patients; IR = Incidence ratio per 1000 ventilator days.

Table 54.3. Central line-associated bloodstream infections (CLABSI) surveillance data (KISS January 2005-June 2006).

UR = Utilization ratio per 100 patients; IR = Incidence ratio per 1000 ventilator days.

The diagnosis of VAP in critically ill patients can be challenging because of unspecific clinical symptoms and problems with interpreting bedside chest films. Chest computed tomography (CT) can be helpful.

Ideally, a sample of lower respiratory tract secretions is obtained before empiric antibiotic treatment is started. Specimens obtained by bronchoscopy, bronchoaveolar lavage (BAL) or mini-BAL with special protected catheters might be preferable to tracheal aspirates.

Regardless of the origin, each respiratory specimen should be transported to the microbiology laboratory within 2 hours and evaluated by Gram staining and cultured for routine aerobic and facultative bacteria. Additional special stains, rapid tests, PCR tests, and special medium cultures should be performed as directed by the clinical suspicion or epidemiologic situation of the unit. Quantitative culture results can be helpful in experienced hands, and close collaboration with medical microbiology is essential.

Biomarkers such as C reactive protein (CRP), procalcitonin and interleukin 1 can be helpful, as well as soluble triggering receptors expressed on myeloid cells (sTREM) from BAL fluid to facilitate the differential diagnosis of pneumonia versus atelectasis.

A parallel obtained blood culture and fluid from diagnostic and/or therapeutic punctures of pleural effusions can yield additional microbiological culture results. Three consecutive urine specimens should be examined for legionella antigen in case of clinical suspicion or known water contamination.

The repertoire of preventive measures is quite long, and available studies have often shown their effectiveness in so-called bundles only:

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